You are on page 1of 5

Indian Journal of Medical Microbiology, (2016) 34(2): 233-236

1

Brief Communication

An outbreak of hepatitis A virus among children in a flood rescue camp: A
post‑disaster catastrophe
S Pal, *D Juyal, M Sharma, S Kotian, V Negi, N Sharma

Abstract
We report an outbreak of acute viral hepatitis among children in a flood rescue camp at Rudraprayag district of
Uttarakhand State, India. In May 2013, there was a disastrous natural calamity, The Himalayan Tsunami in Himalayan
and Sub‑Himalayan region of Uttarakhand. More than 5700 people were feared dead, and thousands were sheltered in
different rescue camps. A linkage was hypothesised between the infected individuals and the common water sources
feared of being contaminated faecally. Aetiological agent of the present outbreak was HAV that is emerging in an
outbreak form in India, emphasizing a definite need for formulating mandatory vaccination and proper control strategies.
The report exemplifies the basic problems encountered after a natural calamity.
Key words: Hepatitis A virus, Himalayan tsunami, integrated disease surveillance program, most probable number,
outbreak

Introduction
Hepatitis A is an enterically transmitted viral disease of
global public health importance caused by the virus known
as hepatitis A virus (HAV) and is the only member of the
genus Hepatovirus within the family Picornaviridae.[1]
Disease transmission occurs primarily via the faecal‑oral
route, either through ingestion of contaminated food
and water or through direct contact with the infectious
person.[2] Various foodborne and waterborne outbreaks
have been reported previously. Chobe et al. from Shimla,
Himachal Pradesh and Sowmyanarayanan et al. from
Vellore, Tamil Nadu have described the waterborne
outbreaks of hepatitis A originating from a contaminated
water source.[1,3] Infection may also occur among high‑risk
groups such as, travellers to the areas of high endemicity,
men who have sex with men and intravenous drug users.[4,5]
The incidence of hepatitis A is directly proportional to
socioeconomic indicators such as poor water supply, poor
*Corresponding author (email: <deepakk787@gmail.com>)
Department of Microbiology and Immunology (SP, DJ, MS, SK,
VN, NS), Veer Chandra Singh Garhwali Government Medical
Sciences and Research Institute, Srinagar Garhwal, Uttarakhand,
India
Received: 02-05-2015
Accepted: 14-01-2016
Access this article online
Quick Response Code:

Website:
www.ijmm.org

DOI:
10.4103/0255-0857.180354

sewage facilities and sanitary conditions. Improvement
in hygienic and socioeconomic conditions decreases the
incidence of HAV infection.[3]
The mean incubation period of the disease is
approximately 30 days (range 2–6 weeks). Approximately,
85% of infected individuals have a full recovery within
3 months and nearly all have a complete recovery
by 6 months. Anti‑HAV antibodies can be detected during
acute illness. The early antibody response is predominantly
of immunoglobulin M (IgM) class and is used to establish
the diagnosis of acute infection. During convalescence
and during subsequent life, however, anti‑HAV of the
immunoglobulin G (IgG) class becomes the predominant
antibody.[3] The clinical severity of the HAV infection
increases with age and varies from an asymptomatic
infection to a fulminant hepatic failure. Disease is
asymptomatic in only 4–16% of children compared to
75–95% of adults.[6] It is believed that most children acquire
immunity through asymptomatic infection early in life.
The aim of this paper is to describe an outbreak of
HAV among children <10 years of age. The outbreak
evolved between June and July 2013 after the devastating
Himalayan Tsunami of Uttarakhand in May 2013 which
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Pal S, Juyal D, Sharma M, Kotian S, Negi V,
Sharma N. An outbreak of hepatitis A virus among children in a flood
rescue camp: A post-disaster catastrophe. Indian J Med Microbiol
2016;34:233-6.

