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Indian Journal of Community Medicine

A study of hepatitis E outbreak in rural area of Western Maharashtra

Author(s): Gurav YK, Kakade SV, Kakade RV, Kadam YR, Durgawale PM

Vol. 32, No. 3 (2007-07 - 2007-09)

ORIGINAL ARTICLE

Year : 2007 | Volume : 32 | Issue : 3 | Page : 182-184

A study of hepatitis E outbreak in rural area of Western Maharashtra

Gurav YK1, Kakade SV2, Kakade RV2, Kadam YR2, Durgawale PM2
1 Department of PSM, Shri V. N. Government Medical College, Yavatmal, India
2 Department of PSM, Krishna Institute of Medical Sciences, Karad, India
Date of Submission 02-Jan-2006
Date of Acceptance 16-Jan-2007

Correspondence Address:
Gurav Y K
Department of P.S.M, Shri. VN Govt Medical College, Dist. Yavatmal - 445 001, Maharashatra
India

Source of Support: None, Conflict of Interest: None
How to cite this article:
Gurav YK, Kakade SV, Kakade RV, Kadam YR, Durgawale PM. A study of hepatitis E outbreak in rural area of Western Maharashtra. Indian J Community Med 2007;32:182-4
How to cite this URL:
Gurav YK, Kakade SV, Kakade RV, Kadam YR, Durgawale PM. A study of hepatitis E outbreak in rural area of Western Maharashtra. Indian J Community Med [serial online] 2007 [cited 2007 Nov 30];32:182-4. Available from: http://www.ijcm.org.in/text.asp?2007/32/3/182/36822

Abstract

Aim: To study the profile of infective hepatitis cases in the study village. Objective: 1. To study the time, place, and person distribution of hepatitis cases in the study village. 2. To find the source of infection in the study village. Design: Cross-sectional study. Setting: Rethare Khurd village (15 km south of Karad, on bank of River Krishna), over a period of September 4, 2004 to December 5, 2004. Participants: All residents of Rethare Khurd village. Statistical Analysis: Proportions, attack rate, Chi-square test were performed. Results: Total 3749 individuals were surveyed and examined, of which 1920 (51.21%) were males and 1829 (48.78%) were females. Total 8 males and 17 females suffered from infective hepatitis. Blood samples collected from 10 patients for liver function test and serological investigation confirmed a hepatitis E outbreak. Maximum numbers of cases were in the age group of 15-30 years. The overall attack rate was 0.66%. The difference in attack rate of hepatitis of both the sexes was not statistically significant ( P >0.05).Only one ANC had infective hepatitis. Majority of the villagers (61.12%) defecated in the open near the intake well on the bank of River Krishna. Conclusion: This outbreak illustrates the role of the local Government in prevention and control of water borne epidemic and to strengthen the surveillance for water borne diseases in the rural area.

Keywords: Environmental sanitation, infective hepatitis E, rural population

Hepatitis E appears to be a wide-spread problem in developing countries where there is inadequate safe drinking water and sewage disposal problems.[1] Epidemics of enterically transmitted hepatitis is well documented from different parts of India. Almost all outbreaks of viral hepatitis in India are due to faeco-orally transmitted hepatitis E.[2]

During the period of July 2004-August 2004, a large number of jaundice cases were reported in Rethare Khurd village, Taluka Karad District, Satara. On the request of the Medical Superintendent of Sow Venutai Chavan Cottage Hospital, Karad and Medical Officer of Primary Health Center, Rethare, a team of doctors including one epidemiologist visited Rethare Khurd village to study the profile of infective hepatitis cases in the village.

Materials and Methods

The present cross-sectional study was conducted from September 5, 2004 to December 5, 2004 in Rethare Khurd village, situated 15 km south of Karad city on bank of River Krishna. A house-to-house survey was conducted by complete enumeration of all families of the village using pre-designed pro-forma. Relevant information required to assess the possible epidemiological factors (e.g., source of drinking water and excreta disposal) was also collected. Epidemiological investigation and sanitary survey were carried out in the village.

The study sample was also inquired about their exposure, if any, to blood transfusion, hospitalization, injections, and surgical procedures etc. Individuals showing signs and symptoms of hepatitis were examined and investigated to confirm the diagnosis. The laboratory investigation reports available from the subjects were also recorded. The samples of drinking water were tested for probable faecal coliform. Blood samples of hepatitis cases were tested at the Krishna Institute of Medical Sciences, Karad to determine the type of hepatitis outbreak.

Results

The total population of Rethare Khurd village was 3749. There were 764 families in the village, of which 429 (56.15%) were nuclear families. Approximately 242 (31.67%) and 187 (24.47%) families belonged to socioeconomic class III and IV, respectively. Majority of the villagers (81%) were consuming the water supplied by the grampanchayat water tank after chlorination. Majority of the (61.12%) villagers did not have sanitary latrine systems, and hence, defecated in the open on the bank of River Krishna [Table - 1].

Out of 3749 individuals surveyed and examined, maximum cases were in the age group of 15-30 years. The overall attack rate was 0.66% [Table - 2]. Out of 25 cases of hepatitis, 8 were males and 17 were females. None of the family members of the hepatitis cases reported hepatitis positive; this suggested there were no secondary attack rates. Of the 29 pregnant women in the village, only one suffered from hepatitis and had an uncomplicated pregnancy. The course was similar to all other pregnant females in the village who had not developed hepatitis. Healthy pregnant women were given immunoglobulins during this epidemic. The difference in the attack rate of infective hepatitis of both the sexes was not statistically significant ( P > 0.05). The attack rate was 0.4% in males, while it was 0.9% in females. The overall attack rate was 0.6%.

