|Year : 2016 | Volume
| Issue : 2 | Page : 233-236
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
Department of Microbiology and Immunology, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar Garhwal, Uttarakhand, India
|Date of Submission||02-May-2015|
|Date of Acceptance||14-Jan-2016|
|Date of Web Publication||14-Apr-2016|
Department of Microbiology and Immunology, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar Garhwal, Uttarakhand
Source of Support: None, Conflict of Interest: None
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.
Keywords: Hepatitis A virus, Himalayan tsunami, integrated disease surveillance program, most probable number, outbreak
|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
|How to cite this URL:|
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 [serial online] 2016 [cited 2019 Jun 20];34:233-6. Available from: http://www.ijmm.org/text.asp?2016/34/2/233/180354
| ~ 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.  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.  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. , 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. , The incidence of hepatitis A is directly proportional to socioeconomic indicators such as poor water supply, poor sewage facilities and sanitary conditions. Improvement in hygienic and socioeconomic conditions decreases the incidence of HAV infection. 
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.  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.  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 claimed more than 5700 human lives and thousands of domestic animals and livestock were feared dead. The focus of the outbreak was an overcrowded, flood rescue camp with very poor hygienic conditions, in Rudraprayag district of Uttarakhand state, India.
| ~ Materials and Methods|| |
0In June 2013, 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, India. A linkage was hypothesised between the infected individuals and the common water sources feared of being contaminated faecally.
Collection of samples
Blood samples were collected from 28 children (Age: 2-9 years) clinically suspected of having hepatitis, over the period of 29 days (21 st June to 19 th July, 2013) and were sent to Microbiology laboratory of our hospital, a Tertiary Care Centre (Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar Garhwal) for serological investigations. Water samples were also collected from common water sources supplying the camps and were tested for the presence of faecal coliforms by standard methods. 
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, S.r.l, Varese, Italy) for anti-HAV-IgM antibodies.
Each water sample was vortexed before dilution and inoculation to ensure that the organisms present in water were uniformly distributed. The coliform count was assessed by the most probable number technique by using McCrady's tables.  Each sample was diluted 1:10 to give 360 coliforms per 100 ml as the upper limit of accurate estimation.
| ~ Results|| |
Among the 28 samples tested 25 (89.3%) were found positive for anti-HAV IgG and IgM antibodies by card test (screening test), and all were negative for anti-HEV antibodies. Of 25 samples found positive on screening, 23 (92%) were confirmed for Hepatitis A serology by anti-HAV IgM-ELISA. All the cases were children and belonged to age group 2 to 9 years, with male: female ratio of 1:1.3. Mild clinical symptoms were seen, and no mortality due to the infection was reported. All the eight water samples collected from the nearby water sources were found faecally contaminated and had >180 thermotolerant coliforms/100 ml of water.
| ~ Discussion|| |
In this report, 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. As all the cases were identified over a short period of the time and exhibited nearly identical symptoms, they were part of an outbreak that probably must have originated from a common source. This report is noteworthy in that it describes the emergence of an outbreak in a rescue camp, after the flash floods and multiple cloud bursts that affected the Kedarnath valley and the adjacent villages. As this natural calamity took place at the peak of a pilgrim season, so a large number of population was affected and this rescue camp was overcrowded. Moreover, the impact of this disastrous calamity was so severe that there was a complete breakdown of the communication with the affected area. The general condition of the people and the overall hygienic conditions in and around this camp were very poor. In addition, the people residing in the camp were bound to defecate in the open air. Although the packed food and drinking water was being supplied to the people sheltered in the camp but due to bad weather, repeated landslides and road blocks, the supply could not be maintained constantly. The people were also dependent on the natural water sources (Choyaa or Shrot)) which were found faecally contaminated, and the link between these water sources and outbreak was hypothesised. The time frame of disease occurrence and the incubation period of hepatitis A infection also further substantiate this link. The potential for hepatitis A outbreaks after flood-related sewage contamination of water sources has been recognised. Increases in the incidence of hepatitis A have been noted in association with natural disasters and attributed to disruptions in water and sanitation facilities.
The district health authorities were informed of the outbreak, so they could detect possible new cases quickly, report them urgently, advised to take appropriate measures to avoid person to person transmission and maintain the isolation of cases during the infectious period. However, the prevailing situation in the camp was quite poor. The control measures in such situation were difficult to implement as when the outbreak was detected the HAV was already circulating among the population. Besides the hygienic measures, avoidance of faecal-oral transmission was not easy to maintain among the population who by force was bound to defecate in the open air. As the main focus was to rescue the affected people and save as many lives as possible, it was very difficult to maintain the hygienic conditions in the camp which may have resulted in faecal contamination of the water sources. 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.
With the changing epidemiology of HAV, outbreaks of hepatitis A have been recorded in India. , Studies from northern India indicate that hepatitis A is becoming a major cause of sporadic hepatitis in children.  Earlier reports also suggest that India is hyperendemic for HAV infection with very high infection rates in the first few years of life.  The degree of endemicity is closely related to the prevailing hygiene and sanitary conditions, socio-economic level and other developmental indicators.  In the present report, given the poor environmental hygiene, it was interesting to note that all the affected children were between 2 and 9 years of age. All these children had a symptomatic disease which possibly reflects the outbreak of unknown magnitude.