© 2016 Indian Journal of Medical Microbiology Published by Wolters Kluwer - Medknow

and the link between these water sources and outbreak was hypothesised. Results Among the 28 samples tested 25 (89. so they could detect possible new cases quickly. Besides the hygienic measures.[7] Serology Samples were screened for anti‑HAV and anti‑HEV IgM and IgG antibodies by using rapid immunochromatographic assay (SD Bioline IgG/IgM rapid Test) and were confirmed by ELISA (DSI. This report is noteworthy in that it describes the emergence of an outbreak in a rescue camp. in Rudraprayag district of Uttarakhand state.234 Indian Journal of Medical Microbiology vol. the impact of this disastrous calamity was so severe that there was a complete breakdown of the communication with the affected area. The people were also dependent on the natural water sources (Choyaa or Shrot) which were found faecally contaminated. The coliform count was assessed by the most probable number technique by using McCrady’s tables. However. Srinagar Garhwal) for serological investigations.3.3%) were found positive for anti‑HAV IgG and IgM antibodies by card test (screening test). 2 claimed more than 5700 human lives and thousands of domestic animals and livestock were feared dead. No. India. a report under infectious disease surveillance program was received from the local health authorities regarding the suspected outbreak of acute viral hepatitis among children in a flood rescue camp in Rudraprayag District of Uttarakhand State. over the period of 29 days (21st June to 19th July. repeated landslides and road blocks. The focus of the outbreak was an overcrowded. Materials and Methods Discussion Study area In this report. In June 2013. All the eight water samples collected from the nearby water sources were found faecally contaminated and had >180 thermotolerant coliforms/100 ml of water.ijmm. Increases in the incidence of hepatitis A have been noted in association with natural disasters and attributed to disruptions in water and sanitation facilities. they were part of an outbreak that probably must have originated from a common source. we identified 23 cases over a period of 29 days and due to this sudden increase linked to time and space we considered this an outbreak of HAV. Although the packed food and drinking water was being supplied to the people sheltered in the camp but due to bad weather. S. after the flash floods and multiple cloud bursts that affected the Kedarnath valley and the adjacent villages. 34.r. and all were negative for anti‑HEV antibodies. with male: female The district health authorities were informed of the outbreak. avoidance of faecal-oral transmission was not easy to maintain among the population who by force was bound to defecate in the open air. The control measures in such situation were difficult to implement as when the outbreak was detected the HAV was already circulating among the population. 2013) and were sent to Microbiology laboratory of our hospital. Collection of samples Blood samples were collected from 28 children (Age: 2–9 years) clinically suspected of having hepatitis. As all the cases were identified over a short period of the time and exhibited nearly identical symptoms. Water samples were also collected from common water sources supplying the camps and were tested for the presence of faecal coliforms by standard methods. The potential for hepatitis A outbreaks after flood‑related sewage contamination of water sources has been recognised.[7] Each sample was diluted 1:10 to give 360 coliforms per 100 ml as the upper limit of accurate estimation. it was very difficult to maintain the hygienic www. Moreover. Varese. As this natural calamity took place at the peak of a pilgrim season. India. the people residing in the camp were bound to defecate in the open air. Water analysis Each water sample was vortexed before dilution and inoculation to ensure that the organisms present in water were uniformly distributed. Mild clinical symptoms were seen. All the cases were children and belonged to age group 2 to 9 years. the supply could not be maintained constantly. ratio of 1:1. The time frame of disease occurrence and the incubation period of hepatitis A infection also further substantiate this link. Of 25 samples found positive on screening. report them urgently. a Tertiary Care Centre (Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute. As the main focus was to rescue the affected people and save as many lives as possible. and no mortality due to the infection was reported. so a large number of population was affected and this rescue camp was overcrowded.org . advised to take appropriate measures to avoid person to person transmission and maintain the isolation of cases during the infectious period.l. In addition. flood rescue camp with very poor hygienic conditions. Italy) for anti‑HAV‑IgM antibodies. A linkage was hypothesised between the infected individuals and the common water sources feared of being contaminated faecally. 23 (92%) were confirmed for Hepatitis A serology by anti‑HAV IgM‑ELISA. The general condition of the people and the overall hygienic conditions in and around this camp were very poor. the prevailing situation in the camp was quite poor.

