Situation Analysis of Murshidabad District, West Bengal

FIELD PROJECT REPORTS

Tapas Kumar Ray (MAE- FETP Scholar 2007-2008)

Submitted in partial fulfillment of the requirements for the degree of

Master of Applied Epidemiology (M.A.E) of

Sree Chitra Tirunallnstitute for Medical Sciences and Technology,

Thiruvananthapuram, Kerala-695 011

This work has been done as part of the two year Field Epidemiology Training Programme (FETP) conducted at

National Institute of Epidemiology, (Indian Council of Medical Research), R-127, TamilNadu Housing Board, Ayapakkam, Chennai-77, India.

January 2009 FIELD PROJECT REPORTS

Tapas Kumar Ray (MAE- FETP Scholar 2007 -2008) • ~

Submitted in partial fulfillment of the requirements for the degree of

Master of Applied Epidemiology (M.A.E) of

Sree Chitra Tirunal Institute for Medical Sciences and Technology,

Thiruvananthapuram, Kerala-695 011

This work has been done as part of the two year Field Epidemiology Training Programme (FETP) conducted at

National Institute of Epidemiology, (Indian Council of Medical Research), R-127, Tamil Nadu Housing Board, Ayapakkam, Chennai-77, India.

January 2009 CERTIFICATION

This is to certify that all the field projects submitted in this Bound Volume are original work carried out by Dr. Tapas Kumar Ray during the two field postings of six months each under the guidance of faculty of National Institute of Epidemiology (ICMR), Chennai and the local supervisor specially nominated for this purpose. This is in partial fulfillment of the requirements for the degree of Master of Applied Epidemiology and has not been submitted earlier by him in part or whole for any other (Publication or degree) purpose

Date: Acknowledgement

Several dignitaries and institutions have extended their valuable time, advice and assistance to me during preparation of this report. I extend with gratitude my sincere thanks to: Dr. V. Kumaraswamy, Director, National Institute of Epidemiology, Chennai for his valuable guidance amidst his busy schedule. Dr. M. V. Murhekar, Deputy Director and Course coordinator, Master of Applied Epidemiology, National Institute of Epidemiology, Chennai and my mentor for the field projects. I express my sincere thanks and honest gratitude to him for going through the details of my project reports closely and giving suggestions and advice. Dr. Y. Hutin, World Health Organisation, India country office, Dr. B. N. Murthy, Deputy Director, R. Ramakrishnan, Deputy Director, Dr. Vidhya Ramachandran, Deputy Director, Dr P.Manickam Research Officer National Institute of Epidemiology, Chennai for his kind guidance and suggestions.

Dr. S. Baksi, Director of Health Services, West Bengal for allowing me to take up MAE-FETP course at National Institute of Epidemiology, Chennai. Dr. S. Mandai, CMOH, Murshidabad, Dr. T. K. Sen and Dr. A. K. Biswas, MAE graduate, Dr. S. Roy, Dy. CMOH-111, Murshidabad, Dr. J. Dinda, Dy. CMOH-11, Murshidabad, Dr. B. P. Bag, ACMOH, Jangipur and all colleagues of my department for their guidance, support and cooperation.

I will really do injustice if I do not mention several scientists and staff of NIE like Dr. Sundarmurthy, Dr. Jabber, librarian S. Satish and Mrs Uma.

Last but not the least I am indebted to my family for helping me in this endeavor of hard work with patience.

Finally all the respondent who very graciously spared me their valuable time and extend their cooperation.

Date: Tapas Kumar Ray Table of Contents

Section 1: First Field Posting ...... 1-49 1.1 Situational analysis of Murshidabad District, West Bengal, 2-30 India, 2006 1.2 Secondary data analysis of malaria epidemiological 31-49 situation of Murshidabad District, West Bengal, India, 2007

Section 2: Second Field Posting ...... 50-91 2.1 Evaluation of surveillance of acute flaccid paralysis for 51-70 poliomyelitis in Murshidabad District, West Bengal, India, 2007

2.2 Evaluation of the existing anthrax control activities in 71-91 () Murshidabad district, India, 2007

Section 3: Outbreak investigations ...... ~ ... , ...... 92-146 3.1 An·outbreak investigation of Measles at Dihigram village of 93-104 Murshidabad district, West Bengal, India, 2007 3.2 Cutaneous Anthrax outbreaks in two villages of 105-119 Murshidabad, west Bengal, India, 2007 -~ 3.3 An outbreak of Cutaneous Anthrax, at Burakuli village, 120-133 Murshidabad, West Bengal, India, 2007 3.4 An investigation on Measles outbreak at Kulgachi village of 134-146 Murshidabad, West Bengal, India, 2008

Section 4: Journal critique ...... 147-154 4.1 Critical evaluation of published research 148-154

Section 5: Paper presentation ...... 155-163 5.1 Oral presentation in National Conference on Emerging Issues in Public Health, AMCCON, Trivandrum, Kerala, 156-157 January 11-13, 2008 5.2 Oral presentation in International Night session, 57th Annual EIS Conference, April14-18, 2008, Centers for Disease 158-159 Control and Prevention, Atlanta, USA

5.3 Poster presentation in, 5th Global TEPHINET Conference, 160-161 1st-6th November 2008, Kualalumpur, Malaysia

5.4 Oral presentation in, 5th Global TEPHINET Conference, 162-163 1st-6th November 2008, Kualalumpur, Malaysia

- -· -· -·---··------· ------Section 1: First Field Posting

Pageno.1 Situation analysis of Murshidabad district, West Bengal,

India, 2007 o

Introduction

Indian public health scenario

The public sector health system of India is one of the largest systems in the world in terms of its infrastructure. India has its own declared National Health and

National Population Policy. Smallpox as well as Gunea worm has been eradicated and Plague is not a problem now1. Morbidity from diarrhoeal diseases has come down to a great extent. The birth rate has come down from 33.7/1000 population to 23.8/ population, crude death rate from 12.6/1000 to 7.6/1000 population and the infant mortality rate from 114/1000 live births to 58/1000 live births2. The problems of malnutrition, poor sanitation, and Illiteracy are hindering the improvement in the burden. The major public health problems have not been changed so much in last six decades. The prevalence of tuberculosis, leprosy, filariasis, viral hepatitis, diarrhea, dysentery and disorders of malnutrition has not shown any significant change. MDR-TB is posing a potential threat to tuberculosis control in the country.

Diarrhoeal diseases and acute respiratory diseases are still the major killer diseases. Malaria and Kala-Azar which showed a decline in the 1960s have come back3. Japanese encephalitis and Meningococcal encephalitis have shown. an

Page no. 2 increasing trend. Some non-communicable diseases like diabetes, heart disease, cancer, mental illness, hypertension accidents and injuries etc show a growing threat. The factors which play a role in the changing pattern of the disease include demographic factors, changing lifestyles and living standards, urbanization and industrialization, medical intervention, transmission of genetic defects and the widespread effect of technology on ecosystem. The changing pattern of the disease in this country and the emergence of new problems highlight the need for an aggressive change in health planning and management.

Public health scenario in West Bengal

West Bengal had a population of 68,077,965 with population density of 903/sq.km making it the most densely populated state in lndia4. The birth rate is 18.8/1000 population, crude death rate 6.4/1000 population, the infant mortality rate 38/1000 live births2 and the Maternal mortality ratio is 194/100000 live births4. The diseases like Malaria, Dengue, Kala-azar, Diarrheal Diseases, HIV, Tuberculosis, and Arsenicosis are the major public health problems the state is trying to combat5.

I have been worked as Assistant Chief Medical Officer of Health, Jangipur, under

Murshidabad district before enrollment in the Master of Applied Epidemiology course. The job responsibility was to plan, implement, monitor and supervise all

Family Welfare & Public Health programmes as well as administrative function at

Sub-divisional level. Since the district faces multiple Family Welfare & Public

Page no. 3 Health problems including Malaria, Kala-azar, Filarial, Leprosy and Tuberculosis, the post demands hard working for successful surveillance activities. The post carries responsibility of Sub~divisional level nodal officer for all national programmes. Moreover the Assistant Chief Medical Officer of Health, Jangipur ~ office is a Unit office for National Vector Born Disease Control Programme as per

Government of India norm. As such the undersigned has to procure medicines and equipments for the above programme from state and distribution of the same for the all "blocks of Jangipur, Lalbagh sub-division and 2 blocks of Domkol subdivision. As well as fund management for the above programme was also done regt,.~larly. These includes compilation, collection, interpretation and feedback of all data generated at Sub-division level related to indicators of reproductive and child 0 health programme, all national public health programmes and health care facilities .. I had to send the report to Chief Medical officer of Health of the district and respective district programme officers.

As field epidemiology training programme (FETP) scholar, I shall work as medical officer on training reserve under the Government of West Bengal and shall be placed under the Chief Medical Officer of Health, Murshidabad and Assistant

Chief Medical Officer of Health, Jangipur, Murshidabad for doing my field epidemiology training in terms of doing projects to be assigned time to time by the

National Institute of Epidemiology, Chennai. I shall meet Director of Health

Services and appraise him about my assignments. I shall also meet Joint Director of Health Services (Public Health and Communicable Disease) and other officers to discuss and interview them for getting data pertaining to the government orders

Page no. 4 and existing surveillance system at health directorate which is in the Swasthya

Bhavan, Salt Lake, Kolkata - 700091.

0 The objectives of the situational analysis of Murshidabad district, West Bengal are

to (1) describe of geography, population and economical resources (2) know

organization of the health system (3) understand major public health priorities and

(4) present health status related to indicators towards the millennium

development goals.

Method

In Murshidabad district, I shall visit district health offices, meet all district level ~ . officers, interview them as per my project methodology to know ,about the present

health scenario, secondary data, existing surveillance system including flow of

data and getting data for evaluation of the surveillance system. I shall visit the

0 health facilities (Health Sub center, Primary Health Center, Block Primary Health

Center, Sub-division and District hospital) to collect information related to the

present health scenario, secondary data, and existing surveillance system. I shall 0 also share my observations time to time with the workers at all level for the

betterment of health care services.

The key elements of the situational analysis were to describe geographical

characteristics, demographic characteristics, socio-economic characteristics,

important health related millennium development goals indicators (such as

prevalence and death rate associated with tuberculosis, infant mortality rate.•

. Page no. 5 maternal mortality ratio per 100,000 live birth, measles immunization among children under one, under-five mortality rate per 1000 children, percent of children under age 0-3 months on exclusively breast fed, percentage of children 12-59 month of age who received one dose of vitamin A in the past six months, couple protection rate), organizational set up of the state and district, major public health priorities with flow chart in context of the Murshidabad district, West Bengal, India.

Data collection

We visited different offices of health and other related department at district and community block level to explain our objectives and the importance of verification of records and collection of reports. We also discussed with them to understand the organizational set up of health system. We also consulted with various reports published at state and district level by ~apartment of health and family welfare, cl) bureau of applied economics and statistics, government of West Bengal. The reports included (1) District statistical hand book, 2005 (2) Census data, 2001 (3)

SRS report, 2004 (4) West Bengal human development report, 2004 (5) National

Family Health Survey 2 & 3 report (6) Health on march 2005-06, West Bengal (7)

Millennium development goals, India country profile, World bank and (8) The

World Health report, 2004.

Page no. 6 Result

Location, climate, geography, population and economical resources:

Murshidabad district lies between 23.4° and 24.5° north latitude and 87.5° and

88.5° east longitude in the eastern side of the State West Bengal, lndia6 (Figure

1). The total geographical area of the district was 5324 Sq. KM 5. The district was surrounded by the Maida, Birbhum, Nadia, and Burdwan districts of the state of

West Bengal and Pakur district of the state of Jharkhand. International border of

Bangladesh is at its eastern side. The main rivers passing through or bordering the district were Ganges, Bhagirathi, Mayurakshi and Padma which are connected by their tributaries like Jalangi, Bhairab, Bansoli, Babla, Dwarka,

Brahmani, Pagla etc. Murshidabad district had a tropical climate and is characterized by evaporation and low precipitation. Average annual rainfall varied between 1255 and 1753 mm6. Annual temperature of the district varied over a range of 7° Celsius in winter to 43° Celsius in summer6. Murshidabad district headquarter was located at Berhampur town. The district had five administrative sub-divisions, called Sadar, Kandi, Jangipr, Lalbagh and Domkol. There were 26 police stations, 26 Community developments Blocks (figure 1), 7 Municipalities,

254 Gram Panchayats and 3633 Gram Sansads6. There are 3 and 19

Parliamentary and Assembly constituency. As per 2001 census the total

Population of the district was 5,866,569. Of this 5,133,835 (87.51 %) were residing in rural areas6. About 2,861,569 (48.77%) of the populations were females. The

Page no. 7 proportion of Schedule caste and Schedule tribes were 11.99% and 1.29% respectively. The projected population 2007 is 6,702,000. The district had an <> average population density 11 02 per Sq. KM with a decennial growth rate 23.76%

(Table 1 ). The proportion of literate population among above 7 years of the district 0 was 54.3%. The male literacy was 60.7% as compared to 47.6% for female6 . • About 28.5% of the total pop.ulation of the district was classified as main worker,

5.7% as marginal workers and 65.8% as non-workers. Of the main workers

18.7% were cultivators, 28% were agricultural labours and 20.4% were engaged ) in household industries and rest in other activities5.

Major public health priorities

The public health problems in the district related with maternal conditions, communicable diseases, non-communicable diseases and injuries. Important communicable diseases were diarrhoeal diseases, acute respiratory infection

(including pneumonia), tuberculosis, malaria, filarial, leprosy, enteric fever, viral hepatitis and sexually transmitted· diseases. Malaria, acute poliomyelitis and

Tuberculosis, Kalaazar and leprosy were the five public health priorities in

Murshidabad districf (Table 2).

Organization of the health system

At district level Chief Medical Officer of Health was overall in charge and responsible for the health care delivering system. The Director of Health Services of the state and District Health and Family Welfare Samity, Murs~idabad guided him. The District Health and Family Welfare Samity was a society with

Page no. 8 Savadhipati, Murshidabad Zila Parishad as Chairman, District Magistrate,

Murshidabad as Vice-Chairman and Chief Medical Officer of Health as member . secretary and other members from respective department took deG:isions on policy making and implementation of different health activities as per guidance from state and national level. For assisting Chief Medical Officer of Hea1th at the district level there were a good number of health Officials namely Dy. Chief

Medical Officer of Health-! (responsible· for looking stores, vehicle and administration). Dy. Chief Medical Officer of Health-11 (responsible for looking

Public Health Programmes), Dy. Chief Medical Officer of Health-Ill (responsible for looking Reproductive and Child Health programme), Zonal Leprosy Officer

(responsible for looking National Leprosy Eradication programme), District

Immunization Officer .and District Tuberculosis Officer (responsible for looking

Revised National Tuberculosis Control programme). One Asst. Chief Medical

Officer (Medical and Administration) was looking day-to-day administration with guidance from Chief Medical Officer of Health. The Superintendents who were accountable to Chief Medical Officer of Health administers hospital administrations. At the sub-divisional level Assistant Chief Medical Officer of

Health (Subdivision) was responsible for discharging health cares delivery services in their respective sub divisions. Block Medical Officers of Health were overall responsible for discharging curative and preventive services in the community block. Chief Medical Officer Health, Asst. Chief Medical Officer of

Health (Sub division) and Block Health and Family Welfare Samity (a society similar to the district level) guided him to take dicision. Other Medical Officers (for

Page no. 9 I 0 curative and preventive services) assisted him for discharging services. Block

Public Health Nurse, Block Sanitary Inspector, Social Welfare Officer, Public

Health Nurse, Sanitary Inspector Malaria Inspector, and Computer assisted him

for discharging preventive services. PHC Medical Officer headed- .each primary

health center cover a population of 30000-40000. Health supervisor (Gram

Panchayat) assisted a PHC Medical Officer as well as Block Medical Officer of

Health for health care services at Gram Panchayat level. A sub center was the

basic unit of preventive activity and it covered a population of 5000-7000. Health

assistants female and male discharged the services. Within a sub center there

were some support personnel for every 1000 population namely Anganwari

Worker, Community Health Guide and trained dai, Link persons, ASHA workers to

help in organizing health activities in respective areas.

Indicators towards the Millennium Development Goals

Malaria death rate was high in the district in relation to state and national level.

High import of Pf cases to the district was the possible explanation. However

other health related millennium goals indicators were not available in the district

like, HIV prevalence among 15 ~ 24 years of all women, condom use rate of the

contraceptive prevalence rate, Target of Goal 4 was to reduce the under-five

mortality rate by two-thirds, which was two third of 123 per 1000 between 1990

and 2015 but as per record the under-five mortality rate in district and state was

much less than national level in the year 2007. Goal 5 target was to reduce by

three-quarters, between 1990 and 2015, the maternal mortality ratio. The district

level figure was 178 per 100000 live births that are better than the national level

Pageno. 10 figure. Death rate of Tuberculosis both were more in the district than the state and the national level. Proportion of tuberculosis cases detected and cured under

DOTS was also higher in the district as well as in the in comparison to the national level (Table 7).

Laboratory resources

There are very less hospitals both in public and private sectors and the major

0 responsibility to manage and control public health in the city lies on the Public sector. 1 District Diagnostic and Public Health laboratory at CMOH office. It has

53 malaria clinics for the detection and treatment of malaria. 5 chest clinics and

52 microscopy centres for the diagnosis and treatment of tuberculosis patients which follows Revised National Tuberculosis Control Programme (RNTCP) guidelines.

Primary level: The routine investigations are usually done at BPHC/ RH laboratory eg. MP, Sputum for AFB, Aldehyde/ RK- 39. Slides for Malaria parasite are examined at the Malaria clinics. Sputum for acid-fast bacilli and x-ray are done at microscopy centres under the Revised National Tuberculosis Control Programme.

1 lab was established under Public Private Partnership at Krishnapur RH.

Secondary Level: Routine blood tests, e.g. VORL, HIV, MP, HbsAg, cross matching, etc., basic biochemical tests and stool, and urine are done at state general hospitals situated within Kolkata city. A voluntary counseling and testing centre for HIV is available only at Sadar Hospital, Berhampur.

Page no. 11 Tertiary level & State /eve/laboratory: No such laboratory present at district level.

Samples are sent for various virological diagnostic tests (e.g. Hepatitis A,B,C,D,E and HIV, dengue, Japanese encephalitis, chikungunia etc.), special bacteriological tests (e.g. leptospira antibody study) and protozoal studies (e.g. direct agglutination test for kalaazar) to the School of Tropical Medical Medicine,

Kolkata, which is a state level laboratory.

Central level laboratory: such lab. Is not present at district /eve:. For cholera and enteric diseases (mainly for rotavirus, detection of the bacterial strain and serotyping for cholera), samples are sent to the National Institute of Cholera and

Enteric Diseases in Kolkata. For specific virological studies that are not available in Kolkata, samples are sent to the National Institute of Virology, Pune. Various investigations which are not done in Kolkata, are sent to the National Institute of

Communicable Diseases in New Delhi.

Discussion

Situated in the middle part of the state West Bengal, Murshidabad district had good climate and average rainfall but the district is flood prone. This affected the agriculture of the non-industry based district and in tern the economy of the

people. Poor economy, little literacy (particularly female literacy) and inadequate

infrastructure support reflected to high prevalence of public health problems

related to almost all public health diseases. Indicators of millennium development

Page no. 12 goals were far away from target demanded special attention and specific micro

plan.

The sub tropical climate with low precipitation made the district dominancy of waterborne and vector borne diseases in the district particularly in post monsoon. > Poor economic reflected in results of high prevalence of tuberculosis in the district.

Poliomyelitis was the public health priorities in the district as a part of international eradication. Existence of cases in adjacent districts demanded high quality acute flaccid paralysis surveillance as well as other eradication activities including

routine immunization. Malaria was the second public health priorities for high

incidence rate and case fatality rate particularly in western and southern part of the district. Tuberculosis, the disease under national control target is highly

prevalent in this district. Kalaazar incidence is very high in this district. Leprosy,

disease under elimination target in the country was one of the public health

priorities. Organizational set up though in existence at different level, there were

vacancies of manpower that in terns affect the activities. More over each level

(Community Health Center, Primary Health Center and Health Sub Center) at

present served a larger population to their norms. This increased the workload at

the cost of quality of services.