The epidemic curve of the weekly incidence of hepatitis cases showed that the outbreak initiated in the third week of August, 2004; reached its peak in the first week of September, 2004; and subsided in the fourth week of September, 2004. The first and last cases were reported on August 18 and September 17, 2004, respectively [Figure - 1]. After the last case of hepatitis, no cases were found during the follow-up visits up to the second week of November 2004. Clinical manifestation of the cases showed that all cases had yellow discoloration of eyes, 88% had history of fever, and 80% had dark coloured urine. On an average, the pre-icteric phase lasted for 4 days and icteric phase lasted for 6 weeks. Majority of the cases (72%) had taken allopathic treatment and only two cases had taken ayurvedic treatment. Laboratory investigations of the patient showed raised serum bilirubin levels (>2 mg/dl). On an average, the liver function tests showed results on the higher side. Mean serum bilirubin was 4 mg/dl, mean S.G.O.T. was 270 IU, mean S.G.P.T. was 294 IU, and mean serum alkaline phosphatase was 321 IU.

Ten serum samples of hepatitis patients investigated at Krishna Institute of Medical Sciences, Karad showed anti-HEV IgM antibodies, and hence, confirmed the epidemic of hepatitis E virus. No dual infection was seen in this epidemic. There was no history of surgery, hospitalization, or blood transfusion among the cases during the last six months prior to the onset of jaundice.

On bacteriological examination, 80% water samples showed faecal coliform. Sanitary survey revealed that sewage water was mixed with the water in the intake well from which the water, after chlorination, was supplied by the grampanchayat water tank to all villagers. Additionally, at many places, the water pipelines were close to nalas where the sewage water and the effluent from the gobar gas plant drained.

Discussion

This study confirms the fact that there was an epidemic of infective hepatitis E in Rethare Khurd village between August 2004 and September 2004. A total 10 (40%) hepatitis patients were investigated. Epidemiologically, the outbreak was an explosive one, as out of 25 cases of hepatitis, 23 suffered from infective hepatitis within a span of four weeks and the phenomenon pointed toward a common source. This may be due to the heavy rains in mid July and August 2004; all the waste water from various sewage lines in the village were flushed and mixed with the upstream of River Krishna and the intake well. Also, the majority (61%) households defecated in the open on the bank of River Krishna, near the intake well, which may be the primary source of infection. The sanitary survey also revealed leakage in the water supply system.

In the present outbreak, the overall attack rate was 0.66%, which was found to be as low as compared to another reported outbreaks where it was 1.4% [3] to 3.76%, [4] respectively. Similar low attack rate (0.79%) was reported in epidemic of viral hWepatitis occurred in the city of Karnal, Haryana.[5] Age specific attack rate in present outbreak was found to be maximum in 15-30 years, which is similar to that reported in other studies.[5],[6] Contrary to this finding, another study reported maximum occurrence of cases in the age group of under 15 years.[7] In the present study, the difference in the attack rate of hepatitis of both the sexes was not statistically significant (χ2 = 3.72, df = 1, P > 0.05). Similar findings were reported by another study.[7] There was no difference in the course of clinical hepatitis between males and females.

Termination of the outbreak appeared to be due to the contact effect of field staff emphasizing personal and domestic hygienic practices, supply of safe water, and improving environmental sanitation. Reparations of the water and sewer lines were undertaken with close coordination by the public health engineering department.

Acknowledgements

The authors are grateful to and acknowledge the cooperation and support of the Principal, Krishna Institute of Medical Sciences Karad; District Health Officer, Satara; Medical Superintendent, Sow Venutai Chavan Cottage Hospital, Karad; and Medical Officer, P.H.C. Rethre.

References

1. Park K. Park's text book of preventive and social medicine. 18 th ed. Bhanot Publisher: Jabalpur; 2005. p. 175.
2. Directorate of Health Services, Maharashatra. Disease surveillance-Training Module, National Surveillance Programme for Communicable Diseases: 1999. p. 45-55.
3. Kane MA, Bradley DW, Shrestha SM, Maynard JE, Cook EH, Mishra RP, et al . Epidemic non -A, non-B hepatitis in Nepal: Recovery of a possible etiological agent and transmission studies in marmosets. JAMA 1984;252:3140-5.
4. Naik SR, Aggarwal R, Salunke PN, Mehrotra NN. A large water borne viral hepatitis E epidemic in Kanpur, India. Bull WHO 1992;70:597-604.
5. Dilawari JB, Singh K, Chawla YK, Ramesh GN, Chauhan A, Bhusnurmath SR, et al . Hepatitis E Virus: Epidemiological, clinical and serological studies of a North Indian Epidemic. Indian J Gastroenterol 1994;13:44-8.
6. Tandon BN, Joshi YK, Jain SK. An epidemic or non-A, non -B hepatitis in North India. Indian J Med Res 1982;75:739-44.
7. Das D, Biswas R, Pal D. An epidemiological investigation of jaundice outbreak in a slum area of Chetla, Kolkata. Indian J Public Health 2004;48:212-5.

Figures

Click on image for larger view

Figure 1: Epidemic curve showing weekly incidence of hepatitis cases in Rethare Khurd village

Figure 1: Epidemic curve showing weekly incidence of hepatitis cases in Rethare Khurd village

Tables

Table 1: Socio-demographic characteristics of study population

Table 1: Socio-demographic characteristics of study population

Table 2: Distribution of study population by age, sex, and attack rate of infective hepatitis

Table 2: Distribution of study population by age, sex, and attack rate of infective hepatitis

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