as seen prior to this outbreak in the Kedarnath valley which is well known as Himalayan Tsunami. as during travel this is quite difficult to 235 maintain. Vaccination against HAV is also an important measure. Preplanning and a core outbreak management team trained to deal with such situations should be formed. the long‑term prevention of outbreaks will be achieved through implementation of high vaccination rate in schools and day care centres. New Delhi. Furthermore.130:179‑84. scientists predict an increased frequency of floods due to greater intensity of rainfall events and the glacier lake outburst floods (GLOFs) in mountainous regions. Chobe LP.9] Studies from northern India indicate that hepatitis A is becoming a major cause of sporadic hepatitis in children.[11.13] Floods create conducive environments for disease transmission as faecally contaminated flood water increases the rate of faecal‑oral disease transmission. Shen et al. it should also be kept in mind that it is quite difficult to achieve the ideal control measures in the extreme situations like discussed in the current report. the frequency of GLOFs rose during the past few years. www.[10] Earlier reports also suggest that India is hyperendemic for HAV infection with very high infection rates in the first few years of life. A combination hepatitis A/hepatitis B vaccine consisting of HAVRIX and Engerix B (Twinrix.[11] The intergovernmental panel on climate change noted in its 2007 report. Investigation of a hepatitis A outbreak from Shimla Himachal Pradesh. Gangotri and Yamunotri) every year may introduce the disease in this region. so an epidemiological investigation of this outbreak was not possible at that particular moment of time and this is a primary limitation of our report.. Kedarnath. A pretravel health advisory should be issued to travellers. Infectious disease distribution involves complex social and demographic factors.: Hepatitis A virus outbreak in flood rescue camp conditions in the camp which may have resulted in faecal contamination of the water sources.[8.[14] demonstrated that the effectiveness of post‑exposure vaccination was 100% in a common source outbreak. Though Rudraprayag and the adjacent villages are not endemic for Hepatitis A but still the people visiting Char Dhams (Badrinath. It is of particular concern in Himalayan and Sub‑Himalayan regions as in the situation of flood the access to clean water and sanitation is limited. complications arising from natural calamities are still common. Arankalle VA. reminding them to follow good personal and food hygiene. outbreaks of hepatitis A have been recorded in India. Inc. In South Asia.org . As the prevailing situation in the camp and overall environmental and climatic conditions were not favourable. All these children had a symptomatic disease which possibly reflects the outbreak of unknown magnitude. Financial support and sponsorship Integrated Disease Surveillance Programme.[11] Diarrheal diseases are largely attributable to unsafe drinking water and lack of basic sanitation. References 1. allowing diarrheal disease and other bacterial and viral illness to flourish.[10] The degree of endemicity is closely related to the prevailing hygiene and sanitary conditions. this report exemplifies the basic problems encountered after a natural calamity and we believe it can be helpful in the development of control strategies for effective management of such situations. socio‑economic level and other developmental indicators. thus reductions in the availability of fresh water are likely to increase the incidence of such diseases. India.) are available against HAV. Glaxo Smith Kline) is also commercially available. et al.April-June 2016 Pal. Meteorological factors such as temperature. However. Detection of confirmed HAV infections (with or without symptoms) should be a statutorily reportable situation for clinical laboratories. These trends are already being seen.[9] In the present report. where resources are limited. Indian J Med Res 2009. Our report can serve as a template for the development of local guidelines for prevention and appropriate management of such outbreaks. India and Bangladesh. With the changing epidemiology of HAV. to allow a quick investigation of sources of infection and contacts for further appropriate and timely intervention. Such situations are more problematic for developing countries like India. given the poor environmental hygiene. Several safe and effective vaccines such as HAVRIX (Glaxo Smith Kline) and VAQTA (Merck and Co. It is obvious that improved sanitation will lead to more success in controlling the spread of HAV and vaccination of susceptible population is the cornerstone of outbreak control. Conclusion Despite great advances in medicine over the past decades. humidity and rainfall patterns may influence the infectious disease transmission.[12] The effect of climate change on human health in India is a broad topic. Nepal.ijmm. it was interesting to note that all the affected children were between 2 and 9 years of age. Post‑exposure vaccination is also effective and can be considered. By the time further control measures like vaccination of children and close contacts could be implemented most of these cases were rescued from the area. However. Conflicts of interest There are no conflicts of interest. that climate change may contribute to the expansion of high‑risk areas for infectious diseases and may significantly increase the burden of diarrheal diseases. In the Himalayan region of South Asia particularly in Pakistan.