In the district level some data were regularly generated but some data pertaining

to the indicators of millennium development goals were not being generated and

for this, some modifications were required in the forms (data collection

instruments). In addition to this, analysis of the raw data were to be done at the

Page no. 13 level of block and district also so that the officer concerned can take appropriate measures at their own level as per the result of analysis. we proposed potential areas of work for my various assignments which included

(1) National anti malaria programme (secondary data analysis), (2) acute flaccid paralysis for poliomyelitis (surveillance system evaluation) and (3) Evaluation of anti anthrax activities, going on in the district (programme evaluation).

Page no. 14 References: ~

1. Government of India, Department of Health and Family Welfare, National

Rural Health Mission ( 2005-2012 ), Mission Document

2. Government of India, Sample registration system bulletin, 2005

3. Government of India, National Vector borne Diseases Control Programme,

report, 2006

4. Government of India, Census of India, 2001

5. Government of West Bengal, Department of Health and Family Welfare,

Health on march- 2006-2007

6. Government of West Bengal, District statistical handbook, Murshidabad

district

7. Government of West Bengal, Department of Health and Family Welfare,

Murshidabad district, 2006-07 (unpublished data)

8. Government of India, Department of Health and Family Welfare, National

Family Health Survey-3

9. Government of India, District Level Household Survey-11

10. Government of India, annual report, Revised National Tuberculosis Control

Programme, 2006

Page no. 15 Figure 1. The map of the state of West Bengal showing Murshidabad district with blocks, India, 2007

N D

MAP MURSHIDABAD 2006

aarddlam,tin Bankut!l* Medln!pur

Page no. 16 Table 1: Characteristics of the population of Murshidabad district, West Bengal, India, 2007

Population group Population size (in thousands) Proportion of the total (%)

0-4 years of age 0 798 12

5 - 9 years of age 967 14

10 -14 years of age 904 13 ,, 15-44 years of age 3021 45

44-59 years of age 626 <.> 9

60 + years of age 386 6 0 Male 3433 51

Female 3269 0 49

Hindu 2408 36

Muslim 4268 64

Christians & others 26 - Above poverty level 3799 57

Below poverty level 2903 43

Page no. 17 Population size (in thousands) Proportion of the total(%)

General caste + OBC 5811 87 • Schedule caste 804 12

Schedule tribe 87 1

Literacy 3639 54 - Total population size (Estimated) 6702 100

,~ Ct ~~

Pageno. 18 Table 2. Key public health priorities in Murshidabad, West Bengal, India, 2006

Public health Ongoing prevention and control programmes Key elements priority Malaria • 5.8 million (100%) of population at 1. Preventive strategy risk (a) Early detection and prompt treatment • More than 1.5 thousand annual (b) Selective vector control episodes (c) Pers~nal protection • Plasmodium falciparum infection is as (d) Information, education and communication high as 15% to 20% of total malaria 2. Control strategy "' cases (a) Treatment of uncomplicated malaria at community • Deaths reported from endemic areas level • ABER ( 4.86% in 2006) is far away (b) Treatment of complicated malaria at health facility from target of 10% 3. Early detection and management of cases

Acute Poliomyelitis • Disease under international 1. Pulse polio immunization eradication programme 2. Routine immunization • Cases detected in 2006 in adjacent 3. Mopping up if wild virus is identified Samserganj block 4. Acute flaccid paralysis surveillance - investigation and • I compatable case in each Dhuliyan follow up of cases Municipality, Lalgola, Samserganj, Suti-1 in 2006

Pageno. 19 ft -- .. ' f * ri I The data was collected was of sufficient quality. Yes ./

The analysis is thought beforehand and appropriate. ./ Age and sex distribution analysis lacking .

The indicators generated are appropriate and well Demographic and socio- economic indicators calculated. ./ were lacking

0 The statistical tests used are appropriate and well Statistical tests used are well computed except computed. ./ Population attributable fraction

Appropriate attention has been given to human Ethical issues are not mentioned . subject protection issues. ./

------

Pageno. 152 Tuberculosis • Disease under national control 1. M.O at PHI is the key person. programme 2. Eostablishes the diagnosis. • Sputum examination 686/ 1 lakh 3. Decides the type of pt. & categories of treatment. population, Total ACDR-118.56 per 4. Counseling -disease, treatment, contacts, DOTs Lakh NSP ACDR- 58.42 per lakh, 5. Determines DOT centre & DOT provider. Conversion rate- 91.82%, Cure rate- 6. Card initiation (treatment & I-card) 88.67% 7. Card updating- Multipurpose Supervisor. • Defaulter 3.81% in 2001 increases to 8. Monthly PHI programm~ Management report. 5.92% in 2006 9. Defaulter retrievals and Awareness camp. Kalaazar • Disease under national control 1. Preventive strategy programme a) Early detection by aldehyde test and RK-39 kit and • No. of cases 575 with death 6 in treatment of cases. 2006. b) Treatment of cases by admitting in IPD • Death in increasing in respect of c). Community awareness 2005 where death was 2. • Mainly Farakka, Samserganj, Suti-11, 2. Other strategy Sagardighi, Lalgola, Murshidabad a) Insecticide spray Jiaganj, Nabagram blocks are b) Arrangement of Houses for the BPL kalaazar affected. patients.

Page no. 20 Leprosy • Disease under national elimination 1. Preventive strategy programme (a) Detection and treatment at health facility • Low prevalence rate (0.57 per 1OOdO (b) Information, education and communicatlon population) compared to state West (c) Community programmes like Mass Leprosy Bengal Elimination • Elimination goal has reached at Campaign, Block Leprosy Awareness Campaign prevalence rate at one or less per ten 2. Other strategy thousand. (d) Cleaning of register (e) Disability management including reconstructive surgery. "'

Page no. 21 Figure 2. Flow chart illustrating the administrative structure of the health system, Murshidabad, West Bengal, India, 2006

Department of Health & Family Welfare

District Health & Family Welfare Samity Chief Medical Officer of Health IRKS H I I ~ ~ ~ ~ ~ ~ J () ~l Dy. Dy. CMOH- Dy. CMOH- ZLO ACMOH ACMOH DMCHO Superintendent, I CMOH-1 II Ill (MA) (PH&FW) Distrisct Hospital I J RKS ~ Superintendent, ACMOH, Superintendent, RKS S.G. Hospital Sub- divisions S.D. hospital H I ~ Block Health & family Welfare Samity ~ Superintendent! BMOH, (MO), RKS R.H./ BPHC r------. PHCs .. I I Rogi Kalyan Samity ~ BSI. BPHN. SWO. Sl. PHN. MI. Comouter I ~ G. P. Head Gram Panchayat Non G. P. Quarter Sub- (G.P. Supervisors) Head Quarter centre Sub-centre

l l l v l Health Health Assistant Health Health Assistant (Male)/ Assistant (F) (Male) Assistant (M) Voluntary Male worker

1. Community Health Guide- 1 per 1000 population, 4. ASHA- 1 per Mouza Page no. 22 2. Trained Birth Attendant - 1 per 1000 population, 5. Link person- 1 per Mouza 3. Anganwari Worker- 1 per 1000 population Abbreviations:

Dy. CMOH - Deputy Chief Medical Officer of Health

, 010- District Immunization Officer

ZLO - Zonal Leprosy Officer

DTO- District Tuberculosis Officer

ACMOH - Assistant Chief Medical Officer of Health

SO - Sub division

BMOH- Block Medical Officer of Health

MO- Medical Officer

RKS- Rogi Kalyan Samity

BSI- Block Sanitary Inspector

BPHN - Block Public Health Nurse

SWO- Social Welfare Officer

Ml- Malaria Inspector

MA - Medical & Administration

ASHA- Accredited Social Health Activists

Page no. 23 Table- 3: Health infrastructure in the district of Murshidabad, West Bengal, India, 2006

Sl. No. FaC

1 Sub Centres 832

2 Public Health Centres 70

3 Block Public Health Centres 18

4 Rural Hospitals 9

5 Sub Divisional Hospitals 4

6 State General Hospital 1

7 District Hospital 1

8 Total Beds 1067 "' 9 Approved MTP centers 4

10 Ayurvedic Dispensaries 8

11 Homeopathic Dispensaries 15

12 No. of ICDS Blocks 26

13 No. of Diagnostic facilities 26

14 No. of USG Clinics 4

15 No. of private Nursing Homes 54

Page no. 24 Table- 3: Health manpower in the district, Murshidabad, West Bengal, India, 2006 "

Sanctioned Sl. No. Category of Staff In position Vacancy Strength

1 District & Sub Division Level Officers 19 18 1

2 MO (West Bengal Health Service) 202 157 45

3 MO (Ayurvedic) 27 21 6

4 MO (Homeo) 39 22 17

5 Dental Surgeon 16 12 4

6 Pharmacist 123 91 32 0 7 Social Welfare Officer 74 25 49

8 Sub-Divisional Food Inspector 4 0 4

9 Ophthalmic Assistant. 30 30 0

C') 10 Public Health Nurse 52 38 14

11 General Nurse Midwife 764 749 15

12 Block Sanitary Inspector and Sanitary Inspector 58 0 58

Page no. 25

0 Sanctioned Category of Staff In position Vacancy Strength

13 Malaria Inspector 26 0 26 ll 14 Health Assistant (F) 832 770 62

15 Health Assistant (M) 861 450 411

16 Health Supervisor (GP) 254 129 125

17 Medical Technologist (Lab.) 82 63 19

18 Group -'D' Staff including Sweeper 1410 1380 30

Page no. 26 Table 7: Indicators of progress for health related millennium development goals, Murshidabad, West Bengal,

India, 2007

(,) -- Value of the indicators

Goal Indicator Murshidabad West Bengal India

Goal1 Prevalence of underweight children < 5 years of age 52.42% 7 43.50%8 45.90%8 (0-6 in Murshidabad) Proportion of population below minimum level of dietary energy consumption % of children 6-59 month of age who received one 27.83%7 41.20%8 21%8 dose of vitamin A in the past six months Proportion of infants under six months who are 20.10%7 58.60%8 46.30%8 exclusively breastfed

Goal4 Under-five mortality rate (per 1000 live births) 22.04 67.6 74

Infant mortality rate (per 1000 live births) 40 38 582

Measles immunization among children under one 56.40%9 74.70%8 58.8%8

GoalS Maternal mortality ratio 266 - 194

Proportion of births attended by skilled health personnel 40.14% 45.70%8 48.30%8

Page no. 27 0 GoalS Contraceptive prevalence rate in %( current use of - 49.90%8 48.50%8 contraception) %of women receiving antenatal care (mothers who 58.97% 62.4 50.70% had at least 3 antenatal care for their last birth) HIV prevalence among 15-24 years old pregnant Goal6 2.10%7 women

8 8 Condom use rate of the contraceptive prevalence rate - 4.50% 5.30%

7 Number of children orphaned by HIV/AIDS 11 54.49% Targef % of people using a condom during most recent higher risk sexual encounter Group (CSWs)

%of clients with Sexually Transmitted Infections 41.52% (STis) who are diagnosed and treated according to 0 guidelines Percentage of HIV-positive women receiving anti- retroviral treatment during pregnancy to prevent mother to child transmission of HIV " Goal6 Malaria mortality rate 0.84%5 0.13%5 0.05%3 (Malaria)

Page no. 28 •

Goal6 Proportion of people with uncomplicated malaria getting correct treatment at the health facility and (Malaria) 100%5 100%5 community levels, according to the national guidelines, within 24 hours of the onset of symptoms Percentage of pregnant women who have taken chemoprophylaxis or drug treatment for malaria

The proportion of households having at least one - - 3,775,0001 insecticide treated bed nets

Goal6 Prevalence of tuberculosis (per lakh) 10 119 127 125

(TB) Tuberculosis mortality rate10 • 4.63% 3.98% 3.84%

Proportion of tuberculosis cases detected through - - 61%) DOTS approach (NSP) 10

DOTS cure rate 10 89.00% 86% 83% " DOTS success rate10 92% 87% 86%

Percentage of estimated new smear-positive 10 tuberculosis cases registered under the DOTS 89% 78% 66% 0 approach10

Page no. 29 Goal7 Proportion of population with sustainable access to an 27.90% 42.00% improved water source ( urban and rural) Proportion of urban population with access to 0 59.50% 44.50% improved sanitation GoalS Proportion of population with access to affordable essential drugs on a sustainable basis

Page no. 30 Secondary data analysis on malaria epidemiological situation of Murshidabad district, West Bengal, India, 2007

Introduction

Malaria is preventable, treatable and curable disease. Four types of malaria

parasites can infect humans: Plasmodium falciparum, P. vivax, P. ovale, and

P. malariae; Malaria is transmitted by the infective bite of female Anopheles

mosquito. The genetic complexity of the parasite and more than 40 mosquito

species that transmit it, the tendency to develop resistance (both to insecticide

and anti-malarial drug), and the variations in human susceptibility and

immunological response combined with an absolute need for prompt access to

quality drugs make malaria control a matter of enormous technical

complexity. 1

Analysis of malaria situation is the essential for planning anti-malaria action. A

complete malaria situation analysis would include a description of distribution of malaria and its consequences and an explanation of that distribution in terms of its causal factors (geographical, physical, environmental etc.). An

· important component of any plan is collection of additional, valid information

necessary for re-planning purposes to improve the programme. Many factors

contributes to the epidemiology of malaria, such as distribution and relative

prevalence of plasmodium species and their response to drugs, the distribution of vector species and their susceptibility to insecticides, the intensity of transmission etc. The economic and geographic characteristics of different

areas, socio-economical conditions of the populations, climatic and

Page no. 31 meteorological factors play a major role. Based upon the analysis of malaria situation, certain key decisions need to be made.

Malaria is the most important of the parasitic diseases of humans, with 107 countries and territories having areas at risk of transmission. About 50 percent of the world's population is at risk of malaria.2 More than 3 billion people live in malarious areas and the disease causes between 1 million and 3 million deaths each year3. Recent estimates of the global falciparum malaria morbidity burden have increased the number to 515 million cases, with Africa suffering the vast majority of this toll. 4 In addition, almost 5 billion clinical episodes resembling malaria occur in endemic areas annually, with more than 90 percent of this burden occurring in Africa. 3 In 2001, the World Health

Organization ranked malaria as the eighth-highest contributor to the global disease burden as reflected in disability adjusted life years (DAL Ys). 5 Of the

10.6 million yearly deaths in children" younger than 5 years, eight percent are ascribed to malaria. 6 About 4 percent of maternal deaths or 5,300 deaths per year are the result of malaria related conditions. 7 The disease has res urged in many parts of the tropics, and non-malarious countries. Large areas of Central and South America, Hispaniola (the Caribbean island that is divided between

Haiti and the Dominican Republic), Africa, the Indian subcontinent, Southeast

Asia, the Middle East, and Oceania are considered malaria-risk areas. 8

Malaria has been a major public health problem in India. About 95% . population in the country resides in malaria endemic areas and 80% of malaria

reported in country is confined to areas consisting 20% population residing in tribal, hilly, difficult and inaccessible areas. 9 Ten Indian states account f®r 93% of the total disease burden. While Madhya Pradesh, Orissa, Rajasthan, Bihar,

Page no. 32 Andhra Pradesh and Maharastra account for over 80 percent of total cases,

Madhya Pradesh and Orissa alone account for 50 percent of mortality.10 ·

Nearly half of the total malaria cases in India are due too P. falciparum. 11

The Murshidabad district of West Bengal having a population 5.8 million is one of the low endemic districts in the state. During 2006 there were 1658 malaria

<:> cases; plasmodium falciparum infection is as high as 16.5% of total malaria cases and 14 deaths. The annual blood examination rate was 4.8%. 12

We conducted a secondary data analysis on malaria epidemiological situation in Murshidabad with the objectives of ( 1) describing the malaria situation in the district and (2) recommending strategies for planning of control measures.

Methods

Study design

Descriptive study based on secondary data

Study population

The population of the Murshidabad district (n=5.8 million), West Bengal.

Data collection

We visited the district programme officer's office to collect data from the records and reports. We explained the purpose of our exercise and got a verbal permission, and then we proceeded with the data collection. We obtained ten years malaria surveillance data (1997-2006) for all the 26 Block

Primary Health Centers along with the district and state head quarter. We collected data on demographic characteristics from the District Statistical Cell,

Page no. 33 Murshidabad, State Bureau of Health Intelligence, West Bengal and

Demography and evaluation cell of Health department, Govt. of West Bengal,

Swasthwa Bhavan, Kolkata.

Analysis plan

We calculated the following indicators of malaria transmission for the year

1997 to 2006:

1. Annual Parasite Incidence: It was calculated by dividing the total

number of slide positive malaria cases in a year by the total population

under surveillance and expressed it per 1000 population.

2. Annual Blood examination rate: It was calculated by dividing the total

number of blood slides examined for malaria by the total population

under surveillance and expressed it as a percentage.

3. Slide positivity rate: It was calculated by dividing the total number of

slides positive for malaria by total number of blood slides examined and

expressed as a percentage.

4. Plasmodium falciparum percentage: It was calculated by dividing the

total number of slide positive for plasmodium falciparum malaria by the

total number of malaria positive slides and expressed as a percentage.

We calculated age and sex specific incidence of malaria for the year 2006.

We drew seasonal trend of malaria episodes from month wise epidemiological data from 2002 to 2006. We prepared an area map according to annual parasite index. We also collected reports related to drug resistance, insecticide resistance in the district. We calculated case fatality ratio from complicated malaria:

Page no. 34 Results

Disease burden:

The annual parasite incidence (API) in Murshidabad district increased from 0.1 per thousand populations in 1997 to 0.26 per thousand populations per thousand in 2006. Though the ABER showed an increasing trend over last ten years, the rate was less than 10% in all the years. The slide positivity rate • (SPR) showed an increasing trend from 0.09% in 1997 to 0.54% in 2006. The

PF% in the district ranged between 15-21%. During the year 2006,

Murshidabad district contributed 1% of total malaria and 0.6% of falciparum cases of the state of West Bengal. (Table-1, Figure 1 and 3)

Age and sex distribution:

Malaria affected all age groups except the infants. The incidenc~ by sex indicated higher incidence rate among male than females (0.38 versus 0.11 per 1000 population). (Table 2)

Seasonality:

Analysis of month wise malaria incidence of 2002-2006 indicated that malaria transmission occurred in all the months with a seasonal rise from the month of

July and a peak during October (Figure 2).

Backlog of slides:

Analysis of the data regarding blood slides examined and backlog of slides to be examined for the year 2003-2006 revealed that 23%-35% of blood slides were not examined every year (Figure 4).

Page no. 35 The geographical distribution indicated that malaria is a problem in five blocks of the district with two blocks (Bhagawangola-11 and Nabagram block) having

API more than 1 . These five community blocks inhibited by only 19% of the total population accounted for of the 58% of total number of malaria cases,

53% of plasmodium falciparum cases and 57% of malarial deaths. Malaria control activities need to be strengthened in these blocks.

According to the guidelines of the National Anti-malaria Programme, the annual blood examination rate should be 10% or more. In Murshidabad district, the ABER was never more than 5%. Low ABER could be on account of inadequate fever surveillance or due to high backlog of slides to be examined. The situation analysis of the district revealed that only one-third of the male health workers (who are involved in active fever surveillance) were in

position. About 23-35% of the blood slides collected in the district every year were not examined. This might have under-estimated the indicators of malaria transmission like API, SPR~and PF%. The possible reasons for this backlog

could either be due to lack of laboratory technicians in the health facility or due to workload on laboratory technicians. Availability of reagents slides and

microscope was adequate in all the health facilities in the district. It is

'\-- necessary to·· strengthen malaria surveillance in the district especially in the five endemic blocks. It is also necessary that all the health facilities are

provided with adequate number of laboratory technicians.

