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Report Investigation on Chicken Pox outbreak in Faridpur, Bangladesh Dr.Kh.

Mahbuba Jamil, Senior Scientific officer-Virology, IEDCR Chicken pox with secondary Bacterial infection: Outbreak investigation report, B angladesh: Background: On 6 June 2010, IEDCR got information from Civil Surgeon office Faridpur on outb reak of suspected Chicken pox with three deaths. Civil Surgeon communicated th e message to Director, IEDCR over telephone for taking immediate and necessary a ctions. Accordingly IEDCR formed and mobilized one investigation teams to invest igate the death and infected patients of respective areas. The team started for affected area on 7 June, 2010, stayed and investigated. ICDDR’B provide technical support to investigation team Team for Faridpur: Director IEDCR prepared a team and ordered for investigation of suspected outbre ak in Faridpur. Team Members: 1. Dr. Kh. Mahbuba Jamil, Senior Scientific Officer (Medical doctor &Virologist) , Department of Virology, IEDCR 2. Dr.Md. Monir, Medical officer, IEDCR 3. Dr. Farhana Haque , Outbreak Investigation officer , ICDDRB 4. Dr. Shahed Sazzad Shovon, Research investigator, ICDDRB 5. Riaz Ahmed, Medical Technologist, Department of Entomology, IEDCR 6. Abdul Hai Mondol, Data Collector, IEDCR B. Methodology •Formation of The Team for outbreak Investigation in Faridpur Briefing session with Civil surgeon , UHFPO, Local Physicians, medical assistant, Prepared a new list of infected patients attending union sub center Detailed interviewing of the parents and local people who live in the surroundin g region Physical examination, sample collection Photography of case and signs conducted home visit Laboratory testing of collected serum specimen At Civil Surgeon office Faridpur The team started for Faridpur from IEDCR, Dhaka in afternoon on 07 June, 2010 an d reached Faridpur by 11.30 pm. On 08 June, following a briefing session by Civi l Surgeon on the prevailing condition, the team initiated their investigation. T he first phase of investigation was comprised of collection of information about 2 deaths among three by in-depth interview of Doctors managing first death of c hickenpox in this season. From civil surgeon office we received a line list of c ases and deaths was sent by Upazilla Health Officer (UHFPO), Bhabga, Faridpur. At Kawlibera union of Bhanga Upazila Health Complex Team reached Bhanga UHC in Faridpur at 9:30 am on 08 June. The first site of inv estigation was Bhanga Upazila Health Complex where no patient of suspected chick en pox was admitted. Following another briefing session at UHFPO, the team started for incident site i n Kawlibera union and reached at 10:30 AM. Two villages ( Poraron & Khatra) wer e affected in Kawlibera union. Suspected Cases of fever followed by eruption of generalized blisters were identi fied, and enlisted by local health authority. Health assistant listed affected h

ouses before. From these selected household cases were identified and gave verba l consent for investigation. Case Investigation: According to the line list prepared by local health authority , cases were investigated by team. Team conducted in-depth interview of 13 cases . Data were collected in structured questioner and physical examination was done . The team also interviewed their relatives, relatives of two death cases and me dical assistant in charge. Specimens were collected. Specimen: Blood samples were collected from 11 cases willing to give and swabs we re taken from active case having blisters and ruptured blister with wet base. Sl ide smears were prepared from swabs collected from blisters or wounds and then s wabs were kept in viral Transport medium. Laboratory Investigations: Specimen:Blood samples were collected for serological evidence of suspected dise ase from all clinically diagnosed cases having new and old blisters.Swabs were c ollected from blisters and kept in viral transport medium. Smeared were prepared by swabs collected from ruptured blisters. Transport and preservation: All specimen were kept in cool box (4°C temp), transpo rted to laboratory. Serum was separated by centrifugation and two aliquots were made, one was preserved in -20°C. Other aliquot of serum and All VTM were put in 70°C refrigerator at Virology laboratory in IEDCR for longer period. Laboratory test: Serum was tested for detection of IgM to Varicella Zoster Virus (VZV) by Classical ELISA technique in Virology laboratory in IEDCR by skilled V irologist and laboratory personnel. The HUMAN VZV IgM ELISA test kit, Germany wa s used for these tests. Slides were stained with giemsa and gram stain. For isol ation of virus, monolayer of vero cells were inoculated after processing of spec imen in VTM. After 2 to 3 days when CPE was appeared, smeared were prepared by C PE positive cell and stained with giemsa for microscopy.Due to absent of reagent Immunofluorescence or PCR could not be done. C. Result and Finding: 1. At the site of incident Bhanga Upazila: i) Background and situation analysis •Bhanga is one of the large Upazilla in Faridpur District. There are 12 Unions & o ne Municipality. Total population of the Upazilla is 272737. 25-31% population i s bellows lower poverty line. Literacy 37.5 Food insecurity is very high. •Two villages of Kawlibera union was affected by disease. •In Kawlibera, out break of this disease started in late April 2010. A lot of chil dren as well as adult became infected and recovered. . It is noted from some pat ients (recovered) that during that two month period they visited their infected relatives and got infected. Three death cases came to the Upazila and District health centers, diagnosed cli nically as chicken pox by attending physician, provided supportive treatment and but they refused to take medicine regularly; moreover these three had other ol d age related disease like heart disease( irregular chest pain). Two had chicken pox at their child hood. •old man (1st death) had extensive blisters in oropharynx, could not take food and medicine. •It is reported by son in law of second death that the victim was the neighbor fi rst death, got huge big sized watery bulla like blisters attached to each other , had severe burning sensation . It was so extensive that no normal skin was see n. Some blister( Foshca) water were absorbed and some were ruptured, dried and t he skin became plain without leaving any scar. He received antibiotic and analg esic. He had of chicken pox at childhood.