Infectious disease distribution involves complex social and demographic factors. Meteorological factors such as temperature, humidity and rainfall patterns may influence the infectious disease transmission.  The intergovernmental panel on climate change noted in its 2007 report, that climate change may contribute to the expansion of high-risk areas for infectious diseases and may significantly increase the burden of diarrheal diseases.  The effect of climate change on human health in India is a broad topic. In South Asia, scientists predict an increased frequency of floods due to greater intensity of rainfall events and the glacier lake outburst floods (GLOFs) in mountainous regions. These trends are already being seen, as seen prior to this outbreak in the Kedarnath valley which is well known as Himalayan Tsunami. In the Himalayan region of South Asia particularly in Pakistan, Nepal, India and Bangladesh, the frequency of GLOFs rose during the past few years. ,
Floods create conducive environments for disease transmission as faecally contaminated flood water increases the rate of faecal-oral disease transmission, allowing diarrheal disease and other bacterial and viral illness to flourish. 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.  Diarrheal diseases are largely attributable to unsafe drinking water and lack of basic sanitation; thus reductions in the availability of fresh water are likely to increase the incidence of such diseases. Though Rudraprayag and the adjacent villages are not endemic for Hepatitis A but still the people visiting Char Dhams (Badrinath, Kedarnath, Gangotri and Yamunotri) every year may introduce the disease in this region. A pretravel health advisory should be issued to travellers, reminding them to follow good personal and food hygiene, as during travel this is quite difficult to maintain. Vaccination against HAV is also an important measure. Several safe and effective vaccines such as HAVRIX (Glaxo Smith Kline) and VAQTA (Merck and Co., Inc.) are available against HAV. A combination hepatitis A/hepatitis B vaccine consisting of HAVRIX and Engerix B (Twinrix, Glaxo Smith Kline) is also commercially available. Post-exposure vaccination is also effective and can be considered. Shen et al. demonstrated that the effectiveness of post-exposure vaccination was 100% in a common source outbreak.
As the prevailing situation in the camp and overall environmental and climatic conditions were not favourable, 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. However, 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.
| ~ Conclusion|| |
Despite great advances in medicine over the past decades, complications arising from natural calamities are still common. Such situations are more problematic for developing countries like India, where resources are limited. 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. However, 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. Preplanning and a core outbreak management team trained to deal with such situations should be formed. Furthermore, the long-term prevention of outbreaks will be achieved through implementation of high vaccination rate in schools and day care centres. Detection of confirmed HAV infections (with or without symptoms) should be a statutorily reportable situation for clinical laboratories, to allow a quick investigation of sources of infection and contacts for further appropriate and timely intervention. Our report can serve as a template for the development of local guidelines for prevention and appropriate management of such outbreaks.
Financial support and sponsorship
Integrated Disease Surveillance Programme, New Delhi, India.
Conflicts of interest
There are no conflicts of interest.
| ~ References|| |
Chobe LP, Arankalle VA. Investigation of a hepatitis A outbreak from Shimla Himachal Pradesh. Indian J Med Res 2009;130:179-84.
Verma R, Khanna P. Hepatitis A vaccine should receive priority in national immunization schedule in India. Hum Vaccin Immunother 2012;8:1132-4.
Sowmyanarayanan TV, Mukhopadhya A, Gladstone BP, Sarkar R, Kang G. Investigation of a hepatitis A outbreak in children in an urban slum in Vellore, Tamil Nadu, using geographic information systems. Indian J Med Res 2008;128:32-7.
Adamson R, Reddy V, Jones L, Antwi M, Bregman B, Weiss D, et al.
Epidemiology and burden of hepatitis A, malaria and typhoid in New York city associated with travel: Implications for public health policy. Am J Public Health 2010;100:1249-52.
Galmes-Truyols A, Gimenez-Duran J, Nicolau-Riutort A, Bosch-Isabel C, Vanrell-Berga JM, Portell-Arbona M. Outbreak of hepatitis A in a nursery school. Biomed Res Int 2013;2013:684908.
Stapleton TJ, Lemon SM. Infectious diseases. In: Hoeprich PD, Jordan MC, Ronald AR, editors. Hepatitis A and Hepatitis E. 5 th
ed. Philadelphia: Saunders; 1994. p. 790-800.
Senior BW. Examination of water, milk, food and air. In: Collee JG, Duguid JP, Fraser AG, Marmion BP, editors. Mackie and McCartney Practical Medical Microbiology. 13 th
ed. Edinburgh: Churchill Livingstone; 1989. p. 204-39.
Arankalle VA, Sarada Devi KL, Lole KS, Shenoy KT, Verma V, Haneephabi M. Molecular characterization of hepatitis A virus from a large outbreak from Kerala, India. Indian J Med Res 2006;123:760-9.
Chobe LP, Arankalle VA. Investigation of a hepatitis A outbreak from Shimla Himachal Pradesh. Indian J Med Res 2009;130:179-84.
Hussain Z, Das BC, Husain SA, Murthy NS, Kar P. Increasing trend of acute hepatitis A in North India: Need for identification of high-risk population for vaccination. J Gastroenterol Hepatol 2006;21:689-93.
Dhara VR, Schramm PJ, Luber G. Climate change and infectious diseases in India: Implications for health care providers. Indian J Med Res 2013;138:847-52.
Confalonieri U, Menne B, Akhtar R, Ebi KL, Hauengue M, Kovats RS, et al
., editors. In: Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, UK: Cambridge University Press; 2007.
Bajracharya SR, Mool PK, Shrestha BR. The Impact of Global Warming on the Glaciers of the Himalaya. International Symposium on Geo-disasters, Infrastructure Management and Protection of World Heritage Sites, 25-26 November, 2006; Nepal Engineering College, Ehime College and National Society for Earthquake Technology Nepal; 2006. p. 231-42.
Shen YG, Gu XJ, Zhou JH. Protective effect of inactivated hepatitis A vaccine against the outbreak of hepatitis A in an open rural community. World J Gastroenterol 2008;14:2771-5.