S

Eric A. Tayag, MD, PHSAE, FPSMID Director IV, National Epidemiology Center
The views expressed in this paper are the views of the authors and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Directors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequences of their use. Terminology used may not necessarily be consistent with ADB official terms.

2nd National Sanitation Summit: Better Water Quality and Safety

FETP teams were deployed to CALAMBA and ILO-ILO following reports of increasing number of typhoid fever in March 2008.

2nd National Sanitation Summit: Better Water Quality and Safety

Why should we investigate?
• To establish the existence of the outbreak • To determine its source • To determine the mode of transmission • To identify risk factors • To recommend control and preventive measures

2nd National Sanitation Summit: Better Water Quality and Safety

Who are the Cases?
Suspect: ill persons presenting with acute onset of fever and headaches, abdominal discomfort, diarrhea, constipation or bloody stools. Probable: ill persons epidemiologicallylinked to confirmed cases. Confirmed: ill persons with blood or stool positive for Salmonella Typhi
2nd National Sanitation Summit: Better Water Quality and Safety

The Tale of Calamba

2nd National Sanitation Summit: Better Water Quality and Safety

Typhoid Cases by Age Group (N=2,462) Calamba City, Laguna, February 10 – March 14, 2008

Male Female

0

200

400

600

2nd National Sanitation Summit: Better Water Quality and Safety

Typhoid Cases by Geographical Location (N=1,261) Calamba City, Laguna, March 3, 2008
Legend:
Zero Case Cases 5 – 10 1 –50 51 Cases 3 –00 151 Cases >300 Cases

2nd National Sanitation Summit: Better Water Quality and Safety

Typhoid Cases by Geographical Location (N=2,462) Calamba City, Laguna February 10-March 14, 2008
Legend:
Zero Case Cases 5 – 10 1 –50 51 Cases 3 –00 151 Cases >300 Cases

2nd National Sanitation Summit: Better Water Quality and Safety

Laboratory Results
• 16% (+) Salmonella typhi

2nd National Sanitation Summit: Better Water Quality and Safety

Summary of Chlorine Residual
Calamba City, as of March 12, 2008
D ATE L O C A T IO N R E S U L T S  (p p m   o r  m g / l) 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 5 0 .2 0 .1 3 0 .0 8 T e s t in g   A gen cy CW D* CW D* CW D* CW D* CW D* CW D* CW D* CW D* CW D* CW D* CW D* CW D* D O H** REM ARKS F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d F a ile d

Standard = 0.3 mg/l

2 / 1 1 / 0 8 P a la o 2 /1 8 /0 8 V D C H a la n g R e a l  Tubo M a k ilin g 2 /2 6 /0 8 V P B V illa  C o n s o la c io n SCG H A z te c  H o m e s M a b o lo  S t. P h .3   3 / 1 1 / 0 8 P a ria n  W D  F a u c e t  R O W E N A  L A J A R A   B u c a l P u m p in g   3 /1 2 /0 8 S ta tio n L E  C p d ., B r y . 5   R O E L IO  L A R IN O
* C a la m b a W a te r D is tr ic t * * D e p a r tm e n t o f H e a lth

Source: National Epidemiology Center

2nd National Sanitation Summit: Better Water Quality and Safety

Summary of Water Quality Monitoring (N=221)
Calamba City, as of March 14, 2008
DATE 2/11/08 3/2/08 3/3/08 3/4/08 3/5/08 3/6/08 3/7/08 3/10/08 3/11/08 3/12/08 3/14/08 Total NO. OF SAMPLES  (+) FOR TOTAL  COLLECTED COLIFORM 19 1 7 24 26 35 13 28 9 13 1 4 179 0 4 11 10 1 9 2 1 1 3 43 % 5% 0% 17% 42% 29% 8% 32% 22% 8% 100% 75% 24% (+) For  E.Coli 0 0 0 0 1 0 0 0 0 1 1 3 % 0% 0% 0% 0% 3% 0% 0% 0% 0% 100% 25% 2%