•Contacts: We known from Physician and relatives that in same house of second dea th case three other got pox (two children and on adult)and recovered. •No patients was hospitalized during investigation ii) patients and attendant gave history of low grade Fever followed by watery b listers erupted mainly in the covered area of body. oMaculo papular rash followed by blisters ( fluid containing single vesicle), a ppeared first in trunk oItching and pain oHeadache oBurning of the eyes oPain in mouth and throat oCough ( one case, child) oDeath case had chest pain, severe head ache, disorientation, sever body ache wi th burning sensation. a) On physical examination we found: •vesicular eruption, monocular, most were infected, had whitish head, accumulated pus •Scabs, •Plain Scar marks (in some cases) •They came to out patient department and received supportive treatment.( Paracetam ol, Antihistamin, sometimes Antibiotic) •None of them were admitted to the hospital. b) Epidemiological relation •All have a history to meet or visit infected children/person/relatives •A good percentage of people did not take medicine prescribed by medical Doctor ra ther follow treatment by traditional healer. c) Seasonal correlation: •It is known from the health care providers and local peoples that outbreak of thi s disease has been started from early April 2010. A lot of patients came to the out patient department of Bhangra upazila and union sub centers. The weather was very dry at that time. The incidence has been falling down from early of May, 2 010, Again it has been started since last week of May and continuing during our visit. d) Laboratory Diagnosis: Test results: •Total 11 Serum samples were tested for detection of VZV specific IgM antibodies b y ELISA. Among them 9 was IgM positive. Rest two was antibody negative. •Microscopy of Gram stained smear revealed presence of Streptococci and Diplococci . Microscopy of giemsa stain shows intranuclear inclusion bodies in slides of fou r cases. D. Discussion: It was found and noted all patients had distinct clinical features such as fever and blisters in body,trunk, upper lower limbs, and very few on face. Clear bli sters sometimes found with contaminated fluid. Unilocular blisters appeared main ly in covered area of body like trunk, back, axils, mucous membrane of mouth whi ch correlated strongly with and suggesting a clinical diagnosis of Chicken pox. In small pox, blisters would be multiloculer/grouped, noncollapsing, usually app ear extensively in open part of body.

It was observed that most of the patients did not receive any treatment which mi ght reduce their intensity of sufferings. It was their believe to avoid medicine and protein diet during suffering from this type of disease for their bettement . Though different study reported that Immunocomprimised , 15 years of age and o lder , Pregnant women are at High risk for complications need essential manageme nt measure. We motivated the patient about taking prescribed medicine and available nutritio us food. The situation has been improving and patients have been recovered. After Testing of 11 serum specimen by ELISA, 9 were VZV specific IgM antibody p ositive, and 2 were found Negative for VZV with suffering period of 5 days only. If we test the serum sample of those two negative after 2 week the result might be change to positive due to increased antibody at detectable level. Intranuclear inclusion bodies on giemsa stained slides of characteristically dit ributed blistre suggestive of herpes virus. Presence of gram positive streptococ ci and diplococcic in vesicular wound specimen suggestive of bacterial contamina tion. Based on clinical diagnosis, epidemiological investigation and laboratory findin gs, the outbreak was appeared due to of chicken pox. E. Conclusion On reviewing the preliminary findings, Characteristics of pox was similar to chi cken pox. Clinical, epidemiological and laboratory findings do support the occurrence of c hicken pox. Limitation: Team has collected dentification. But due to lack Test could not done for small we have the technical skill to swabs in Viral Transport medium for virological i of reagent we could do Immunofluorescence or PCR. pox due to unavailablity of reagent also, though do.

F. Recommendation: •Susceptible and high-risk persons should be contacted by healthcare provider to d etermine if vaccination or pre/post-exposure prophylaxis is indicated •The local medical community should be notified if a varicella outbreak is occurri ng •Exclude students or staff with chickenpox from school and workplace until all les ions have crusted. This is usually 4-7 days (typically 6 days) after the rash be gan. •Healthcare providers are currently required to report critically ill chickenpox c ases and chickenpox-related deaths. •Reagent should be made available for rapid diagnosis of critically ill suspected cases. Acknowledgement: •Civil surgeon office, Faridpur •UHFPO office, Bhangra •Paracytology department, IEDCR, Dhaka * Virology laboratory, IPH, Dhaka Prepared by Submitted on Dr. Kh. Mahbuba Jamil, MBBS Mphil( Virology) 17.06.2010 Senior Scientific Officer

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