The study was purely based on the raw data available with the block and

district health administration. We did not examine the completeness of the

Page no. 37 data, functioning of surveillance system, operational issues related to malaria control and quality control mechanism. So it may or may not simulate with the actual malaria situation in terms of distribution and magnitude of malaria related morbidity and or mortality.

Based on our findings, we recommend ( 1) strengthening malaria control activities in five endemic blocks (2) fill up vacancy of male health workers (3) arrange for prompt examination of blood slides by deploying additional laboratory technicians. 0

Page no. 38 Reference:

1. Warrell D A et al, Essential Malariology. Fourth Edition. 2002

2. Hay S. I. et al, Annual Plasmodium falciparum Entomological

Inoculation Rates (EIR) across Africa: Literature Survey, Internet

Access, and Review." Transactions of the Royal Society of Tropical

Medicine and Hygiene, 2004: 113-27

3. Breman, J G et al, Conquering the Intolerable, Burden of Malaria:

0 What's New, What's Needed: A Summary; American Journal of Tropical

Medicine and Hygiene 71, 2004 (Suppl. 2): 1-15

4. Snow et al, The Global Distribution of Clinical Episodes of Plasmodium

falciparum Malaria, 2005; Nature 434: 214-17 "' 5. Twef]tieth Report of the WHO Expert Committee on Malaria, 2000.

Technical Report Series 892. Geneva: WHO

6. Bryce J, the WHO Child Health Epidemiology Reference Group. 2005.

"WHO Estimates of the Causes of Deaths of Children", Lancet 365

(9465): 1114-6

7. Dean T Jet al, Priorities in Health, The World Bank, 2006, Page: 72-76

8. Question and answer sheet, 2006, Nation Vector Borne Disease

Control Programme, Government of India

9. Millennium Development Goals, India country report, world Health

Organisation, 2005, Page: 68-71

1O.lndia Health Report, 2003, Government of India

11. National Health System profile, Government of India; Page, :43-45

12. The Health on March, 2006-07, Department of Health and Family

Welfare, Government of West Bengal

Page no. 39 13. WHO : World Health Report 2002, World Health Organization, South

East Asia region, New Delhi, 2002

14. The public health report, Chief Medical Officer of Health, Murshidabad,

West Bengal

Page no. 40 Figure 1: Year wise distribution of malaria cases in Murshidabad district, West Bengal, India, 1997 to

2006

so -I / Malaria incidence I • 100,000 population

40 Slide positive I U"' QJ 10000 slides U"' - «< u examined Pf cases I 100 0 30 - • blood slides ~- examined E ::::s )( z / Death 20

0 1997 1998 1999 2000 2001 2002 2003 2004 '2005 2006 Year

Page no. 41 Table 1: Comparison of indicators of National anti Malaria Programme of Murshidabad districts, West Bengal, India, 2007

Year BSE Total case PF case Pf% SPR% SfR ABER% API e Death I 1997 98974 524 88 16.8 0.09 0.09 1.9 0.10 0

1998 105980 699 141 20.1 0.136 0.13 2.0 0.13 3

1999 125160 665 122 18.3 0.09 0.10 2.3 0.12 3

2000 144380 652 98 15 0.45 0.07 2.7 0.12 4

2001 183420 768 158 20.5 0.41 0.09 3.1 0.13 2

2002 255064 746 153 20.5 0.292 0.06 4.4 0.127 5

2003 233770 571 94 16.46 0.244 0.04 4.0 0.098 5

2004 236906 931 129 13.86 0.393 0.05 4.04 0.159 7 0 - u 2005 269244 1254 258 20.57 0.46 0.10 4.58 0.21 14

2006 306845 1658 274 16.52 0.54 0.09 4.86 0.26 14

------

Page no. 42 Table 2: Incidence of malaria by age and sex, Murshidabad district, West Bengal, India, 2006

Incidence rate per No of episode Population (in millions) thousands population 2004 2006

Age group (in years) 0-1 0.2 0 0.00

1 or more 6.5 • 1658 0.26

Male 3.43 1290 0.38 Sex ~ Female 3.27 368 0.11

Total 6.7 1658 0.25

Page no. 43 Table 3: Comparison of incidence rates of plasmodium falciparum episodes between six endemic blocks • with other blocks of Murshidabad districts, West Bengal, India, 2007

No of plasmodium Incidence rate of plasmodium Population Blocks falciparum falciparum perthousands (in million) episodes population

Six pla~modium falciparum endemic blocks 1.3 144 0.11

(Bhagawangola-11, Nabagram, Lalgola,

Murshidabad Jiaganj, Domkol)

Other 21 blocks in district 5.4 130 0.02

Total 6.7 274 0.04

II "'

Page no. 44 Figure 2: Seasonal trend of malaria episodes (average of 2002 to 2006), Murshidabad district, West

Bengal, India, 2006

180

160

140

120

V> Q.) ~100 1;....) 0 -"- Q.) 80 ..0 E 60 ;;z:= 40

0 ...... :.4'.4.. ..,0' $.,~· ~e ~ t:::'-..;::,."'<>' ~4.. ~"b-4.. ":...,s....::.... @-'? . ~ ::::o.q;} ~"1>" ~q ":...:::::; ""-CP :::s::>ct> ""'>"?:!;' «e....,...,....,.::::.: ~..:::::; ..,...... _-e;~ oc..; .,:)l.e~ ~e~ Month ~e..,. ~0 <::.::>¢;

Page no. 45 • Figure 3: Year wise ABER and API of Murshidabad distri~t, West Bengal, India, 1997 to 2006

0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year _._ABFR __._API

Page no. 46 Geographical distribution:

Block-wise distribution of malaria cases detected during the year 2006 indicated that five blocks had an API of 0.5/1000 and above (Figure 6). These five blocks accounted for 58% of total number of malaria cases and 53% of plasmodium falciparum cases of the district in the year 2006 (Table 3). These five blocks had an annual falciparum incidence @f 0.11/1 000 as compared to

0.02 per 1000 in the remaining 21 blocks (Table 3).

Drug and insecticide resistance:

There was no report of the studies about drug and insecticide resistance in the district. •l

Mortality:

Mortality data indicated a low case fatality in last ten years. However, the number of deaths due to malaria is increasin~ (Table 1). 8 of the 14 deaths in • 2006 were from the five malaria endemic blocks.

Discussion

Analysis of the secondary data indicated that malaria is low endemic in

Murshidabad district. Distribution of malaria in the district is mainly restricted in five community blocks. There was seasonal variation in the malaria incidence with an increase in post monsoon period when the conditions are favorable for mosquito breeding. Number of malarial deaths in the district is increasing.

Page no. 36 Figure- 4: B.S. collection, examination and backlog in Murshidabad district, West Bengal, India, 2007

450000

400000

3.50000

300000

Vl ""t- 2.50000 0,_ (1) ...;0 200000 E CJ Baddog :::Ji z ra BSE 150000

100000

50000

0 2003 2004 200.5 2006

Year

Page no. 47 Figure 5: Year wise distribution of malaria cases for the year 1997-2006 in Murshidabad district, West

Bengal, India, 2007

1800

1600

1400

5: 1.?00 ro ''-' '-+- ~1000 <1.1 ..0 E::::; 800 c:J Pf z: llllll!l Pv 600

400

200

0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0 Year,

Page no. 48 Figure 6: Block wise distribution of malaria cases for the year 2006 in

Murshidabad district, West Bengal, India, 2007

Annual parasite index 0 to <0.5 0.5 to 1 >1

Page no. 49 Section 2: Second Field Posting

Page no. 50 Evaluation of surveillance of acute flaccid paralysis for poliomyelitis in Murshidabad District, West Bengal, India, 2007

1. Introduction

In May 1988, members of the 41st World Health Assembly (WHA) passed a resolution calling for the global eradication of poliomyelitis by the year 2000 as part of global polio eradication initiative. 1 Over next 18 years, poliomyelitis was eliminated from most of the countries and by the end of 2006, most of the polio cases were reported from eight countries i.e. Nigeria, India, Pakistan, Somalia,

Afghanistan, Namibia, Bangladesh and Niger. Ninety percent of these cases were linked to the polio "hot spots" in Nigeria and lndia.2

By the end of 2000, eight out of 11 member states of the WHO South-East Asia

Region had interrupted wild poliovirus transmission as a part of global eradication effort. India, Pakistan and Afghanistan however continued to report poliomyelitis cases. Bangladesh reported 18 cases after five years of non-polio state in 2006 though all cases were imported and no active transmission was reported .

. Bangladesh is still considered a non-endemic country by the World Health

Organisation. 3

In 2002, the global goal of poliomyelitis was jeopardized as India suffered from

the largest outbreak in history. There was six folds increase of the number of

, cases in 2002 (1600 cases) as compared to 2001(261 cases). In 2005 only 66

Page no. 51 ) cases from 35 districts were reported in India. In 2006 there was another resurgence with 676 cases from 114 districts. In 2007, 860 cases mostly from

0 Uttar Pradesh and Bihar (till 8th February, 2008) were reported.4 Investigations of the 2007 epidemic indicated that a combination of low routine immunization coverage and an insufficient polio campaigns had led to an accumulation of susceptible children, especially in the states of Uttar Pradesh and Bihar. India has achieved significant progress in reducing transmission of wild poliovirus type 1

(WPV1) in 2007. But there has been an increase in cases of the other circulating strain- wild poliovirus type 3. WPV3 has reinfected Bihar after three years. This increase and spread of WPV3 was anticipated in view of the immunization strategy focusing on WPV1 by using mostly mOPV1 since 2005. 5 1n West Bengal, one cases of polio was reported from Murshidabad in 2006. In the year 2007, two cases, one each from Burdwan and South 24 Paraganas were reported.

Moreover there were nine polio compatible cases in the state of which four were from Murshidabad.6

Surveillance is a key component of polio eradication. The challenges for surveillance of acute flaccid paralysis in Murshidabad district include threat of transmission of poliovirus from the adjacent Burdwan district of West Bengal and

Bhagalpur district of Bihar state where one case was reported on 1st September,

2007 as well as fatigue in surveillance activities. In view of this, we evaluated the surveillance system for acute flaccid paralysis in the district. The objectives of the evaluation were to (1) compare the performance indicators of district at different

Page no. 52 levels with the standards of the National Polio Surveillance Project and (2) examine various attributes of the surveillance system.

2. Methods

Description of surveillance system

To describe the surveillance system we reviewed the Field Guide for Surveillance of Acute Flaccid Paralysis, Government of India, September, 20051, and interviewed key stakeholders.

Evaluation of surveillance system

We used the framework proposed by the Centers for Disease Control and prevention (CDC) to review the attributes of a surveillance system. 7 We considered the following attributes to evaluate the surveillance system. We focused on the weekly reports of AFP surveillance of all the 31 reporting units for

2003-2007. We used the following indicators to assess various attributes of the surveillance system of acute flaccid paralysis.

(1) Simplicity: Proportion of health assistants who used the case definition of acute flaccid paralysis and proportion of Medical Officers, Public health nurses who had the knowledge of collection and transportation of stool specimen.

(2) Acceptability: Proportion of health centres providing reports each week. This was assessed for 52 weeks in 2007.

(3) Sensitivity: Proportion of acute flaccid paralysis cases per 100,000 population aged less than 15 years.

Page no. 53 (4) Positive predictive value: Proportion of AFP cases with 2 adequate stools

· taken reported poliomyelitis

(5) Representativeness: Proportion of reporting units reporting acute flaccid

paralysis

(6) Timeliness: (a) Proportion of AFP cases notified with 10 days of onset (b)

interval between notification of a suspected case and starting of investigation and

· (7) Flexibility: Qualitative assessment of whether the surveillance system could be

used for measles surveillance. (Figure 1)

Data collection

The information required for calculating the above· mentioned attributes was

collected through (1) interviews in semi-;,structured questionnaires of randomly

selected health workers at sub centers, health facilities and district officials

conducted during January 2008 and (2) surveillance records and reports during

the period 2003 to 2007 available at health facilities, hospitals and district. We 0

included all the 31 reporting units of acute flaccid paralysis in district Murshidabad

in sampling frame.

To evaluate sensitivity, acceptability, representativeness, timeliness, predicted

value positive and flexibility we visited the national polio surveillance office and all

reporting units. We collected surveillance data and records for the period 2003 to

2007.

Page no. 54 To evaluate simplicity of surveillance system, we interviewed health assistants working in 97 of the 832 sub-centres. This sample size was calculated based on the following assumptions: 50% Heath assistants are using the correct case definition of acute flaccid paralysis for reporting, confidence coefficient of 95% and with confidence interval of.±. 10%. To select these sub-centres, we sorted blocks alphabetically and listed sub centres alphabetically. We selected the first sub centre by simple random sampling. We selected subsequent sub centre s by population proportionate to size method. We interviewed the health assistant

(female) of selected sub centres by pre-tested questionnaire (in local language).

We also interviewed the Medical Officer in-charge of ~mily welfare and the Public

Health Nurse from each of the 31 reporting units.

The principal investigator and ,his team, who was trained in December 2007 in the method, conducted all interviews at reporting units and sub-centres level. We

analysed data was analysed using Excel and EPI 6. J

3. Result

Description of surveillance system

Surveillance for acute flaccid paralysis is one of the key elements of the strategy for polio eradication. The Ministry of Health and Family Welfare recognized the

need to expand and maintain a surveillance system that can monitor the impact of

pulse polio immunization and identify areas to focus supplemental immunization

in the end stage of eradication. In this connection in 1997, National Polio

Surveillance Project (NPSP) was established as a joint collaboration between the

World Health Organization and Ministry of Health and Family Welfare,

Page no. 55 Government of India, with the primary objective to intensify surveillance for polio 0 eradication through detection and investigation of childhood acute flaccid paralysis (AFP). NPSP with a central unit provides guidance, support, co- ordination, and monitoring and data analysis of various activiti~s related to surveillance of polio. The Surveillance Medical Officers headed the NPSU field units. In Murshidabad district, a network of 31 reporting units, which includes health facilities and hospitals, conduct surveillance of acute flaccid paralysis to see possible acute flaccid cases.

Population under surveillance: Children under the age of 15 years (N=

2,236,095) are under surveillance in Murshidabad district.

Case definitions: The following case definitions are used in AFP surveillance:

Suspected AFP case: A case of acute flaccid paralysis is defined as sudden onset of weakness and floppiness in any part of the body in a child < 15 years of age or paralysis in a person of any age in whom polio is suspected.

0 Confirmed Polio cases: An AFP case is confirmed as polio only by the isolation of wild poliovirus from any stool specimen.

Compatible Polio cases: When there is inadequate stool specimen with no wild polio-virus isolated with residual weakness.

Discarded I non-polio AFP case: When there is adequate stool specimen with no wild polio-virus on examination without any residual weakness.

Cases should not be included as AFP if there is no evidence of weakness and floppiness at the time of examination or any time during the course of illness or if the onset of paralysis is more than 6 months prior to notification. The non-polio

Page no. 56 causes of AFP, includes mainly Guillian-Barre syndrome (GBS), Transverse

myelitis, injection neuritis and Traumatic neuritis account for this background rate,

regardless of whether acute poliomyelitis exists in the community or not. It is

estimated that at least one case of non-polio acute flaccid paralysis occurs for

every 100,000 children aged less than 15 years per year as a result of

background rate.

Type of system: As in other parts of India, in Murshidabad district stimulated

. passive surveillance of acute flaccid paralysis is going on. As soon as one AFP

case was reported, two stool samples are collected from acute flaccid paralysis

cases within 14 days of paralysis onset for virological confirmation of paralytic

poliomyelitis. When a case of acute flaccid paralysis is seen late in the field, stool

specimens may be collected up to 60 days after the onset.

Data structure: Each of 31 units in Murshidabad district reports weekly, even

when no case of acute flaccid paralysis has been identified. The units are 18

Block PHCs, nine rural hospitals, three sub-divisional hospitals and one district

hospital. Though block primary health centres and hospitals are main reporting

units all private practitioners (all system), village doctors, health workers,

Anganwari workers and traditional birth attendance are encouraged to report

cases of acute flaccid paralysis.

Feedback: The nodal officer of the reporting unit is responsible for reporting case

of acute flaccid paralysis to the District Maternal and Child Health Officer I

Surveillance Medical Officer using the quickest possible means (telephone/ fax) at

Weekly Report Form (AFP-H002) on Monday of every week. However, verbal

Page no. 57 communication be followed by written information as soon as possible. The

District Maternal and Child Health Officer records all reported acute flaccid paralysis cases in a standard line-listing format. The District Maternal and Child

Health Officer/ Surveillance Medical Officer of each district collects the AFP

H002 forms from all the reporting units collates them in the AFP- D002 form and compiles and transmits this information in the AFP-D001 form to the State EPI

Officer I Regional Coordinator on the Tuesday of each week. State EPI Officer then report weekly to the national level. On Wednesday, the State EPI Officer I

Regional Coordinator collect the information received in the AFP - D001 forms

and the linelist all the district reports in the state. He collates the district reports

received in the AFP S002 form and prepares the state report in the S001 form.

The State EPI Officer transmits same to the Assistant Commissioner

(Immunisation), Ministry of Health and Family Welfare, Government of India, New

Delhi on every Wednesday. Assistant Commissioner (Immunisation), Ministry of

Health and Family Welfare, Government of India, New Delhi to the WHO's South

East Asian Regional Office (SEARO) at New Delhi on every Thursday. (Figure 2)

Action taken: All reported cases of acute flaccid paralysis are investigated by

District Maternal and Child Health Officer or Surveillance Medical Officer within 48

hours of notification, to confirm the presence of acute flaccid paralysis and to

obtain stool specimen for laboratory investigation. The District Maternal and Child

Health Officer or Surveillance Medical Officer fills laboratory request form, ships

specimen to laboratory and conducts active search. All relevant information

gathered in standard form and transmitted to the State EPI Officer.

Page no. 58 The District Maternal and Child Health Officer or Surveillance Medical Officer must revisit every case of acute flaccid paralysis 60 days after onset to determine the presence or absence of residual weakness.

Evaluation of surveillance system

Simplicity: Of 97 health assistants interviewed, 94 (97%) used the correct case definition of acute flaccid paralysis to report cases. All the 31 medical officers

(100%) and 30 public health nurses (26 from Block & four from PP units) (100%)

had the knowledge of collection and transportation of stool specimen.

Acceptability: All the 31 reporting units sent the weekly reports to district for all the

52 weeks.

Sensitivity: The reported AFP rate in the district ranged from 2.21 per 100,000

(2003) to 8.10 per 100,000 (2007) (figure-3). According to NPSP guidelines,

operational target for India for AFP rate is 2 per 100,000 children aged <15 years.

The acute flaccid cases were not reported uniformly through out the district.

During 2007, four of the 31 reporting units reported zero AFP cases while the

AFP rates of seven reporting units were less than 2 per 100,000 children aged

<15 years. (Figure 4)

Page no. 59 Positive predictive value: No wild poliovirus was isolated from the stool samples of any of the AFP cases during the year 2003, 2004, 2005 and 2007. During

2006, poliovirus was isolated from one out of 106 stool samples from AFP cases collected with 14 days of paralysis.

Representativeness: 94.5% (1523/1612) of reporting units reported in time during all the 52 weeks of 2007. An overall analysis of the last year (2007) indicated that among reported cases (N=197), 152 cases (77%) were below 5 years, 116 case patients (59%) were male and 146 cases (74%) were from Muslim community.

(Table-1)

Timeliness:

Reporting units were supposed to report to the District Maternal and Child Health

Officer/ Surveillance Medical Officer on every Monday of all the weeks during the year. The units reported in time varied from 94.5% in 2007., to 100% in 2005.

