On March 27, 2012, the first death of the year from a mysterious skin diseasesometimes accompanied with multi-organ failure was reported in the Quảng Ngãi Provincein Vietnam.
Since then, the condition, popularly referred to as bệnh lạ (“strange disease”),has affected at least 132 more people in the province this year as of May 14, 2012 andkilled at least 21 of them toal.
However, this is not the first time the disease has strickenQuảng Ngãi. Bệnh lạ first appeared April 2011 and affected 98 people in the region untilJanuary 2012, when the disease disappeared.
A local resident has even claimed that bệnhlạ or a similar disease has been affecting people in the area for the past 5-6 years.
Despitethe time since these first cases, no specific etiology has yet been identified. News agencieshave reported causes ranging from molded rice to the herbicide Kanup 480 SL to the
is not a virus but rather a genus of gram-negative bacteria,
reflecting the dearth of quality in previous investigations).
However, none of thesepurported causes has been proven to cause disease. Considering the ongoing morbidity andmortality caused by bệnh lạ, continued investigation of the disease is critical.
Step 1: Define & Identify the “Numerator”
The first step of my outbreak investigation is to define a bệnh lạ case, which enablesfuture steps of the study. The number of people that fit my definition will be considered the“numerator” in initial statistical measures of attack rate, incidence, and prevalence.Initially, before the disease is extensively characterized, this definition should focuson the most apparent clinical symptoms. Throughout various news sources bothVietnamese and foreign, reported symptoms have varied. Sources invariably identifypainful skin rashes as a symptom but have also included different combinations of limbstiffness, contusions, fever, loss of appetite, miscarriage, miscarriages, eye problems, andsymptoms of liver failure.
However, if investigators only had access to the articlespinpointing contusions as a symptom of bệnh lạ and thus included bruising in their casedefinition, they would exclude all the patients with the same disease caused by the sameagents that fail to present with bruises. Similarly, including miscarriages in the casedefinition would exclude all men from being considered in the numerator. Including thesesymptoms would underestimate the calculated attack rate. It is thus necessary to devise aprecise definition of a case that is comprehensive and includes all patients with bệnh lạ.