Hepatitis A and Hepatitis E. Sarkar R. Infectious diseases. Shen YG. Bajracharya SR. vol. Cambridge. p. food and air. 13th ed. The Impact of Global Warming on the Glaciers of the Himalaya. Chobe LP. Arankalle VA. Haneephabi M. 5th ed. editors. Protective effect of inactivated hepatitis A vaccine against the outbreak of hepatitis A in an open rural community. Dhara VR. International Symposium on Geo‑disasters. Schramm PJ. Arankalle VA. Murthy NS. 2006. 9. Climate change and infectious diseases in India: Implications for health care providers. Marmion BP. p. Outbreak of hepatitis A in a nursery school. milk. using geographic information systems. 2 Indian J Med Res 2006. Adamson R. Mool PK. Fraser AG. Confalonieri U. Shenoy KT. Antwi M. In: Human Health. 4. Das BC. www. Verma R. 10. Kang G. Khanna P. Weiss D. Jordan MC. Hepatitis A vaccine should receive priority in national immunization schedule in India. Ehime College and National Society for Earthquake Technology Nepal. Tamil Nadu. Lole KS. Stapleton TJ. editors. Philadelphia: Saunders. 2006. 204‑39. Sarada Devi KL. Verma V. Climate Change 2007: Impacts. 1994. Duguid JP.130:179‑84. Husain SA. Mukhopadhya A.21:689‑93. Gimenez‑Duran J. Gu XJ.123:760‑9. Bosch‑Isabel C. 790‑800. Examination of water. Indian J Med Res 2008. Luber G. 8. 1989. Nepal Engineering College. Akhtar R. India. 13. 5. Sowmyanarayanan TV. Shrestha BR. 12. Molecular characterization of hepatitis A virus from a large outbreak from Kerala. 25‑26 November. Increasing trend of acute hepatitis A in North India: Need for identification of high‑risk population for vaccination.. Kar P. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Investigation of a hepatitis A outbreak from Shimla Himachal Pradesh. Portell‑Arbona M. Menne B. Biomed Res Int 2013. 7. et al.14:2771‑5. et al. Indian J Med Res 2013. editors. 11. Jones L.100:1249‑52. 3. Gladstone BP. Adaptation and Vulnerability. Bregman B.org . World J Gastroenterol 2008. Vanrell‑Berga JM. Hussain Z. 34. In: Collee JG. Reddy V. Lemon SM. Hauengue M. Ronald AR. Senior BW. No. 2007. Edinburgh: Churchill Livingstone. Infrastructure Management and Protection of World Heritage Sites. 231‑42. Ebi KL.8:1132‑4. 14. In: Hoeprich PD.128:32‑7. Indian J Med Res 2009.138:847‑52. Kovats RS. Epidemiology and burden of hepatitis A. Galmes‑Truyols A. UK: Cambridge University Press. J Gastroenterol Hepatol 2006. Nicolau‑Riutort A.2013:684908. Am J Public Health 2010. p.236 Indian Journal of Medical Microbiology 2. 6. Investigation of a hepatitis A outbreak in children in an urban slum in Vellore. Zhou JH. Mackie and McCartney Practical Medical Microbiology.ijmm. malaria and typhoid in New York city associated with travel: Implications for public health policy. Hum Vaccin Immunother 2012.

users may print. However. or email articles for individual use. . and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.Copyright of Indian Journal of Medical Microbiology is the property of Medknow Publications & Media Pvt. download. Ltd.