(Figure 5)

According to NPSP guidelines, AFP cases need to notify within 10 days of onset of paralysis. In Murshidabad district, the proportion of AFP cases notified within

14 days of onset ranged from 77 (2006) to 85% (2007). (Figure 5)

Investigation by the District Maternal and Child Health Officer/ Surveillance

Medical Officer conducted within 48 hours of notification of AFP cases ranged from 85% in 2007 to 100% in 2003 and 2004. (Figure 5)

Page no. 60 Stool sample of AFP cases need to be collected within 14 days of onset of

paralysis. In this district collection of stool sample varied from 73% in 2006 to

86% in 2005. (Figure 5)

Sixty day follow-up was done in 89% in2006 and 2007 to 100% in 2003 and 2004 of AFP cases.

Flexibility: Since 2007, the AFP surveillance network in the district is utilised to

identify cluster of measles cases and their investigation.

4. Discussion

There are several ways of assessing the quality of polio surveillance. The two

most important criteria from a programmatic point of view are ( 1) the reported rate of acute flaccid paralysis per 100,000 children <15 years of age and (2) the

proportion of acute flaccid paralysis cases have adequate stool collected within

14 days. AFP rate in the district during 2002 to 2007 was well above the expected

annual rate of two per 100,000 children <15 years expect 2003 and 2004. In

2007, the AFP rates of eleven reporting units were less than 2 per 100,000

children <15 years. Stool, collected from of AFP cases detected by the

surveillance system within 14 days of onset of paralysis was more than the nation target of 80% for all the years except 2006.

In 2007, though the AFP rate of the district was adequ·ate, four reporting units

reported zero AFP cases while seven had rates less than 2 per 100,000.

Surveillance activities need to be strengthened in these reporting units.

Page no. 61 The surveillance system in the district was representative as all the reporting units sent the AFP reports to the district.

At the reporting units, medical officers and public health nurses had correct

knowledge of stool sample collection from AFP cases and transportation to appropriate laboratory. Most of the health assistants in the district used the case definition of AFP.

Regarding case reporting number of health facilities reporting each week in time and interval between case onset and notification are considered. A persistent

more than eighty percent reported in all 52 weeks reflects high standard of timeliness in reporting. Case notification of cases within 10 days of onset of

.-:J paralysis is above the NPSP standard of eighty percent in all the years except in

2006. Of persisting challenges for polio surveillance are in the area of timeliness.

Surveillance for acute flaccid paralysis is flexible for integration with other

programme, including the integrated disease surveillance programme. A flexible

surveillance system can adapt to · changing information needs or operating

conditions with little additional time, personnel, or allocation of funds and since

2007 the AFP surveillance adopted measles surveillance. Use of the

infrastructure and reporting mechanism is very worthy and time saving so far for

the integrated disease surveillance programme. During 2007, 9 clusters of

measles were identified by the NPSP of which 2 were investigated and confirmed.

Based on the findings of our evaluation we propose the following

, recommendations. First, improve the sensitivity of AFP surveillance in eleven

blocks where AFP rates were less than two.

Page no. 62 Second, maintain the existing sensitive and improve the timeliness surveillance system of acute flaccid paralysis in the final lap of polio eradication.

Third, hold advocacy meetings fo~ the medical community and the network of village doctors for building awareness to increase the AFP case detection as well as prompt reporting.

Page no. 63 Reference:

1. Field Guide, Surveillance of Acute Flaccid Paralysis, 2005, Child Health

Division, Department of Family Welfare, Ministry of Health & Family

Welfare, New'Delhi

2. World polio weekly update, Global Polio Eradication Initiative, 30 January

2008

3. Wild Poliovirus 2000 - 2008 , World Health Organisation HQ, Geneva, as

of 02 Dec 2008

4. AFP Surveillance Bulletin - India, Government of India I National Polio

Surveillance Project, 12th January 2008, website: www.npspindia.org

5. AFP ALERT, National Polio Surveillance Project, (A Government of India-

WHO initiative); Volume: 11, No. 3, October- December 2007

6. AFP fact sheet, 2007 indicators, National Polio Surveillance Project , (A Government of India-.WHO initiative) 7. Introduction to Program Evaluation for Public Health Programs: A Self-

Study Guide, August 2005, Centers for Disease Control and Prevention

Atlanta, GA, USA

8. Reports from National Polio Surveillance Project, Murshidabad, West

Bengal

9. Reports from district and block health institutions, Murshidabad, West

Bengal

Page no. 64 Figure 1: Logical frame indicating surveillance attribute indicators corresponding to different strategies of surveillance of acute flaccid paralysis, Murshidabad district, West Bengal, India, 2007.

Surveillance Case reporting Case investigation attribute Sensitivity No. of acute flaccid paralysis cases per 100,000 under 15 years population Positive Proportion of AFP cases with 2 adequate stools predictive value reported positive by laboratory test Representativeness No. of reporting units reported acute flaccid paralysis Timeliness Reporting units send the AFP reports in time Interval between onset and notification 0 throughout the year Interval between notification of a suspect case and investigation Interval of stool collection and onset of paralysis Follow up of cases at 60-70 days Simplicity No. of health assistant know the case definition of acute flaccid paralysis Acceptability No. of health centres provided report each week Flexibility Qualitative assessment of whether this could be used for others

Page no. 65 Figure 2. Flow chart of feedback system of acute flaccid paralysis report, Murshidabad, West Bengal, India, 2007

j PHC II Practitioners II NGO I ~

Report Form (AFP-H002) on every Monday (block report)

District Maternal and Child Health Officer/ SMO >

AFP-0001 form on every Tuesday (district report)

State EPI officer/ RC (NPSP)

AFP- S001 form on every Wednesday (state report)

Assistant Commissioner (Immunisation)

AFP report on every Thursday (national report)

Regional Director, SEARO

Page no. 66 Figure 3: Reported rcite of acute flaccid paralysis (AFP/1 00000 <15 years population), Murshidabad district, West Bengal, India, 2003-2007

10.00

9.00

8.00

7.00 .s [ Op;r~ti~~al t~~ge~f~r lndi~ >2/1 00,00~ I ~ 6.00 a. LL <( 5.00

4.00

3.00

2.00

1.00

0.00 2003 2004 2005 2006 2007

Year •

Page no. 67 Table 1: Average reported rate of acute flaccid paralysis by age, sex and religion wise, Murshidabad district, West Bengal, India 2007

Population No of AFP cases AFP rate per 100,000

Age group <5 years 1321329 152 11.50

5-15 years 914766 43 4.70

Sex Male 1126518 116 10.30

Female 1109577 81 7.30

Religion Hindu 770775 50 6.49

Muslim 1422970 146 10.26

Others 42350 1 2.36

Total 2236095 197 8.81

Page no. 68 Figure 4: Reporting unit wise acute flaccid paralysis rate, Murshidabad district, West Bengal, India, 2007

Acute flaccid paralysis rate 0 <2 2-<5 5-

Page no. 69 Q

Figure 5: Timeliness of acute flaccid paralysis surveillance, Murshidabad district, West Bengal, India 2003-2007

120 ---RU s repor ting on time

Target in India >80% 110 -.-AFPcases (I) (%} reported within 10 Bc days 8100... -.--Investigation (I) (%)within 48 D.. hrs 90 --i*'-Stool collected (L/0) within 14 80 days

60 ---.------···------. 2003 2004 2005 2006 2007 Year

Page no. 70

~ Evaluation of the existing anthrax control activities in Murshidabad district, India, 2007

1ntroduction

Anthrax is a zoonotic disease caused by a bacterium, Bacillus anthracis. Anthrax usually attacks animals but can also infect humans usually as the result of coming into contact with infected animal hides, fur, wool, leather or contaminated soil. Bacillus anthracis is found characteristically in specific regions in the world called "incubator zones" or "anthrax districts" or "cursed fields"1.

These are areas where infected animals die, contaminate the soils with spores, and these reinfect new animals in a cyclical pattern. Anthrax in humans is classically divided in two ways, a) by occupation of the individual ~ non industrial anthrax, occurring in farmers, butchers, knackers, veterinarians and industrial anthrax~ occurring in those employed in the processing of bones, hides, wool and other animal products, b) by the route by which the disease was acquired, distinguishes between cutaneous anthrax acquired through a skin lesion, gastrointestinal tract anthrax contracted from ingestion of contaminated food, primarily meat from an animal that died of the disease and pulmonary (inhalation) anthrax from breathing in airborne anthrax spores2.

The estimated annual incidence of anthrax decreased from 20,000 to 100,000 in

1958, to 2,000 during 20001'3. Disease is endemic or potentially endemic to 148

Page no. 71 Evaluation of the existing anthrax control activities in Murshidabad district, India, 2007

1ntroduction

These are areas where infected animals die, contaminate the soils with spores, and these reinfect new animals in a cyclical pattern. Anthrax in humans is classically divided in two ways, a) by occupation of the individual - non industrial anthrax, occurring in farmers, butchers, knackers, veterinarians and industrial anthrax- occurring in those employed in the processing of bones, hides, wool and other animal products, b) by the route by which the disease was acquired, distinguishes between cutaneous anthrax acquired through a skin lesion, gastrointestinal tract anthrax contracted from ingestion of contaminated food, primarily meat from an animal that died of the disease and pulmonary (inhalation) anthrax from breathing in airborne anthrax spores2.

The estimated annual incidence of anthrax decreased from 20,000 to 100,000 in

1958, to 2,000 during 20001.3. Disease is endemic or potentially endemic to 148

Page no. 71 associated with the cutaneous anthrax is contact with raw meat of ill cattle. There is no anthrax control programme in India as the disease is not a public health

problem. Anthrax control programme however is needed for those areas that are endemic. Being a zoonotic disease, involvement of the health as well as veterinary department is necessary for such control programmes.

According to World Health Organization, the model anthrax control programme in

c any area should include (1) correct disposal of anthrax carcasses, (2) infection control in the management of human anthrax cases, (3) disinfection, decontamination and disposal of infected/ contaminated material, (4) human and

animal prophylaxis, 5) intersectoral iss~es and (6) surveillance in animal2. We

assessed anthrax control and prevention activities in Murshidabad district and

compared them with that of the WHO model control programme. The finding would be useful in formulating a model control programme in the district.

Methods

Description of the programme

Though there is no anthrax control programme in India, however as a

consequence of anthrax outbreaks in human and cattle in Murshidabad district,

several preventive and control measures have been initiated. We discussed

different oper,ational issues of the ongoing prevention and control activities in

Murshidabad district with programme managers of health and veterinary

departments at district and block level.

Pageno. 73 We also reviewed in detail thE! Guidelines for the Surveillance and Control of

Anthrax in Human and Animals, 3rd edition, World Health Organization, 1998.

Indicators used

We prepared a logic model based on the anthrax control programme prescribed by the WHO. We used the following indicators to assess the on-going situation of anthrax control activities in the district.

Input indicator 0

Our input indicators, included the proportion of veterinary surgeons and veterinary field worker in position and trained in correct disposal of anthrax carcasses, percentage of medical officers in position and trained on diagnosis and treatment of anthrax, Proportion of laboratory technician trained on confirmation of human anthrax,

Proportion of multipurpose health worker who knew the case definition for suspected anthrax, Proportion of laboratories having facilities for microscopic examination to confirm human anthrax cases, Proportion of PHCs that can treat anthrax cases, the proportion of health facilities with adequate stock of anti-anthrax drugs, disinfectants and materials for information, education and communication. (Figure 1)

Process indicator

Our process indicators included the proportion of suspected anthrax cases investigated for microscopic examination, the proportion of anthrax patient treated with correct anti-anthrax drugs at health facilities, proportion of anthrax carcasses disposed correctly etc.

Page no. 74 Output indicator

Our output indicators included proportion of anthrax cases cured after treatment, proportion of population having correct knowledge about the disease, proportion

0 of vaccination sessions held, proportion of affected area disinfected, proportion of

Joint action team formed, proportion of animal isolated etc.

Outcome indicator

Our impact indicators included case fatality rate, proportion of livestock handlers protected and Proportion of animal population vaccinated.

Survey

We conducted a survey at all blocks of district. We selected thirty-five villages with a probability proportional to population size. We calculated the sample size of

525 by using Right size software, assuming the highest possible utilization rate of health services at the community level at 50% (as there was no data available about the percentage of utilization of the services), cluster size- 15, confidence coefficient 95%, confidence interval ± 5% and anticipated proportion of non- response of 5%. In each household we selected one adult above the age of 20 years randomly for interview. If any household was locked or no adult was available, we collected data from the next house. We also selected sub centers, veterinary centers and health care facilities in which the population of the sample had access to. We used pre-tested questionnaire to collect information from the district, health facilities, sub centers and the community. We translated pre-tested questionnaires of sub center and household into Bengali. The principal

Page no. 75 investigator and his trained staffs conducted the interview. We analyzed evaluation data by using excel and EPI 6. We also analyzed programme data routinely reported from the sub center to the district.

Results

Q WHO- Model Anthrax Control Programme

The basic strategy of model anthrax programme was: 1) correct disposal cf anthrax carcasses, 2) infection control in the management of human anthrax cases, 3) disinfection, decontamination and disposal of infected/ contaminated material, 4) prophylaxis, 5) intersectoral issues and 6) surveillance in animal.

Disposal of anthrax carcasses: The most preferred method of disposal of an anthrax carcass is incineration, burial is the best alternative.

Infection control in the management of human anthrax cases: Cutaneous anthrax lesions need to be dressed for the first 24- 48 hours after treatment with antibiotics. Penicillins, Doxycycline, Ciprofloxacin are the antibiotics of choice.

Disinfection, decontamination and disposal of infected/contaminated material: Disinfection, decontamination and correct disposal of infected/contaminated material are required to prevent transmission of anthrax.

Anthrax contaminated materials as bedding, feed stuff, manure should be incinerated or autoclaved. Immersion in 4% formaldehyde for >12 hours is an alternative. Disinfection of contaminated surfaces is a three step approach aimed at (i) preliminary disinfection, (ii) cleaning and (iii) final disinfection. 10% chlorine solutions may be used for laboratory. Soil at the site of an anthrax carcass should be removed up to a depth of 20 em and incinerated or heat treated. Hides and

Page no. 76 skins should be decontaminated by formaldehyde or ethylene oxide fumigation or

by irradiation prior to processing.

Prophylaxis: (A) Animal vaccines: The protective effect of a single dose of

vaccine is said to last about 1 year and annual boosters are recommended in

endemic areas. (B): Human vaccines: Human vaccine is for persons at risk,

particularly in industries concerned with processing- of animal products from

endemic regions.

lntersectoral issues: lntersectoral cooperation between the general

administration, health department, animal resource development and above all

the three tier Panchyat Raj system is very much necessary to tackle the anthrax

problem.

Surveillance in animal: Routine cross notification and close collaboration during

epidemiological investigations between the veterinary and health sectors should

0 be the rule.

Action in the event of an outbreak of anthrax in livestock: The carcasses of

infected cattle are burnt at the site of death. Other animals are to be vaccinated

with a buffer zone of 20-30 km wide. Affected cattle are to be quarantined for 20

days after last case or 6 weeks after vaccination, whichever is later. Milk collected

from a cow showing a sign of anthrax within 8 hours of milking is to be destroyed.

People entering infected properties are required to wear protective clothing and

footwear.

Precautions for exposed personnel: People, who have to handle animals

known to be, or suspected of being infected with anthrax, or carcasses, should be

Pageno. 77 vaccinated against anthrax if available. Avoid all blood spilling operations including slaughtering on infected or suspected animals I carcasses. Use protective clothing such as strong gloves, boots, coveralls, etc. to avoid direct contact with infected I contaminated materials. Properly dress skin lesions before putting on the protective clothing. Equipment used must be adequately disinfected or appropriately destroyed. Avoid any contact with other persons or animals, without first changing clothing, washing hands, and taking appropriate disinfection measures. Report to a physician any suspicious symptoms appearing after contact with infected animals or materials for early diagnosis and prompt treatment.

Anthrax control activities in Murshidabad

Input indicator

Correct disposal of anthrax carcasses: Of the 35 sanctioned posts of Veterinary field workers in the selected villages, 23 (66%) were in position. Neither the veterinary field workers nor the Veterinary surgeons in the district received any training on anthrax. There was no IEC material on anthrax at the block or district animal health centers. Thirteen of the 35 (46%) villages surveyed had burial ground for cattle. ·

Infection control in the management of human anthrax cases: 89% of the Medical

Officers and 94% of the multipurpose health workers were in position. The facility for laboratory diagnosis of anthrax is available only at the district diagnostic and

Pageno. 78 public health laboratory. Nineteen of the 24 Medical Officers (from 11 of the 16

BPHCs/PHCs) knew the clinical presentation of anthrax and treatment of the cases. None of the Medical personnel in the district received any training of diagnosis and management of anthrax cases.

Disinfection, decontamination and disposal of infected/contaminated material: All the blocks had bleaching and lime as disinfectant for contaminated material.

Prophylaxis: No vaccine is available for individuals at higher risk of acquiring the disease. Vaccine for animals is available in the district and is generally administered after human or animal outbreaks.

lntersectoral issues: No joint team is formed at the district or block level for anthrax control activities.

Surveillance in animal: 71% of the veterinary surgeons in the selected area were in place. None of the veterinary officers was trained on diagnosis and treatment of anthrax. Routine surveillance for anthrax is not conducted. However, after animal outbreaks, veterinary laboratory technicians confirm the cases. The facility for laboratory confirmation is available in three out of four laboratories in the district.

Process indicator

Correct disposal of anthrax carcasses and disinfection, decontamination and disposal of infected/contaminated material: Seven of the 23 (30%) veterinary

Page no. 79 worker knew the correct disposal of anthrax carcasses. None of the 16 burial grounds had incinerator.

Infection control in the management of human anthrax cases: During 2007, five of

17 outbreaks were laboratory confirmed. All the human anthrax cases were treated with antibiotics. All the PHCs are maintaining treatment card and registers of suspected anthrax cases.

Output indicator

During 2007, thirty two cattle died during 18 anthrax outbreaks, 14 (44%) of which were buried six feet deep with lime. The rest of the dead animals were thrown in the open space. A total of 315 suspected anthrax cases were treated in the district during 2007. All except two got cured. Of the 525 individuals interviewed during the survey, 163 (31%) had heard about symptoms if animal develops animal anthrax (Tarka). They however were unaware about the correct disposal of carcasses of animal died with symptoms of Tarka or disposal of contaminated material. Of the five laboratory confirmed human outbreaks in the district, only one outbreak was followed by vaccination in animal population. 0

Outcome indicator

In 2007, two of the 315 suspected cases died with a case-fatality rate of 0.6%.

Only thirteen percent of the animal population was vaccinated after one human

outbreak in 2007.

Page no. 80 0

Discussion

There are human anthrax outbreaks reported in every year at Murshidabad since

long. The district reported 304 cases of human cutaneous anthrax between 2003

and 2006 (un-published data) and 315 cases from 17 outbreaks in 2007. In 1998,

the district health authorities organized for anthrax diagnosis in the district. Mainly

six blocks namely, Domkol, Hariharpara, Kandi, Jalangi, Bhagawangola-1,

Beldanga-1 are endemic though other blocks are susceptib1e.

In this district 64% population was constituted by the Muslim community. All most

all human anthrax cases were from this community. The poor people are in a

habit to slaughter the ill looking cattle as there is no value of dead cattle.

The slaughtering and handling of meat of ill cattle made the people vulnerable to

cutaneous anthrax mostly.

There was well defined health as well as veterinary infrastructure in this district.

Manpower as well as laboratory facilities are available there. The available

infrastructure may be strengthened to make the anthrax control activities of the

district a model anthrax control programme as prescribed by the World Health

Organisation.

To make this existing anthrax control activities a model programme the following

steps are recommended.

First, we have to arrange training for the veterinary surgeons and the veterinary

field workers on correct disposal of anthrax carcasses, surveillance in animal and

confirmation animal anthrax. Second, we have to arrange training for the medical

Page no. 81 officers and multipurpose workers on case diagnosis, case suspect, confirmation and treatment.

Third, we have to organize the informq,tion, education and communication campaigns primarily targeting to the people of endemic blocks and later on in the whole district.