Standard = 80 samples/mo and <20% positive

Source: National Epidemiology Center

2nd National Sanitation Summit: Better Water Quality and Safety

Calamba Water District
1 3

Treated and Tested for Chlorine Residual Storage Collection

5

4

2
Supplied to consumers

7 pumping stations

32,401 residential 2,014 commercial

2nd National Sanitation Summit: Better Water Quality and Safety

Environmental Survey

2nd National Sanitation Summit: Better Water Quality and Safety

Environmental Survey

Bonded water lines

Submerged pipes in contaminated water

2nd National Sanitation Summit: Better Water Quality and Safety

Distribution of Typhoid Fever Cases (N=2,462) Calamba City, Laguna
epidemiological  FETP did investigation 27% of water  samples  were (+) for  TC 24% of water  samples  were (+) for  TC of Cases Number water testing Joint Declared  Contained
Suspected Probable Confirmed

Low chlorine Residuals

Onset of Illness
Source: National Epidemiology Center

2nd National Sanitation Summit: Better Water Quality and Safety

Sidelights
• Overcrowding in hospitals • Costly treatment alternatives • PNRC to the rescue • CWD vs. DOH • The Vaccine Romp

2nd National Sanitation Summit: Better Water Quality and Safety

Conclusions
• There was a Typhoid Fever Outbreak in Calamba City, Laguna. • Probable source was contaminated, inadequately treated water • Contamination occurred at source, distribution, households

2nd National Sanitation Summit: Better Water Quality and Safety

The Tale of Iloilo

2nd National Sanitation Summit: Better Water Quality and Safety

2nd National Sanitation Summit: Better Water Quality and Safety

2nd National Sanitation Summit: Better Water Quality and Safety

Spot Map of Affected Areas
Iloilo City, January 1 – March 15, 2008 Iloilo City City Proper, Iloilo city Waterfront Area

LEGEND:

2nd National Sanitation Summit: Better Water Quality and Safety

Laboratory Results
• Blood culture
(‐) Salmonella typhi

• Rectal Swabs
9% (+) Aeromonas hydrophila  4% (+) Aeromonas caviae

2nd National Sanitation Summit: Better Water Quality and Safety

Laboratory Results
Bacteriologic Water Analysis Household water samples (+) Aeromonas hydrophila (+) Aeromonas caviae

2nd National Sanitation Summit: Better Water Quality and Safety

Environmental Survey
Narrow Pathways leading to interior of the Barangays Rubber Bands Used to Patch Leaking Pipes

2nd National Sanitation Summit: Better Water Quality and Safety

Environmental Survey
No Septic Tank Communal Deepwell

2nd National Sanitation Summit: Better Water Quality and Safety

Risk Factors
• Living in household with ill person • Use of public toilet • Drinking water from deep well • Drinking piped water

2nd National Sanitation Summit: Better Water Quality and Safety

Protective Factors
• Boiling water for drinking • Drinking rationed water • Hand washing

2nd National Sanitation Summit: Better Water Quality and Safety

Conclusions
• Outbreak of emerging pathogen • Outbreak due to combination of breakdown in water quality, inadequacy of water supply, inadequate sanitation and poor home hygiene

2nd National Sanitation Summit: Better Water Quality and Safety

Lessons Learned from the Tale of Two Cities

2nd National Sanitation Summit: Better Water Quality and Safety

Enforcing Standards
• Functional disease surveillance system • Regular, Adequate, Accurate Water Sampling • Responsive Alert System for Water Quality • Threshold for Boil Water Advisory • Post-outbreak Water Quality Monitoring • Ensuring Adequate Water supply • Improving Sanitation • Promoting Home Hygiene

2nd National Sanitation Summit: Better Water Quality and Safety

To be continued…

2nd National Sanitation Summit: Better Water Quality and Safety

Sign up to vote on this title
UsefulNot useful