Fourth, we have to vaccinate all the cattle yearly in the endemic areas and in areas where the human or animal outbreak will be reported keeping a buffer zone on 20-30 km radius.

Page no. 82 References,

1. Untilled document, http://www.vetmed.wise.edu/pbs/zoonoses/anthrax/

anthrax index.html

2. WHO, Guidelines for the Surveillance and Control of Anthrax in Human

and Animals. 3rd edition, World Health Organization, Emerging and other

Communicable Diseases, Surveillance and Control, 1998

3. www.gideon.com- Global Infectious Disease and Epidemiology Network

4. The Control of Neglected Zoonotic Diseases, A route to poverty alleviation,

Report of a Joint WHO/DFID-AHP Meeting with the participation of FAO

and OlE Geneva, 20 and 21, September ~005

5. World Anthrax data Site, A Service of the WHO Collaborating Centre for

Remote Sensing and Geographical Information System for Public Health,

www.vetmed.lsu.edu/whocc/mp-world.htm

6. Guidelines for Prevention and Control of Anthrax, Zoonosis Division,

Organization (2006)

7. Public health report, Department of Health & Family Welfare, West Bengal

(unpublished data)

8. Rao GRR et al, An outbreak of cutaneous anthrax in a non-endemic

district- Visakhapatnam in Andhra Pradesh, Indian Journal of Dermatology,

Venereology and Leprology; Year: 2005, Volume: 71, Issue: 2

9. lctihpujani RL, An outbreak of human anthrax in Mysore (India), J Commun

Dis. 2004 Sep;36(3):199-204

Page no. 83 10.Thappa DM, An outbreak of human anthrax : a report of 15 cases of

Cutaneous anthrax, Indian Journal of Dermatology, 2000- Vol- 45, Issue- 4

11. Vijaikumar M et al, Cutaneous Anthrax: An Endemic Outbreak in South

India, Department of Dermatology and STD, Jawaharlal Institute of

Postgraduate Medical Education and Research (JlPMER), Pondicherry,

India

Page no. 84 Figure 1: Logical frame indicating input, process, output and outcome indicators corresponding to different strategies of anthrax programme, Murshidabad district, West Bengal, India, 2008 1. Correct disposal 12. Infection control in the management of 13. Disinfection of 4. 15. I 6. Surveillance in of anthrax human anthrax cases contaminated Prophylaxis Intersect Animal carcasses material oral issues Input Proportion of Proportion of medical officer in position Proportion of Availability Proporti Proportion of veterinary field Proportion of medical officer trained on health facilities of human on joint veterinary surgeons wor~er in position diagnosis and treatment with adequate vaccine team at in position Proportion of Proportion of health facilities with adequate stock of Availability district Proportion of veterinary field stock of anti-anthrax drugs disinfectants of animal level veterinary surgeons worker trained Proportion of laboratory technician trained on vaccine formed trained Number of IEC confirmation Proporti material Proportion of multipurpose health worker who on of Percentage of knew the case definition for suspected anthrax joint villages with burial Proportion of laboratories having facilities for team at ground microscopic examination.to confirm human block anthrax cases level Proportion of PHCs that can treat anthrax o formed cases Process Proportion of Proportion of outbreaks confirmed Proportion veterinary worker Proportion of anthrax cases treated of knew the correct Proportion of PHCs maintaining treatment card vaccination disposal and registers sessions Proportion of burial held ground with facility of incinerator Output Percentage of Proportion of anthrax cases cured after Proportion of Proportion Proportion of cattle buried out of treatment affected area of animal population having died due to anthrax disinfected vaccinated correct knowledge about the disease Proportion of animal isolated Outcome Case fatality rate·· Proportion of livestock handlers ~rotected

Page no. 85 Table 1. Selected indicators of correct disposal of anthrax carcasses of the national anthrax programme evaluation, Murshidabad district, West Bengal, India, 2008

Indicators n/N %

Input Proportion of Veterinary field worker in position 23/35 66% Proportion of veterinary field worker trained 5/23 22% Number of IEC material 0 0% Proportion of village with burial ground 16/35 46% Process Proportion of veterinary worker knew the correct disposal of anthrax carcasses 7/23 30% Proportion of burial ground with incinerator facility 0/16 0% Output Percentage of cattle buried out of died due to anthrax * 14/32 44%

* The veterinary department arranged lime and bleaching powder and deep burial.

Page no. 86 Table 2. Selected indicators of infection control in the management of human anthrax cases of the national anthrax programme evaluation, Murshidabad district, West Bengal, India, 2008

Indicators n/N %

Input Percentage of medical officer in position 24/27 89% Proportion of medical officer trained on diagnosis and treatment 0/24 0% Proportion of health facilities with adequate stock of anti-anthrax drugs 16/16 100% Proportion of laboratory technician trained on confirmation 0/6 0% Proportion of multipurpose health worker in position 33/35 94% Proportion of multipurpose health worker trained in case suspect 0/33 ·a% Proportion of laboratories having facilities for microscopic examination 1/6 17% Proportion of PHCs can treat cases 11/16 67% Process Proportion of outbreaks confirmed in the district 5/17 29% Proportion of anthrax cases treated in the district 315/315 100% Proportion of PHCs maintaining treatment card and registers 11/11 100% Output Proportion of anthrax cases cured after treatment 313/315 99% Outcome Case fatality rate in the district 2/315 0.6%

Page no. 87 Table 3. Selected indicators of disinfection, decontamination and disposal of infected/ contaminated material of the national anthrax programme evaluation, Murshidabad district, West Bengal, India, 2008

' Indicators n/N %

Input Proportion of health facilities with adequate stock of disinfectants 23/23 100% Output Proportion of affected area disinfect~d decontaminated and disposed in district 14/32 44%

Page no. 88 0 Table 4. Selected indicators of prophylaxis of the national anthrax programtne evaluation, Murshidabad district, West Bengal, India, 2008

Indicators n/N % Input Availability of human vaccine Not available Availability of animal vaccine Available at district Process Proportion of vaccination sessions held 2/18 11%

Output Proportion of animal vaccinated 76/593 13%

Outcome Proportion of livestock handlers protected 0/488 0%

Page no. 89

~---~--.=.-:; Table 5. Selected indicators of intersectoral issues of the national anthrax programme evaluation, Murshidabad district, West Bengal, India, 2008

Indicators n/N % Input Proportion of district team formed 0/1 0% 0/5 0%

0 Page no. 90 u Table 6. Selected indicators of surveillance in animal of the national anthrax programme evaluation, Murshidabad district, West Bengal, India, 2008

Indicators n/N %

Input Proportion of veterinary officer in position 10/14 71% Proportion of veterinary officer trained on diagnosis and treatment 0/10 0% Proportion of population having correct knowledge about the disease Output 163/525 31% Proportion of animal isolated 0/46 0%

Page no. 91 Section 3: Outbreak investigations

Page no. 92 An outbreak investigation of Measles at Dihigram village of

Murshidabad district, West Bengal, India, 2007.

Introduction

Measles is an acute viral infectious disease. Measles virus is a paramixovirus of genus Morbillivirus. The incubation period of measles is from 10 to 12 days.

Complication may arise in approximately 30% of measles cases, common in childrerf less than 5 years of age. Measles is the leading cause of childhood morbidity and mortality from vaccine preventable diseases. The case fatality rate ranges from 0.06 to 2.2 per 1000 cases in population with good nutrition and medical care to as high as 20 to 150 per 1000 in developing countries, where malnutrition is prevalent. Failure to deliver at least one dose of measles vaccine to all infants remains the primary reason for high measles mortality and morbidity in developing countries 1.

In 2006, 373,421 measles cases were reported throughout the world2. World health Organisation estimated that measles vaccination coverage reached 80% . for the first time in 2006 in world. Despite this progress, in 2006, an estimated

26.2 million (20%) infants worldwide missed receiving their first dose of measles vaccine through routine immunization services by age 12 months. Of these, 12.8 million (49%) resided in the WHO South-East Asia Region. A 56% decrease was observed in the number of reported measles cases worldwide in 2006 (373,421 ), compared with 2000 (852,937). The number of reported cases in the South-East

Asia Region increased from 78,574 in 2000 to 94,562 in 2006. From 2000 to

Page no. 93 2006, estimated measles deaths worldwide declined 68%, from 757,000 deaths in

2000 to 242,000 deaths in 2006. The reduction in the South-East Asia region was only 26% because certain countries with large populations (e.g., ~India and

Pakistan) had not yet begun large-scale measles SIAs and because little improvement in routine vaccination coverage had occurred. The immunization coverage of South East Asia region was 65% in 20063.

In 2001, WHO and UNICEF adopted a strategy for measles mortality reduction and regional elimination. The goal of this strategy was to reduce measles 0) mortality by 50% in 2005 relative to 1999 estimates. Four components of the strategic plan were 1) achieving at least 90% routine vaccination coverage with at least one dose of measles vaccine, 2) provision of second opportunity for measles vaccination for all childre~, 3) measles surveillance and 4) improved management of complicated cases4. Approximately 15% of children vaccinated at

9 month and 5%- 10% of those vaccinated at 12 months of age are not protected after vaccination.

In India, though measles immunization started since 1985 as part of Universal

Immunisation Programme throughout the country, only 58.8% children of 12-23 months of age have received measles vaccine in 20055. And 60,751 cases were

reported in 20064. The immunisation coverage as estimated by World Health

Organization was 67% in 2006. National Strategic Plan for Measles Mortality

Reduction was formulated in 2005 with the objectives of 1) achieving 90% vaccination coverage in 90% of the districts, 2) reducing the measles mortality by two-thirds by 2010, compared to 2000 estimates, 3) establishing effective

Page no. 94 measles surveillance, 4) improving management of measles cases, including

vitamin A supplementation and 5) consideration a second opportunity for "' measles6.

In West Bengal 74.7% children 12-23 months of age have received measles

vaccine in 2005-065.

In Murshidabad there were more than 5000 measles cases, about one third of the

state of West Bengal, in ea"ch year7·8 . The minority community population was

64%. There were also 5,597 measles cases and 4 deaths due to measles were

reported in under 5 years with case fatality rate of 0.1% in 2006-078.

The Block Medical Officer of Health, Suti-11 sent the information of suspected 14

measles cases from Dihigram Bagan para village on 5th May 2007. We

investigated the outbreak to (1) estimate the magnitude of the outbreak, (2)

improve the management of cases (3) analyse data including estimation of

vaccine efficacy and (4) propose recommendations for control.

Methods

Descriptive epidemiology

We collected information on background data of measles, population movement,

change in surveillance system from the Block Medical Officer of Health, Suti-11

block.

Case definition: We defined a case of measles as occurrence of fever and

maculo-papular non-vesicular rash with at least one of the following cough,

Page no. 95 coryza (running nose) or conjunctivitis (red eyes) among residents of Dihigram,

during the period 6th April, 2007 to 8th June, 2007.

"' Case search: We contlucted an active house to house case search. We collected

information from the parents of cases on age, sex, residence, date of onset,

vaccination status of children, symptoms, sign, post measles complication and

outcome of cases. Complications and deaths were considered as a sequel of

measles if these occurred within 30 days of onset.

We examined the dynamic of the outbreak through the construction of an

epidemic curve. We draw a map of the village by location of households to show

the distribution of measles cases by residence.

Laboratory investigation: We collected sera samples from 11 case-patients and

sent to the National Institute of Virology, Pune under cold chain for serological

confirmation.

Analytic epidemiological

We conducted a retrospective cohort study. Our study population was the children

upto 10 years of age of Dihigram village.

Our null hypothesis was that the measles vaccine was not associated with any

protection against the disease. Our exposure variable was the vaccination status.

Our outcome variable was the disease status. To ascertain the immunization

status we either reviewed the immunization card or interviewed mothers where

the immunization card was not available.

We estimated vaccine coverage in that area. We calculated the attack rate among

immunisaed and unimmunised. We calculated the vaccine efficacy and its 95%

Page no. 96 confidence interval (CI) among children aged 9 month- 10 years using the following formula.

Results

Descriptive epidemiology

The immunization coverage was only 27%. We identified 32 case patients among all 332 children with an attack rate of 9.6%. 9 out of 11 sera, sent to NIV, Pune, were confirmed serologically.

The median age of the cases was 3 years with a range of 6 months to 9 years.

The attack rate in males was more (10.6%) than females (8.8%). The attack rate

0 of 9-12 months children was highest, 33.3%. Out of 32 case patients 4 were" vaccinated. Almost 44% (38/87) children had complication after measles. Almost

15 (44%) children had complications. The most common complications were respiratory tract infection 47% (7/15), followed by diarrhoea 27% (4/15). Vitamin-

A in oil was given to all cases as per WHO guideline.

The first case occurred on 13th April, 2007 and the last case occurred on 4th June,

2007. The Epidemic curve showed a propagated type of outbreak (Fig-1 ). Spot map showing distribution of measles cases by household, showed aggregation of cases at the eastern side of the village near the mosque. (Figure-2).

We knew from the members of the community and the local health staff, that the area was resistant to Intensified Pulse Polio Immunization programme previously.

All villagers are from the religious minority community. Among the villagers 88% of the villagers are engaged in making bidi (local cigarettes).

Page no. 97 Analytic epidemiological

We included all 332 children aged upto 10 years in the village for our cohort study. Among the children 90 (27%) had received measles im!;llunization and 242

(73%) were unvaccinated. The fore most causes for non- immunization is fear to was time and wedge (44%) and unaware for immunization (28%).

Attack rate among immunised children was 4.4% and among non immunised children was 11.6%, and the relative risk was 0.38 (95% C.l.: 0.14- 1.06).

Vaccine efficacy: The calculated of vaccine efficacy was 64% (95% Gl: 0.1% to

87%).

Discussion

A measles outbreak affected the Dihigram village of Suti- II block in the district of

Murshidabad between April, 2007 and June, 2008. The age group mostly affected was 9-12 months. The attack rate among males was higher than females. The

relative risk of getting measles among non immunised was 2.6 times higher than the immunised children. About half of the children suffered from complications.

The immunization coverage of the village was very poor. The results of the

investigation indicated that the outbreak occurred in a population with low vaccine

coverage. Poor delivery of immunization services and I low demand in community

might be the cause of this low vaccine coverage. The possible reasons for poor

participation in immunization activities by the religious minority community must

Page no. 98 be explored and all efforts will have to be taken to improve immunization

0 coverage.

In addition, there was also low vaccine efficacy. The cause of poor vaccine efficacy may be due to cold chain failure. It was likely that there had been a cold chain failure or that reconstituted vaccine had been kept in the refrigerator and later used or that there was a problem with the original potency of the vaccine

(inappropriate immunization practices). Review of cold chain system including the programmatic features might be investigated further to rule out the inappropriate immunization practices.

There was no death. We treated the cases and referred the complicated cases during our investigation to nearest health centre. It suggests that there was need of appropriate treatment for complicated cases at the hospital.

In spite of our efforts we have some limitations in our study "'1) as 58% of the immunization cards were missing we had to depend on interview of the parents,

2) we could not gather data for calculating the coverage among bidi workers and

3) we could not search details of cold chain status.

This outbreak investigation provided us the opportunity to recommend 1) to strengthen routine immunization by arranging vaccination at door steps, in local club, mosque and Anganwari centres, 2) to look into the cold chain status and injection practices, 3) to raise awareness of vaccination among village people by involving local community leaders and the bidi merchant association, 4) to manage cases effectively and 5) improve measles surveillance.

Page no. 99 countries3. Human cases of anthrax are mostly found in Africa, the Middle East and central and southern Asia2. Of 60 countries reporting anthrax in 2004, nearly

60% were developing countries4. Asia reported 880 cases and 14 deaths in 2006.

The Southeast Asian region reported 1,626 cases ( 130 fatal) during 1961 to

19703. The disease is most common in regions of animal husbandry and processing of meat, wool and hides.

0 India is an endemic zone for anthrax and reported human anthrax cases every year. In the recent past, the maximum number of cases were reported in 2003

(100 cases including 8 deaths) 5. Anthrax is enzootic in southern and eastern

India but is less frequent in the northern Indian states. In the past years, anthrax cases have been reported from Andhra Pradesh, Jammu and Kashmir, Tamil

Nadu, Orissa, Karnataka and West Bengal7.

The state of West Bengal reported 102 cases in 2006 of which 71 cases were from Murshidabad districf. There may be loss of data during transmission. The disease is known locally as "T arka". Outbreaks of cutaneous anthrax are frequently reported in the district. In 2007, there were total 17 outbreaks of cutaneous anthrax at different villages of Murshidabad district with 315 cases7.

The mode of transmission is handling meat of ill cow or ill goat before cooking.

Among the outbreaks in 2007, five were laboratory confirmed7•

Anthrax is endemic in few districts of India including Murshidabad7•8•9·10•11 .

Cutaneous anthrax is the commonest form of the disease in India, though a few

cases of gastrointestinal anthrax were also reported. The common risk factor

Page no. 72 References,

1. WHO UNICEF Measles mortality reduction and regional elimination.

Strategic plan 2001-2005. WHON&B/01.13 March 2003

2. WHO, Programmes and projects, Immunization surveillance, assessment

and monitoring, Vaccine-preventable diseases, 2006 global case.htm

3. Centers for Disease control and Prevention (CDC), Progress in Global

Measles Control and Mortality Reduction, 2000-2006, Morbidity Mortality

Weekly Report, November 30, 2007 I 56(47); 1237-1241

4. WHO-UNICEF. Measles mortality reduction and regional elimination. 0 Strategic plan. WHON&B/01.13 Rev. 1, 2001

5. Nation Family Health survey-Ill, 2005

6. Measles Mortality Reduction, India Strategic Plan, 2005-2010, Ministry of

Health and Family Welfare, Government of India

7. Government of West Bengal, Department of Health & Family Welfare,

unpublished data

8. Government of West Bengal, Department of Health & family Welfare,

Murhidabad district, unpublished data

9. Report from office of the Block Medical Officer of Health, Mahesail BPHC,

Suti-11 Murshidabad, unpublished data

Pageno. 100 nf ...... :s ...... 0 c L-9 0 :::::: -; 9-17 Q) v C) c: ~ ~ c ""') 0... Q) £-Z lXI ~-~£ -1/) ;: OC-6G gz-a; "0co .c co 9G-9G :2 .c vZ-£2: ~ :::l 2 zz-~z E OG-6~ ...co C) 9J..-L~ >- .c co 9~-9~ 0 ~ 0 1/) v~-£~ Q) - 1/) 0 0"' co z~-~~ (J N 1/) 0~-6 -J: ..! (I) 1/) nl co 9-L a.. Q) E c: 9-9 ·-~ --~-~--- (I) 0 -c 17-£ 0 ..:::l .c 'i: ,._0 .!!! - sz-Lz 0 "0 Q) Q) ~ E 9G-9G nl .. ----- 0 vZ-£2: .c~ zz-~z 'i: a; Q. ...> <{ :::l OG-6~ (J ·e(J 9~-L~ Q) 9~-9~ "0 ·a N v~-£~ w -('/') ~ II z~-~~ """e c ~~~, ~--~-- ~ -~------~ -......

Fig 2, Spot Map, by place distribution, . by time distribution of measles cases, Dihigram, Murshidabad, West Bengal, India, 2007, (n= 32) West t

liD D .r"----__,0 D D

D D D Ill D D D D D D oo D D D D D D D D D D D D D D II D D D D •D D D D D •oo D oo D D .o D II D D oo D .o D D D D o••o• D lb D D • D D • D D oDD D D D D

Ill House with one case • House with two cases • House with four cases

Pageno. 102 Fig 2, Spot Map, by place distribution, by time distribution of measles cases, Dihigram, Murshidabad, West Bengal, India, 2007, (n= 32) West t

~ House with one case Ul House with two cases • House with four cases

Page no. 102 Table 1, Incidence of measles by age & sex, Dihigram, Murshidabad, West Bengal, India, 2007

No of cases Population Attack rate (%)

0-<9 months 2 32 6.2 9-12 months 7 21 33.3 Age 13-24 months 4 0 43 9.3 25-60 months 14 101 13.9 61-120 months 5 135 3.7 Male 17 161 10.6 Sex Female 15 171 8.8

Total Total 32 332 9.6

Page no. 103 Table 2: Attack rates of measles by age and vaccination status, Dihigram, Murshidabad, West Bengal, India, 2007

Children immunised against measles Children not immunised against measles

Age group Attack rate Attack rate (month) Cases Total Cases Total (%) (%) "

0-<9 0 0 0 2 32 6.3 9-12 0 7 0 7 14 50 13-24 0 19 0 4 24 16.7

25-60 4 39 10.3 10 62 16.1

61-120 0 25 0 5 110 4.6

Total 4 90 4.4 28 242 11.6

Page no. 104 CUTANEOUS ANTHRAX OUTBREAKS IN TWO VILLAGES OF MURSHIDABAD, WEST BENGAL, INDIA, 2007: THE DANGER OF UNSAFE HANDLING OF INFECTED COW MEAT

Introduction

Anthrax is a zoonotic disease that affects primarily herbivores 1. It is caused by

spore-forming, gram positive bacteria called Bacillus anthracis1• Spores are

present in contaminated soils and contaminated animal products 1• Herbivores I'

acquire infection while grazing and may develop septicemia. After death, the

vegetative form is present in the meat and body fluids and the spores may be

present on the hides. Carcasses and remains may contaminate soils 1. However, it

is not exclusively infrequent in dogs, scavenging anthrax carcasses and in

carnivorous animals in zoological gardens and wildlife sanctuaries or parks 1. In

·· humans, the disease manifests itself in three forms: cutaneous, pulmonary and

intestinal. Cutaneous anthrax accounts for 95% of the cases1 • Handling

contaminated meat, hides or skins may lead to inoculation of vegetative form 1 or

spores through cuts and abrasions and cause the cutaneous form. Heating at

100°C for 10-60 1 minutes kills spores and the vegetative form.

It has been estimated that globally, 20,000 to 100,000 human cases of anthrax

occur annual!/. At least 2,000 cases were estimated for the year 2000 (personal

communication with Martin Hugh-Jones, Professor Emeritus , Department of

Environmental Sciences , School of the Coast & Environment, Rm 2279, Energy,

Coast & Environment Building Louisiana State University, Baton Rouge, LA

70803-5703, USA, email: Martin Hugh-Jones, [email protected]). In 2004,

Pageno. 105 sixty countries mostly from Africa, Middle East, Central and Southern Asia reported human anthrax1·3 In 2006 India reported 17 cases4. The majority of the

Indian population follows Hinduism and abstains from eating beef. However, several states, including Jammu and Kashmir, Orissa, Andhra Pradesh,

Tamilnadu and West Bengal reported human outbreaks5. Most of these occurred among non-Hindus who eat beef or in a poor Hindu village as of Harijans

("untouchables")6 or among workers who handle skin; wool. India does not have a . nationally organized control programme as occurrence is focal, affecting only a small number of districts. As a consequence, human anthrax is not a national notifiable disease.

In the Murshidabad district of West Bengal (2007 population: 67,02,000), 64% of the population is Muslim. The district reported 304 cases of human anthrax between 2003 and 2006 (un-published data). In 1998, the district health authorities organized for anthrax diagnosis in the district. On 8 June 2007, the

Domkol Block Primary Health Centre reported twelve cases of cutaneous anthrax from a village called Sarkarpara. Few weeks after that first outbreak, on 4 August

2007, the Bhagawangola-1 Block Primary Health Centre located 50 km away from the first cluster reported eight cases of cutaneous anthrax from another village called Charbinpara. These two outbreaks were associated with the slaughtering of four cows (one in the first village and three in the second). We investigated both outbreaks with the objectives of (1) confirming the diagnosis, (2) estimating the magnitude, (3) treating patients and (4) proposing recommendations to control the present outbreaks and prevent future ones.

Page no. 106 Methods

Descriptive epidemiology

Case definition and search:

We defined a case of cutaneous anthrax as a painless skin lesion (papule, vesicle or eschar) that appeared between June and August 2007 in a resident of the two villages. Trained community health workers search'ed for cases house to house. 9 We enumerated the population and collected information on age, sex, residence, date of onset and signs and symptoms among all case-patients.

Data analysis:

We plotted, an epidemic curve to represent the distribution of cases over time. We drew maps showing the number of cases in each house and the places where slaughtering occurred. We calculated age and sex specific attack rates by dividing the number of cases by the enumerated population size.

Analytical epidemiology

We conducted a retrospective cohort study among the families who handled or ate meat of the cows slaughtered in the week before onset. We interviewed the participants using structured standardized questionnaires written in Bengali, the local language. We collected information regarding age, sex and history of possible exposures, including ( 1) slaughtering cows, (2) handling meat or skin and (3) eating beef. We divided the incidence among exposed by the incidence

Page no. 107 among unexposed to calculate the relative risk of anthrax for the potential risk factors considered. We restricted our analysis among persons who had not handled meat to examine the association between eating meat and illness. We

CS:IIculated 95% confidence interval using Epi-lnfo software version 6 (CDC). We calculated the fraction of cases attributable to selected exposures in the population by multiplying the proportion of cases exposed by [(relative risk - 1) I relative risk], the attributable fraction among exposed (CDC).

Laboratory investigations:

We collected swabs and smears from the skin lesions of a rando'm sample of suspected case-patients. We sent the specimens to the district public health laboratory using cold chain. The laboratory cultured the swabs for anthrax and examined the smears microscopically using Gram stain.

Environmental investigations:

We interviewed the villagers who slaughtered the animals, handled the meat or touched the skin to obtain information regarding personal protection practices and measures taken for disposal of the remains. We also interviewed women regarding cooking practices.

Results

Descriptive epidemiology

In Sarkarpara village, we identified 45 cases of cutaneous anthrax from among a population of 361 persons with 2 deaths (attack rate: 12%, case fatality rate: 4%).

Villagers slaughtered a cow on 2 June 2007. The outbreak started on 3 June,

Page no. 108 peaked on 6 June and ended on 10 June (Figure 1 ). The median interval between slaughtering and onset was five days (Range: 1-8). Cases were scattered throughout the small village. The attack rate was higher among persons between

15 and 44 years of age (18%) and females (14%, Table 1). The two deaths in

Sarkarpara was possibly due to irregular intake of medicine. In Charbinpara village, out of a population of 835, we identified 44 cases. (attack rate: 5%, no deaths). Three slaughters took place on 16 July, 23 July and 1

August. The first case occurred on 17 July, was followed by three peaks on 18

July, 25 July and 3 August after each of the slaughters and the outbreak ended on 7 August (Figure 1 ). The median interval between slaughtering and onset was four days (Range: 1-10). Cases were clustered around the slaughtering places in the large village. Attack rates were higher among persons between 15 and 44 years of age (6%) and males (8%) (Table 1 ).

Laboratory investigations:

On microscopic examination, seven of 20 smears (5/10 from Sarkarpara and 2/10 from Charbinpara) had gram positive, spore bearing, bacillus that were characteristic of Bacillus anthracis. Three of the 11 swabs (2/4 from Sarkarpara and 1/7 from Charbinpara) grew Bacillus anthracis in culture.

Analytical epidemiology

In Sarkarpara, we included 296 persons in 59 families that either handled or ate beef in the cohort study. The median age was 20 years and 47% were female.

Compared with others, persons who had slaughtered cows or handled skins had

Page no. 109 a higher risk of illness (Relative risk [RR]: 8.7, 95% Confidence interval [CI]: 5.8-

13 and RR: 6. 7, 95% Cl: 5.1-8.8, respectively, Table 2). Handling meat was less strongly associated with illness (RR: 2.6, 95% Cl: 1.5-4.4). A substantial proportion of the population had engaged in slaughtering cows or handling meat

(8% and 33%, respectively). These practices accounted for the larger proportion of cases (Population attributable fraction [PAF]: 37%, and 34%, respectively). 0 Few case-patients had handled skins. That practice accounted for a minority of cases (PAF: 2%).

In Charbinpara, we included 687 persons in 118 families in the cohort study. The median age was 20 years and 51% were female. Slaughtering cows and distributing meat were strongly associated with illness (RR: 19, 95% Cl: 11-30 and RR: 11, 95% Cl: 6.8-19, respectively, Table 2). Handling skin was less strongly associated with illness and the confidence interval was wider (RR: 8,

95% Cl: 1.9- 33). As in the other village, slaughtering and handling were common practices (Table 2) and accounted for the larger proportion of cases (PAF: 41% and 20%, respectively) while skin handling accounted for only two percent of cases.

17% and 7% of the persons who ate beef developed anthrax in Sarkarpara and

Charbinpara, respectively. However, eating was not significantly associated with illness when we restricted the analysis for individuals who did not handle meat or skin (Table- 2). No case occurred in any of the two villages among persons whose sole exposure was eating meat.

Page no. 110 Environmental investigations:

Persons who slaughtered the cows were not butchers. They used their bare hands and did not wear any protective equipment. Helpers of the slaughterers distributed the meat in the neighboring households without any protection either.

Three persons involved in skin trading carried them to some market in another village for selling. Women in the village reported that they boiled the beef for half an hour before serving.

Discussion

This outbreak provided useful information about anthrax in an endemic focus in

India. There were four sequential clusters of cutaneous anthrax in two villages of one district. The three clusters in the second village were reported late, preventing effective public health action. Slaughtering of ill cows and handling of raw meat were strongly associated with illness and accounted for the majority of cases. A few cases were attributable to handling skins. There was no evidence suggesting that eating cooked meat was ,associated with illness. Review of this evidence may help in the formulation of preventive measures.

During these four clusters, late reporting prevented effective public health action.

In the first village, the community health worker knew the symptoms suggested anthrax and that this disease needed to be reported. As a result, an early intervention took place. There were no secondary clusters. In the second village, the community health worker knew nothing about the disease, could not make the diagnosis and did not report it. As a result, reporting was delayed until the third

Page no. 111 cluster. If the event in the second village had been reported early, decontamination of remains after slaughtering could have taken place, which

might have prevented further clusters. WHO recommends a number of measures as standard secondary prevention during human clusters traced back to a slaughter1. These include abstaining from slaughtering ill cows, decontamination of remains and vaccination of animals in the area 1.

Slaughtering of ill cows and handling of raw meat in the absence of personal

protection measures accounted for the majority of cases during this outbreak.

Other epidemiological studies also reported that these practices were key modes of acquisition of cutaneous anthrax7•8•9. In the case of cutaneous anthrax, the agent present in the meat is usually inoculated through injured skin of persons who come in direct contact with it1. Three interventions may prevent disease

among those who slaughter animals or handle meat1• First, sick cows should not

be slaughtered. However, this is difficult to enforce in poor areas such as

Murshidabad as there is a common practice of killing ill looking cows before they

die (dead animals have little monetary value). Second, slaughterers and handlers

can be vaccinated. However, the human vaccine is not available in India. Further,

there were many slaughterers/ handlers in the area. The practi~e was not just

isolated among a small number of butchers. Thus, had a vaccine be available, it

would have been difficult to individualize and target a high-risk population for

immunization. Third, slaughterers and handlers may protect themselves with

specific gear (personal protective equipments). This option is probably the most

feasible and the most adapted to the local situation. Cutaneous anthrax as a

Page no. 112 result of contact with hides or skins has been reported in India 10 but accounted only for a minority of cases during this outbreak. Personal protection among those who handled skins would also have prevented such cases.

During the two Murshidabad outbreaks, there was no evidence that eating beef cooked through prolonged boiling as per the local recipe caused cutaneous anthrax. Further, there were no cases of intestinal anthrax. Epidemiological studies suggest that consumption of cooked contaminated meat is not a risk ) factor for cutaneous anthrax 6.7. Cooking (100 to 150°c for 10-60 minutes1) sterilizes raw animal materials that may .then be consumed safely1. However, in areas where meat is eaten raw or roasted for a short duration rather than boiled

(e.g., brochettes in the Mlddle East), gastrointestinal anthrax may be endemic and associated with meat consumption 11 .

Our investigation suffered from one main limitation. We were unable to formally establish a causal link between these four clusters. As a result, we cannot exclude that this sequence was a mere coincidence or that common circumstances independently led to the four clusters. For example, the events happened during the summer, which is the typical season of anthrax in India.

However, the four clusters occurred in two villages located 40 kilometres apart and within a three-month time frame. Further, the incubation period for anthrax in

herbivores (36 to 72 hours) is compatible with the hypothesis of a causal link

between the animal illnesses that caused the three clusters in the second village.

In addition, cows grazed freely in the area and would have had an opportunity to access the slaughtering sites that were open, allowing for infection from grass

Page no. 113 contaminated by remains. Establishing a formal causal link between the clusters would not have changed the response anyways as the WHO recommendations for secondary prevention following slaughters of infected animals should have been applied regardless of a causal link between the clusters.

During this episode, late notification delayed public health action, leading to additiqnal cases that could have been prevented. This delayed notification was ' due to a lack of knowledge of the disease among community health care workers. 0 Q ) Failure to use personal protection while slaughtering, handling meat and handling skins was the main mode of transmission. The local practice of prolonged boiling of the meat before consumption may have prevented cases of intestinal anthrax.

These conclusions point to a number of recommendations. First, we need to educate our community health workers in district where the disease may occur.

They need to be able to recognize the disease and report it promptly. Early reports of human cases would allow secondary prevention measures, including

(a) decontamination of slaughtering sites, (b) surveillance of animals, (c) advice to avoid slaughtering ill cows and (d) vaccination of herbivores. Collaboration with the animal husbandry department may increase the effectiveness such measures.

Second, we must educate the population for them to use personal protective equipments including gumboots, gloves, aprons during cow slaughtering and handling of meat and skins. Implementation of these measures in the district where anthrax has been reported will allow the non-Hindu populations to continue consuming beef safely, all the more as the local cooking practices prevent intestinal anthrax.

Page no. 114 References:

1. Guidelines for the Surveillance and Control of Anthrax in Human and

Animals. 3rd edition, World Health Organization, Emerging and other

Communicable Diseases, Surveillarlce and Control

2. Rao G Raghu Rama et al, Indian Journal of Dermatology, Venereology and

Leprology, An outbreak of cutaneous anthrax in a non-endemic district -

Visakhapatnam in Andhra Pradesh. Year: 2005, Volume : 71, Issue : 2

3. Report of a Joint WHO/DFID-AHP Meeting with the participation of FAO

and OlE Geneva, The Control of Neglected Zoonotic Diseases, A route to

poverty alleviation, 20 and 21, September 2005

4. World Anthrax data Site, A Service of the WHO Collaborating Centre for

Remote Sensing and Geographical Information System for Public Health,

www.vetmed.lsu.edu/whocc/mp-world.htm

5. Guidelines for Prevention and Control ofoAnthrax, ZOONOSIS DIVISION.

World Health Organization (2006)

6. Sekhar PC, Singh RS, Sridhar MS, Bhaskar CJ, Rao YS, Outbreak of

human anthrax in Ramabhadrapuram village of Chittoor district in Andhra

Pradesh. Indian J Med Res [A] 1990; 91 :448-52.

7. CHRISTOPHER W. WOODS, KENES 0SPANOV, AKYLBEK MYRZABEKOV, MICHAEL

FAVOROV, BRIAN PUKAYTIS AND DAVID A. ASHFORD ET AL, RISK FACTOR FOR

HUMAN ANTHRAX AMONG CONTACTS OF ANTHRAX- INFECTED LIVESTOCK IN

2004 by The American Society of Tropical Medicine and Hygiene

8. Park CW, Park JL, Cheong JY, Lee SH, Chang CH, Oh CJ, Cho BM, Lim

JY, Oh CK, Kweun KS et al, , Clinical Characteristics of a Cutaneous

Anthrax Outbreak Occurred in the Chang-Nyeong, Kyoungsangnamdo,

Korea. Korean J Infect Dis. 2002 Aug; 34(4):203-209.

9. Rao G Raghu Rama1, Padmaja Jyothi1, Lalitha MK2, Rao P V. Krishna1,

Go pal K VT1, Kumar Hari Kishan Y1 et al, An outbreak of cutaneous

anthrax in a non-endemic district - Visakhapatnam in Andhra Pradesh, ,

Mohanraj Promila2, Departments of Dermatology and Microbiology,

Andhra Medical College, Visakhapatnam, India., 2 Department of Clinical

Microbiology, Christian Medical College, Vellore, India,

[email protected]

10.Lalitha MK; Kumar A et al, Anthrax : a continuing problem in southern

India. Indian Journal of Medical Microbiology. 1996 Apr; 14(2): 63-72, ,

Department of Clinical Microbiology, Christian Medical College & Hospital,

Vellore-632 004

11.Zeina A. Kanafani,* Antoine Ghossain,t Ala I. Sharara,* Joseph M.

Hatem,t and Souha S. Kanj* et al, Endemic Gastrointestinal Anthrax in

1960s Lebanon: Clinical Manifestations and Surgical Findings, *American

University of Beirut Medical Center, Beirut, Lebanon; and tSaint-Joseph

University, Beirut, Lebano, Available from: URL:

http :1/www. cdc. gov/ncidod/E I D/vol9no5/02 -0388. htm

Page no. 116 Table 1: Incidence of cutaneous anthrax by age and sex, Sarkarpara and Charbinpara villages, Murshidabad, West Bengal, India, 2007

Sarkarpara Charbinpara Total

Characteristics Cases Population Attack rate Cases Population Attack rate Cases Population Attack rate

0-4 0 24 0 2 69 3 2 93 2 Age

5-14 10 119 8 13 254 5 23 373 6

15-44 28 157 18 23 393 6 51 550 9

45-64 6 55 11 5 93 5 11 148 7

65-84 1 6 17 1 26 4 2 32 6

Male 21 190 11 32 413 8 53 603 9 Sex

Female 24 171 14 12 422 3 36 593 6

Total 45 361 12 44 835 5 89 1,196 7

Page no. 117 Table 2: Risk of cutaneous anthrax according to selected exposures, Sarkapara and Charbinpara villages, Murshidabad district, West Bengal, India, 2007

Sarkarpara Charbinpara Risk among Risk among Risk among Risk among exposed unexposed Association exposed unexposed Association - # N % # N % RR 95%CI # N % # N % RR 95%CI Age> median 30 163 18 15 133 11 1.6 0.9-2.9 26 351 7 18 336 5 1.4 0.8-2.5 Female sex 24 142 17 21 154 14 1.2 0.7- 2.1 21 189 11 23 498 5 2.4 1.4- 4.2 Slaughtering 20 24 83 25 272 9 8.7 5.8- 13 22 35 63 21 652 3 19 11-30 Distributing meat ------9 15 60 35 672 5 11 6.8- 19 Cleaning meat ------12 174 7 32 513 6 1.1 0.6-2.1 Handling of raw meat 45 260 0.2 0 36 0 1.9- Carrying skins 1 43 6 8.0 1 1 100 44 295 15 6.7 5.1- 8.8 2 50 685 32.8 Eating meat 45 260 17 0 36 0 -- 44 654 7 0 33 0 u Eating without handling 0 142 0 0 33 0 0 0 0 445 0 0 16 0

Page no. 118 -0\ ...... en sQ) ~ C) ·;:: ...... -~ "0 "0 ro .0 ro :2 ..c en :::::l ::;?; u) Q) 0) ~ t>T E1 ·:;: -u ,_ro -Tt ro a. m c 6 :0,_ -B ro -T ..c -9- () -s "0 --p- c ro --r· ,_ro --z· ro ,_a. 0£' ro -6t ..:::1:.,_ -8t ro -u (J) -9z ..c -sz en vz ro,_ -~::z ...... zz: 0 ...... -u Q) --oz en ~6t c 0 --s1 ...... --zy 0 ---gy ~ Q) ...... 51~ ro "0 >. .0 X ,_ro ..c...... c car-- ...... 0 00 enN Q)en - ro-~ ()"0c

~ <:!" N Q) ro .-; .-; ,_ 0) :::::l c .Q> Q) LLCO An outbreak of Cutaneous Anthrax, Burakuli, Murshidabad, West Bengal, India, 2007

Introduction

Anthrax is a zoonotic disease that affects primarily herbivores 1• It is caused by spore-forming, gram positive bacteria called Bacillus anthracis 1. Spores are present in contaminated soils 1. Herbivores acquire infection while grazing and may develop septicemia. After death, the vegetative form is present in the meat

0 • and body fluids and the spores may be present on- the hides. Carcasses and remains may contaminate soils 1• In humans, the disease manifests itself in three forms: cutaneous, pulmonary and intestinal. Cutaneous anthrax accounts for 95%

li of the cases 1. Handling contaminated meat, hides or skins may lead to inoculation ill 111 ~ of vegetative form or spores through cuts and abrasions and cause the cutaneous I form 1. Heating at 100° C for 10-60 minutes kills spores and the vegetative form 1. II ~~ ill li,I It has been estimated that globally, 20,000 to 100,000 human cases of anthrax occur annuallj. In 2004, sixty countries mostly from Africa, Middle East, Central I lr and Southern Asia reported human anthrax1•3. In 2006 India reported 17 cases4• I II However, several states, including Jammu and Kashmir, Orissa, Andhra Pradesh, ill :l 5 II Tamilnadu and West Bengal reported human outbreaks . Most of these occurred iJ among non-Hindus and who eat beef or in a poor Hindu village as of Harijans j ("untouchables")6 or among workers who handle skin, wool. India has no nationally organized control programme as occurrence of disease is focal, I I Page rio. 120 affecting only a small number of districts. As a consequence, human anthrax is not a national notifiable disease.

In the Murshidabad district of West Bengal (2007 population: 6,702,000), 64% of the population is Muslim. The district reported 304 cases of human anthrax between 2003 and 2006 (un-published data). In 1998, laboratory facilities for the diagnosis of anthrax were established in the district. On 14th October, 2007

Hariharpara Block Primary Health Centre reported one case of cutaneous anthrax from a village called Pirtala. This event was associated with the slaughtering of one cow at Burakuli village. We conducted investigations with the objectives of (1) confirming the diagnosis, (2) estimating the magnitude, (3) treating patients and

(4) proposing recommendations to control the present outbreak and prevent future ones.

Methods

Descriptive epidemiology

Case definition and search:

We defined a case of cutaneous anthrax as a painless skin lesion (papule, vesicle or eschar) that appeared in October, 2007 in a resident Burakuli and Pirtala.

Trained community health workers searched for cases house to house. We

Page no. 121 enumerated the population and collected information on age, sex, residence, date of onset and signs and symptoms among all case-patients.

Data analysis:

We plotted an epidemic curve to represent the distribution of cases over time. We drew maps showing the number of cases in each house and the places where slaughtering occurred. We calculated age and sex specific attack rates by dividing the number of cases by the enumerated population size.

Analytical epidemiology

We conducted a retrospective cohort study among the families who handled or ate meat of the cows slaughtered in the day before onset. We interviewed the participants using structured standardized questionnaires written in Bengali, the local language. We collected information regarding age, sex and history of possible exposures, including 1) slaughtering cow, 2) distribution meat, 3) cleaning meat, 4) carrying skin and 5) eating beef. We divided the incidence among exposed by the incidence among unexposed to calculate the relative risk of anthrax for the potential risk factors considered. We calculated 95% confidence interval using Epi-lnfo software version 6 (CDC). We calculated the fraction of cases attributable to selected exposures in the population by multiplying the proportion of cases exposed by [(relative risk - 1) I relative risk], the attributable fraction among exposed.

Page no. 122 L.aboratory investigations:

We collected smear from the skin lesion of a suspected case-patient. The laboratory examined the smear microscopically using Gram stain.

Environmental investigations;

We interviewed the villagers who slaughtered the animals, distributed and cleaned the meat or touched the skin to obtain information regarding personal protection practices and measures taken for disposal of the remains. We also interviewed women regarding cooking practices.

Results

Descriptive epidemiology

We identified eight cases of cutaneous anthrax from a population of 3203 residing in 507 households (attack rate: 25/ 10,000 population). Villagers slaughtered an ill cow on 6 October. The outbreak started on 7 October and ended on 12 October.

Cases were scattered throughout two small villages. The attack rate was higher among persons between 15 and 44 years of age (47/10,000) and females

(26/10,000) (Table 1). The median incubation period was 4 days (Range 1 - 6 days).

Page no. 123 Laboratory investigations:

On microscopic examination, the smear showed presence of gram positive, spore bearing bacilli that was characteristic of Bacillus anthracis.

Analytical epidemiology

We included 204 persons from 35 households that either handled or ate beef in the cohort study. The highest and lowest attack rate in persons exposed to slaughtering and eating were 45% and 4% respectively. The median age was 20 years and 48% were female. Compared with others, persons who had slaughtered cow or distributed raw meat had a higher risk of illness (Relative risk

[RR]: 29, 95% Confidence interval [CI]: 8-107 and RR: 27, 95% Cl: 7-99, respectively). Cleaning meat was less strongly associated with illness (RR: 3,

95% Cl: 0.8-11 ), (Table 2). Five percent of the population was engaged in slaughtering cow while 6% of the population was involved in distributing meat.

The population attributable fraction [PAF] associated with these practices was 60% each. Few case-patients.. had cleaned meat. That practice accounted for a minority of cases (PAF: 33%).

Environmental investigations:

Persons who slaughtered the cow were not butchers. They used their bare hands and did not wear any protective equipment. Helpers of the slaughterers distributed the meat in the neighboring households without any protection either.

Pageno. 124 Women in the village reported that they boiled the beef for at least half an hour before serving.

Discussion

This outbreak provided useful information about anthrax in an endemic focus in

India. There was one cluster of cutaneous anthrax in two villages of one district, reported late, preventing effective public health action. Slaughtering of ill cow and distribution of raw meat were strongly associated with illness and accounted for the majority of cases. A few cases were attributable to cleaning meat. There was ' no evidence suggesting that eating cooked meat was associated with illness.

Review of this evidence may help in the formulation of preventive measures.

During this cluster, late reporting prevented effective public health action. The community health worker knew nothing about the disease and could not make the diagnosis and did not report it. As a result, reporting was delayed until the last patient from Pirtala came to the outpatient department. WHO recommends a number of measures as standard secondary prevention during_ human cluster traced back to a slaughter1. These include abstaining from slaughtering ill cow, decontamination of remains and vaccination of animals in the area 1.

Slaughtering of ill cow and distribution of raw meat in the absence of personal protection measures accounted for the majority of cases during this outbreak.

Other epidemiological studies also reported that these practices were key modes of acquisition of cutaneous anthrax2•7•8. In the case of cutaneous anthrax, the

Pageno. 125 agent present in the meat is usually inoculated through injured skin of persons

who come in direct contact with it1. Three interventions may prevent disease

among those who slaughter animal or distribute meat1• First, sick cows should not

be. slaughtered. However, this is difficult to enforce in poor areas such as

Murshidabad as there is a common practice of killing ill looking cows before they

die (dead animals have little monetary value). Second, slaughterers and handler~

can be vaccinated. However, the human vaccine is not available in India. Further,

there were many slaughterers/ handlers in the area. The practice was not just I isolated among a small number of butchers. Thus, had a vaccine be available, it

would have been difficult to individualize and target a high-risk population for

immunization. Third, slaughterers and handlers may protect themselves with

specific personal protective equipments. This option is probably the most feasible

and the most adapted to the local situation. During this outbreak, there was no

· evidence that eating beef cooked through prolonged boiling as per the local

recipe caused. cutaneous anthrax. Further, there were no cases of intestinal

anthra~ Epidemiological studies suggest that consumption of cooked

contaminated meat is not a risk factor for cutaneous anthrax 6·7. Cooking (100 to

150°c for 10-60 minutes) sterilizes raw animal materials that may then be

consumed safely1. However, in areas where meat is eaten raw or roasted for a

short duration rather than boiled (e.g., brochettes in the Middle East),

gastrointestinal anthrax may be endemic and associated with meat consumption9.

During this episode, late notification delayed public health action. This delayed

notification was due to a lack of knowledge of the disease among community

Page no. 126 agent present in the meat is usually inoculated through injured skin of persons

who come in direct contact with it1• Three interventions may prevent disease

among those who slaughter animal or distribute meat1. First, sick cows should not

be. slaughtered. However, this is difficult to enforce in poor areas such as

Murshidabad as there is a common practice of killing ill looking cows before they

die (dead animals have little monetary value). Second, slaughterers and handler~

can be vaccinated. However, the human vaccine is not available in India. Further,

there were many slaughterers/ handlers in the area. The practice was not just

isolated among a small number of butchers. Thus, had a vaccine be available, it

would have been difficult to individualize and target a high-risk population for

immunization. Third, slaughterers and handlers may protect themselves with

specific personal protective equipments. This option is probably the most feasible

and the most adapted to the local situation. During this outbreak, there was no

· evidence that eating beef cooked through prolonged boiling as per the local

recipe caused. cutaneous anthrax. Further, there were no cases of intestinal

anthra)b. Epidemiological studies suggest that consumption of cooked

contaminated meat is not a risk factorfor cutaneous anthrax 6•7. Cooking (100 to

150°c for 10-60 minutes) sterilizes raw animal materials that may then be

consumed safely 1. However, in areas where meat is eaten raw or roasted for a

short duration rather than boiled (e.g., brochettes in the Middle East),

gastrointestinal anthrax may be endemic and associated with meat consumptio~ 9 .

During this episode, late notification delayed public health action. This delayed

notification was due to a Jack of knowledge of the disease among community

Pageno. 126 health care workers. Failure to use personal protection while slaughtering, distribution meat and cleaning meat was the main mode of transmission. The local practice of prolonged boiling of the meat before- consumption may have prevented cases of intestinal anthrax. These conclusions point to a number of recommendations. First, we need to educate our community health workers in district where the disease may occur. They need to be able to recognize the disease and report it promptly. Early reports of human cases would allow secondary prevention measures, including (a) decontamination of slaughtering sites, (b) surveillance of animals, (c) advice to avoid slaughtering ill cows and (d) vaccination of herbivores. Collaboration with the animal husbandry department may increase the effectiveness such measures. Second, we must educate the

0 population for them to use personal protective equipments including gumboots, 0 gloves, aprons during and cow slaughtering and handling of meat and skins.

Implementation of these measures in the district where anthrax has been reported will allow the non-Hindu populations to continue consuming beef safely, all the more as the local cooking practices prevent intestinal anthrax.

Pageno. 127 References:

1. Guidelines for the Surveillance and Control of Anthrax in Human and

Animals. 3rd, edition, World Health Organization, Emerging and other

Communicable Diseases, Surveillance and Control

2. Rao GRR et at, An outbreak of cutaneous anthrax in a non-endemic district

- Visakhapatnam in Andhra Pradesh, Indian Journal of Dermatology,

Venereology and Leprology; Year: 2005, Volume: 71, Issue: 2

3. The Control of Neglected Zoonotic Diseases, A route to poverty alleviation, Report of a Joint WHO/DFID-AHP ..Meeting with the participation of FAO and OlE Geneva, to and 21, September 2005

4. World Anthrax data Sheet, A Service of the WHO Collaborating Centre for

Remote Sensing and Geographical Information System for Public Health

5. Guidelines for Prevention and Control of Anthrax, Zoonosis Division,

National Institute of, Communicable Diseases, Copyright- World Health

Organization (2006)

6. Sekhar PC et al, Outbreak of human anthrax in Ramabhadrapuram village

of Chittoor district in Andhra Pradesh, Indian J Med Res [A] 1990; 91 :448-

7. WOODS C et at, Risk Factors for Human Anthrax among contacts of

Anthrax infected livestocks in Kazakhstan, American Journal of Tropical

Medicine and Hygiene, 71(1), 2004, pp. 48-52

Page no. 128 8. Park CW et al, Clinical Characteristics of a Cutaneous Anthrax Outbreak

Occurred in the Chang-Nyeong, Kyoungsangnamdo, Korea, Korean J

Infect Dis. 2002 Aug; 34(4):203-209

9. Zeina AK et al, Endemic Gastrointestinal Anthrax in 1960s Lebanon:

Clinical :> Manifestations and Surgical Findings, available at

http://www.cdc.gov/ncidod/EID/vol9no5/02-0388.htm

10. District Public Health report (unpublished data), Murshidabad, Wet Bengal

Page no. 129 Fig 1, Cutaneous Anthrax cases by date of onset, Burakuli, Murshidabad, West Bengal, India, 2007.

4 J Date of Slaughtering- j j

~ ~ ~ ~ ~ ~ 2 0 :.... ~ ,.Qe z= 1

0 t 6-0ct-07 7-0ct-07 8-0ct-07 9-0ct-07 10-0ct-07 11-0ct-07 12-0ct-07 13-0ct-07

Date of Slau~hterin~

Page no. 130 Fig 2, Cutaneous Anthrax cases by residence, Burakuli, Murshidabad, West Bengal, India, 2007.

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 v 0 0! 0 ro 0 -..... II > 0 0 0 Place of slam!hterin!l 0 II 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 .0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ~I Burakuli 0 oD 0 I Mosaue ~ 0 0 0 0 0 0 0 oo 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DO 0 0 DO 0 DO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Houses with 1 case 0 Houses with 2 cases 11

Page no. 131 Table 1, Incidence of Cutaneous Anthrax cases by age and sex, at Burakuli, Murshidabad, West Bengal, India, 2007.

Demographic characteristic Ill Population at risk Attack rate/1 0000

0-<5 0 237 0

5-14 1 926 11

15-44 7 1492 47

45-64 0 455 0

65-95 0 93 0

Male 4 1666 24

Female 4 1537 26

TOTAL 8 3203 25 0

Page no. 132 Table 2, Cohort study, Incidence of cutaneous anthrax accounting to selected characteristics, Burakuli, Murshidabad, West Bengal, India, 2007.

Risk among exposed Risk among unexposed Association

# N % # N % RR 95% Cl c

Age> 20 6 112 5 2 92 2 3 0.5-12

Female 4 98 4 4 106 4 1 0.3-4

Slaughter 5 11 46 3 193 2 29 8-107 .. Distribute 5 12 42 3 192 2 27 7-99

Clean 4 52 8 4 152 3 3 0.8-11

Carry skin 0 0 0 8 204 4 Eating 6 171 4 2 33 6 0.6 0.1-3

Page no. 133 An investigation on Measles outbreak at Kulgachi village of Murshidabad district, West Bengal, India, 2008.

Introduction

Measles is an acute viral infectious disease. Measles virus is a paramixovirus of genus Morbillivirus. Measles is the leading cause of childhood morbidity and mortality from vaccine preventable diseases 1. The incubation period of measles is from 10 to 12 days. Complication may arise in approximately 30% of measles cases, common in children less than 5 years of age. The case fatality rate ranges from 0.06 to 2.2 per 1000 cases in population with good nutrition and medical care to as high as 20 to 150 per 1000 in developing countries, where malnutrition is prevalent. Failure to deliver at least one dose of measles vaccine to all infants remains the primary reason for high measles mortality and morbidity in developing countries 1.

In 2006, 373,421 measles cases were reported throughout the world2. Despite the

0 availability of a safe and effective vaccine, in the year 2006, measles killed over

242,000 children globally3 . Measles vaccination coverage among infants in

Southeast Asia and Africa is low, ranging between 54-55% in 1999 to 67% in

20064. In 2001, WHO and UNICEF adopted a strategy for measles mortality reduction and regional elimination. The goal of this strategy was to reduce measles mortality by 50% in 2005 relative to 1999 estimates. Four components of the strategic plan were to 1) achieve at least 90% routine vaccination coverage with at least one dose of measles vaccine, 2) provide second opportunity for

Page no. 134 measles vaccination for all children, 3) establish measles surveillance 4) improved management of complicated cases5.

In India, though measles immunization started since 1985 as part of Universal

Immunisation Programme throughout the country, only 58.8% children of 12-23 months of age have received measles vaccine in 20056. During 2006, a total of

60,751 ca~es were reported from country3. Government of India formulated a -

National Strategic Plan for Measles Mortality Reduction in 2005 with the objectives of 1) achieving 90% vaccination coverage in 90% of the districts, 2) reducing the measles mortality by two-thirds by 2010, compared to 2~00 estimates, 3) establishing effective measles surveillance, 4) improving management of measles cases, including vitamin A supplementation and 5)

3 consideration a second opportunity for measles7•

Murshidabad district of West Bengal accounted for one-third of measles cases

reported from the state. About two third of the district population is constituted by

minority community. Measles vaccination coverage in the district was 56.4% in

2003-048.

On 6th February 2008, the Medical officer of the Teghari Block Primary Health

Centre informed the Chief Medical Officer of Health, Murshidabad district about

occurrence of 16 suspected measles cases at Kulgachi village. We investigated

the outbreak to (1) estimate the magnitude of the outbreak, (2) improve the

Page no. 135 management of cases (3) estimate vaccination coverage and vaccine efficacy and (4) propose recommendations for control.

Method

Descriptive epidemiology

We collected information on background data of measles, population movement, and change in surveillance system from the Medical Officer of the T eghuri PHC.

Case definition: We defined a case of measles as occurrence of fever and maculo-papular non-vesicular rash with at least one of the following cough, coryza (running nose) or conjunctivitis (red eyes) among residents of Kulgachi, during the period between November,2007 and March, 2008.

Case search: We conducted an active house-to-house search to detect cases and line listed them. From the case patients, we collected information on age, sex, residence, date of onset, vaccination status of children, symptoms, sign, post measles complication and outcome of cases. We considered the complications and deaths as a sequel of measles if they occurred within 30 days of onset.

Data analysis: We examined the dynamic of the outbreak through the construction of an epidemic curve. We drew a map of the village by location of households to show the distribution of measles cases by residence. We calculated attack rates of measles according to age and sex.

Page no. 136 Laboratory investigation: We collected five ml of blood specimen from six case patients between four and twenty eight days after onset of rash. We sent the sera to the Measles Laboratory, Institute of Serology, Kolkata under cold chain for serological confirmation.

Analytic epidemiological

We conducted a retrospective cohort study. Our study population was the children up to 10 years of age of Kulgachi village. Our null hypothesis was that the measles vaccine was not associated with any protection against the disease. Our exposure variable was the vaccination status. Our outcome variable was the disease status. We ascertained the immunization status of the children through the immunization card or used mother's history in case the card was not available. Children who had measles in the past, as reported by mother were excluded from the study.

We estimated the vaccine coverage in the area. We calculated attack rates among vaccinated and un-vaccinated children. We calculated the vaccine efficacy and its 95% confidence interval (CI) among children aged 9 month- 10 years using the following formula.

Page no. 137 Result

Descriptive epidemiology

J The measles immunization coverage was only 23% in the village. We identified

87 case patients from 446 children in the area with an attack rate of 19.5%. Two case patients died as a result of post measles complication, bronchopneumonia with a case fatality rate of 2.3%. Four of the six sera were positive for lgM against

measles.

The median age of the case patients was 5 years (6 months - 10 years). The

attack rates were higher among females (23%) and children aged Q.-12 months

and 25-60 months (25%) (Table-1). Eleven (13%) of the 87 case-patients were

vaccinated. Thirty eight of the 87 (44%) had complications after measles. The

most common complications were respiratory tract infection 45% (17/38) followed

by diarrhea 29% (11/38). Vitamin- A in oil was given to all cases as per WHO

guidelines.

The first case occurred on 1oth December, 2007 and the last case occurred on

291h February, 2008. The Epidemic curve (Fig-1) showed a propagated type of

outbreak. However, the outbreak was not reported until 56 days after the

occurrence of the first cases and following the death of second case. The

dynamic of the outbreak suggested that there had been a number of generations

of cases with a peak around 22-23 February 2008 (Figure- 1). Spot map showing

Page no. 138 distribution of measles cases by household indicated that cases were distributed 1 throughout the densely populated village (Figure- 2).

From the members of the community and the local health staff, we knew that the

area was resistant to Intensified Pulse Polio Immunization programme previously.

The people of that area were socio- economically poor and mostly Bidi worker

(roller & helper).

Among the villagers 86% belong to religious minority. 66% of the villagers are

engaged in making bidi (local cigarettes). Among minority community 22%

children were immunized as compared to non minority community where the

immunization coverage was 34%.

Analytic epidemiological

We included all 446 children aged 10 years or less in the cohort study. Of these,

100 (22%) had received measles immunizatior,l and 346 (78%) were

unvaccinated. The fore most causes for non- immunization is fear to waste time

and wedge (55%) and unaware for immunization (23%). Coverage of measles

vaccine among minority community children was 22% whereas 34% of the

children belonging to non-minority community had received the vaccine {02=3.34,

p=0.06).

Attack rates of measles among immunized and non immunized children were

11% and 22% respectively. The relative risk associated with measles vaccine was

0.36 (95% Cl: 0.20-0.64). Efficacy of measles vaccine was 48% (95% Cl: 13%-

74%).

Pageno. 139 Discussion

A measles outbreak affected the Kulgachi, Raghunathganj- II block in the district of Murshidabad in India between November, 2007 and February, 2008. The age groups most affected were 9-12 months and 25-60 months. There were 87 case Q patients among which 2 case patients died. The attack rate among females was higher than males. The relative risk of getting measles among nonimmunized was

2 times higher tha"n the immunized children. About half of the children suffered from complications.

The immunization coverage of the village was very poor. The measles immunization coverage of religious minority population was 22% less than that of the non minority population. The results of the investigation indicated that the outbreak occurred in a population with low vaccine coverage. Poor delivery of immunization services and I low demand in community might be the cause of this low vaccine coverage. Thus, the outbreak is explained by a failure to vaccinate.

The religious minority community of that village was known for poor participation in vaccination effort. The possible reasons for poor participation in immunization activities by the religious minority community must explore and all effort to be taken to improve immunization coverage.

In addition, there was also low vaccine efficacy. The cause may be that the mothers could not tell properly whether the child was immunized or not as child not immunized but declared immunized by the mother. Another cause of poor vaccine efficacy may be due to cold chain failure. In this outbreak setting vaccine

Page no. 140 efficacy was found to be low. It was likely that there had been a cold chain failure or that reconstituted vaccine had been kept in the refrigerator and later used or that there was a problem with the original potency of the vaccine (inappropriate immunization practices). Review of cold chain system including the programmatic features might be investigated further to rule out the inappropriate immunization practices.

The case fatality rate was 2.3%. It suggests that there was need of appropriate treatment for complicated cases. The complicated cases may be admitted in the hospital for necessary treatment.

In spite of our efforts we have some limitations in our study 1) as 58% of the immunization cards were missing we had to depend on interview of the parents,

2) we could not gather data for calculating the coverage among bidi workers and

3) we could not search details of cold chain status.

This outbreak investigation provided us opportunity to recommend 1) to strengthen routine immunization by arranging vaccination at door steps, in local club, mosque and Anganwari centers, 2) to look into the cold chain status and injection practices, 3) to raise awareness of vaccination among village people by involving local community leaders including religious leaders and the bidi merchant association, 4) to manage cases effectively and 5) improve measles surveillance.

Page no. 141 References,

::: 1. WHO UNICEF Measles mortality reduction and regional elimination.

Strategic plan 2001-2005. WHON&B/01.13 March 2003

2. WHO, Programmes and projects, Immunization surveillance, assessment

and monitoring, Vaccine-preventable diseases, 2006 global case.htrh

3. World Health Organisation, Immunisation surveillance, assessment and

monitoring, Vaccine-preventable diseases, 2007 global case.htm

4. World Health Organisation, SEAR, 2007, Measles EPI Fact Sheet, IVD, 15

October, 2008; Page 1-6

5. WHO-UNICEF. Measles mortality reduction and regional elimination.

Strategic plan. WHON&B/01.13 Rev. 1, 2001

6. Nation Family Health survey- Ill, 2005

7. Measles Mortality Reduction, India Strategic Plan, 2005-2010, Ministry of

Health and Family Welfare, Government of India

8. Government of India, District Level Household Survey, Round- 2, 2002-04

9. Government of West Bengal, Department of Health & family Welfare,

Murhidabad district, unpublished data

10. Report from office of the Block Medical Officer of Health, Teghari BPHC,

Murshidabad

Page no. 142 (") t:ti " rn l.... ns 8t-Lt ro t) ::l rn c: .....,ro ~rn vt-El ns Cl) E Ol-6 '5 .s:: 9-S rn ns... s:: z-t :.;: rn '5 6Z-8Z Cl) E sz~vz '- ;; Q) ~ ..0 .Q tz-oz E a) Q) u ~ Q) :;, Lt-9t Q (.) ·et) El>lt Cl) ·a"C 6-8 w ~ -1'-- ~ co \,0 N 0 00 \,0 N 0 'l"'"'i 'l"'"'i 'l"'"'i .~ IIs:: ""' 4sf.f jd a:::uJeJeadde Aq""' saseJ JO JaqwnN LL - Fig 2, Spot Map, by place distribution, by time distribution of measles cases, Kulgachi Murshidabad, West Bengal, India, 2008,(n=87)

D 0

0 0 0 D 0 0 ° 0 °

w 0 0 0 • 0 0 w o••o• w 0 0 oc 0 w 0 0 0 0 a a 0 0 0 0 o Cl o

0 0 0 II D 0 0 D

Page no. 144 Table 1, Incidence of measles by age & sex, Kulgachi, Murshidabad, West Bengal, India, 2008

No of cases _,Population Attack rate (%)

Age 0-<9 months 3 28 11

9-12 months 5 • 20 25

0 13-24 months 7 43 16

0 25-60 months 41 163 25

61-120 months 31 192 16 Sex Male 40 238 17

Female 47 208 23 Total Total 87 446 19.5

Page no. 145 / ~ ~ - . -,co,~

Table 2: Attack rates of measles by age and vaccination status, Kulgachi, Murshidabad, West Bengal, India, 2008

Children immunized against measles Children not immunized against measles Age group Attack Attack rate (month) Cases Total rate{%} Cases Total {%} 0-<9 0 0 0 3 28 11

9-12 2 12 17' 3 8 36

13-24 2 24 8 5 19 26

25-60 6 43 14 35 120 29

61-120 1 21 5 30 171 18

Total 11 100 11 76 346 22

Pageno. 146 •

Section 4: Journal critique

Page no. 147 Critical Evaluation of Published Research

General information: There is annual outbreak of acute encephalopathy among children in western part of Uttar-Pradesh due to intoxication of some phytotoxin which causes Hepato- myoencephalopathy, a syndrome which is fatal.

Title of the paper: Cassia Occidentalis as the probable cause of Hepatomyoencephalopathy in children in western Uttar-Pradesh

Authors: V.M. Vashistha, Amod Kumar, T.jacob.John, N.C. Nayak.

References: Indian J Med Res 125, June 2007, pp 756-762.

Date: 21/03/2008

General narrative comments: Outbreaks of acute encephalopathy illness affecting the young children was observed for many years annually in many districts of western Uttar Pradesh, ·India. The public health agencies suggested

Chandipura virus etiology based on other study. Rural children with poor socio- economic background were mostly vulnerable. They learned from the parents about incidents of young, poorly supervised children eating weedy plants and their fruits. The authors suspected the illness was due to fatal multi-system disease (hepatomyeloencephalopathy syndrome) caused by some phytotoxins of cassia occidentalis but not due to viral encephalitis. They conducted a case control study was conducted to investigate the ·risk. Eighteen cases of acute hepatomyeloencephalopathy -syndrome admitted in the secondary level hospital

Page no. 148 in Bijnor district of western Uttar Pradesh in 2005. 3 age matched ( ± 1 year) neighbour controls, sharing same house cluster and similar socio-economic (; conditions, was selected for each case. A semi structured questionnaire with 59 variables was applied to parents. The natural cycle of the plant shows seasonality of the tlisease. The case control study reveals that odds of exposure to eating the

Cassia pods (beans) is 12.89 times higher in cases than controls. Stepwise outbreak investigation procedure was not followed. The study shows the association of Cassia occidentalis and the acute hepatomyelyencephalopathy syndrome, but it would be better to add the population attributable fraction. The overall analytical study was elaborated except PAF. There was some limitation that they could not include all cases in the study.

Pageno. 149 . '~- ' ·~------~----~~----~------~-~~~---- 0

Table 1. Overall assessment of the paper

Grading from 1 (strongly disagree) to 5 (strongly Checklist items agree Explanations 1 2 3 4 5 The background provides a description of the public The background does not provide a issue at the global and local levels and logically description of the public issue at the introduces the need to answer a specific research ../ global and local levels but logically question. introduces the need to answer a specific research question. The methods section provides sufficient information The method section provides information on the methods used, including the type of study; the on method used, sampling strategy and sampling strategy, the case definitions, the data case definition. The case definition was collection and the data analysis. ../ incomplete. The data collection & analysis plan was appropriate. . ! The results reports sound scientific results that meet The result section explained the odds I I the study's objective and the research question. They ratio, 95% confidence interval and p are presented with sufficient details and adequate ../ value. These values are important to statistical information (e.g., Confidence Intervals). show the association and strength of association. The discussion summarizes and interprets the results, Discussion summarises and interprets the discusses the findings in view of what is already result. known, frames what the results of the study can support, defines the limitation of the work and · ../ suggests next steps in terms of (1) intervention and (2) research.

Page no. 150 / ~- m- .

Table 2. Methods of outbreak investigation

Grading from 1 (strongly disagree) Checklist items to 5 (strongly agree) Explanations

1 2 3 4 5

The study design is adequate to meet the objective. ,f Case control study

The study population is well defined and relevant to The age of the children was not mentioned. the research question ,f Place and time were given. Community based study population.

Definitions are specified, sound and based upon ,f The definition was not standardized standardized criteria when available. Sampling methods are statistically sound and Sampling was correctly done from neibourhood adapted. and relatives sharing the same demographic & ,f socioeconomic criteria. •

The sample size was estimated beforehand Sample size is justified at 3 times the number of appropriately. ,f cases as number of cases is small.

The study is exempt from bias. Age matched- no confounding and no selection ./ bias. There may be information bias .

The data that were collected are well described and Data collection is relevant relevant. ,f

------

Page no. 151 The data was collected was of sufficient quality. Yes ./ 0

The analysis is thought beforehand and appropriate. ./ Age and sex distribution analysis lacking.

The indicators generated are appropriate and well Demographic and socio- economic indicators calculated. ./ were lacking

The statistical tests used are appropriate and well Statistical tests used are well computed except computed. ./ Population attributable fraction

Appropriate attention has been given to human Ethical issues are not mentioned. subject protection issues. ./

Page no. 152 Table 3. Writing of outbreak investigation report

Grading from 1 . (strongly disagree) to 5 Checklist items (strongly agree)_ Explanations

1 2 3 4 5 The content is well distributed by chapters Outbreak investigation was not followed step by step and sections. ../

The language is simple and clear. The word Yes, the language is simple and clear. But the word count is count is < 3000. ../ more than 3000.

The writing is sequential, going from one The introduction section contains background, case point to the next. ../ definition was given in Methods and there was result section and discussion. The active voice is used throughout. There was mixture of active and passive voice ../

The vocabulary is precise, consistent and There was repetition of statement. standardized. ../

------

Page no. 153 Table 4. Comments on tables and figures

Grading from 1 (strongly disagree) to 5 (strongly Explanations Checklist items agree

1 2 3 4 5 There are no more than five tables and or There were 2 tables and 1 figure. All needed. figures. All are needed. ,/

The choice of graph or table to display The choice of tables were judicious c information is judicious. ,/

The tables are clear, exact and the totals add Yes up. • ,/

The graphs are effective, appropriate and As there was no epidemic curve, whether it is point source understandable. ,/ or multiple exposures, cannot be concluded.

-·-··- -··-···--··- ---

Page no. 154 Section 5: Paper presentation

Page no. 155 CUTANEOUS ANTHRAX OUTBREAK IN A VILLAGE OF WEST BENGAL,

INDIA, 2007: THE DANGER OF UNSAFE HANDLING OF INFECTED COW

MEAT

Background: Following slaughtering of an ill cow on 2nd June 2007, a cluster of suspected cutaneous anthrax was reported in Sarkarpara, Kushaberia village of

Murshidabad, West Bengal. We investigated this cluster to identify the agent, mode of transmission and formulate recommendations for prevention.

Methods: We defined a suspected anthrax as occurrence of characteristic papule or vesicle with or without eschar formation in a resident of affected village during

2nd -14th June 2007 and searched for cases door to door. We described the outbreak. We collected vesicular fluid from the skin lesions for microscopic examination and culture for Bacillus anthracis. We compared cases with

J unaffected household member of case-patients for exposure to the slaughtered animal while slaughtering, handling the raw meat and consumption of cooked meat. We calculated Relative risk (RR), 95% confidence intervals (CI) and population attributable fraction (PAF).

Results: We identified 45 case-patients of anthrax among 361 villagers with two deaths (Attack rate: 13%; Case fatality rate: 4%) in Sarkarpara. We identified B. anthracis in 5 patients and isolated the organisms from 2 patients. Attack rates were higher among individuals aged 15-45 years (28/157, 18%) and females

(24/171, 14%). We identified slaughtering the cow (RR = 9, 95% Cl: 6- 13; PAR:

37%) and handling raw meat (RR: 3, 95% Cl:2- 4; PAF: 34 as risk factors.

Page no. 156 Conclusions: The outbreak was associated with exposure to slaughtered animal

meat. We educated villagers for not slaughtering ill animals and using personal

protective measures while slaughtering or handling the raw meat.

Key words: Cutaneous Anthrax, outbreak, India

This abstract was invited for an oral presentation in National Conference on

Emerging Issues in Public Health, AMCCON, Trivandrum, Kerala, India, January

11-13, 2008.

Page no. 157 CUTANEOUS ANTHRAX OUTBREAK IN A VILLAGE OF WEST BENGAL,

INDIA, 2007: THE DANGER OF UNSAFE HANDLING OF INFECTED COW

MEAT

Introduction: Following slaughtering of ill cows on 16/07/2007, 23/07/2007 and

01/08/2007, three clusters of suspected cutaneous anthrax was reported in

Charbinpara village of Murshidabad, West Bengal.

Objective: We investigated these clusters to identify the agent, mode of transmission and formulate recommendations for prevention.

Methods: We defined a suspected anthrax as occurrence of characteristic painless skin lesion (papule, vesicle or eschar) that appeared between

16/07/2007 and 15/08/2007 in a resident of the Charbinpara village, Murshidabad,

India and searched for cases door to door. We described the outbreak. We collected vesicular fluid from the skin lesions for microscopic examination and culture for Bacillus anthracis. We compared cases with unaffected household member of case-patients for exposure to the slaughtered animal while slaughtering, handling the raw meat and consumption of cooked meat etc. We calculated Relative risk (RR), 95% confidence intervals (CI) and population attributable fraction (PAF).

Results: We identified 44 case-patients of anthrax among 835 villagers (Attack rate: 5% ). We identified B. anthracis in 2 patients and isolated the organisms from

1 patient. Attack rates were higher among individuals aged 15-45 years (23/393,

6%) and males (32/413, 8%). We identified Slaughtering ill cow (RR-19, 95%

Page no. 158 Cl;11-30; PAF: 41%), Distribution meat (RR: 11, 95% Cl:7-19; PAF: 20%) and carrying skin (RR-8, 95% Cl: 2-32; PAF:2%) as risk factors.

Conclusions: The outbreak was associated with exposure to slaughtered animal meat. We educated villagers for not slaughtering ill animals and using personal protective measures while slaughtering or handling the raw meat.

Key words: Cutaneous Anthrax, outbreak, India

This abstract was invited for an oral presentation in International Night session, 57th Annual EIS Conference, April14-18, 2008, Centers for Disease Control and Prevention, Atlanta GA, USA

Page no. 159 CUTANEOUS ANTHRAX OUTBREAK IN A VILLAGE OF WEST BENGAL,

INDIA, 2007: THE DANGER OF UNSAFE HANDLING OF INFECTED COW

MEAT

Background: Following slaughtering of an ill cow on 6th October 2007, a cluster of suspected cutaneous anthrax was reported in Burakuli and adjacent Pirtala

J village of Murshidabad, West Bengal. We investigated this cluster to identify the agent, mode of transmission and formulate recommendations for prevention.

Methods: We defined a suspected anthrax as occurrence of characteristic papule or vesicle with or without eschar formation in a resident of affected village during

6th to 19th October 2007 and searched for cases door to door. We described the outbreak. We collected vesicular fluid from 1 skin lesion for microscopic examination for Bacillus anthracis. We compared cases with unaffected household member of case-patients for exposure to the slaughtered animal while slaughtering, handling the raw meat and consumption of cooked meat. We calculated Relative risk (RR), 95% confidence intervals (CI) and population attributable fraction (PAF).

Results: We identified 8 case-patients of anthrax among 3203 villagers (Attack rate: 25 per 10000 population) in Burakuli and Pirtala. We identified B. anthracis in 1 case patient. Attack rates were higher among individuals aged 15-45 years

(7/1492, 47 per 10000) and males (4/1666, 24 per 10000). We identified slaughtering of the ill cow and distribution meat were strongly associated with illness (RR:29, 95% Cl: 8- 107; PAF: 60% and RR:27, 95% Cl:7-99; PAF:60% respectively). However cleaning meat was less strongly associated with illness

Page no. 160 f

I (RR:3, 95% Cl: 0.8- 11; PAF: 33). Restricted analysis suggests no association of

0 cutaneous anthrax though there was 4% attack rate among meat eaters.

Conclusions: The outbreak was associated with exposure to slaughtered animal

meat. We educated villagers for not slaughtering ill animals and using personal

protective measures while slaughtering or handling the raw meat.

Key words: Cutaneous Anthrax, outbreak, India

This abstract was invited for a poster presentation in, 5th Global TEPHINET Conference, 1st-6th November 2008, Kualalumpur, Malaysia

Page no. 161 MEASLES OUTBREAK IN A VILLAGE OF WEST BENGAL, INDIA, 2007: THE

CONSEQUENCE OF POOR VACCINATION

Background: On 06/02/08 a cluster of children affecting fever with rash were reported from Kulgachi, Murshidabad, West Bengal. We investigated this cluster to identify the agent, mode of transmission and formulate recommendations for prevention.

Methods: We defined a case with fever and maculo- popular rash (i.e. non vesicular or without fluid), with cough or coryza (running nose) or conjunctivitis

(red eyes) between November and March, 2008 and searched for cases door to door. We described the outbreak. We collected serum sample for lgM antibody.

We calculated attack rate, Relative risk (RR), 95% confidence intervals (CI), vaccine efficacy and susceptible children.

Results: We identified 87 case-patients of measles among 348 children up to 10 years of age with two deaths (Attack rate: 20%; Case fatality rate: 2%) in

Kulgachi. We identified lgM antibody in 4 serum samples. Attack rates were higher among individuals aged 25-60 months (41/163, 25%) and females (47/208,

23% ). Compared with others, children exposed to immunization had a lower risk of getting measles (RR: 0.5, 95% C.l.: 0.3-.9). Over all vaccination coverage of children was 22%. Coverage among children >9 months is 32%. The vaccine efficacy was 48%, 95% CJ. 13% to 74%. All 85 children treated with vitamin A and symptomatic treatment.

Page no. 162 Conclusions: The outbreak was associated with poor immunization coverage of children and poor vaccine efficacy. We proactively vaccinate the unimmunized children and educated villagers for getting their children vaccinated. Requested health administration for improvement of cold chain as well as 2nd opportunity of measles.

Key words: Measles, outbreak, India

This abstract was invited for an oral presentation in, 5th Global TEPHINET Conference, 1st-6th November 2008, Kualalumpur, Malaysia

Page no. 163