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Indian Journal of Community Medicine

Outbreak of Pneumococcal Pneumonia in Miltary Barracks

Author(s): PMP Singh, AK Jaiswal, SK Handa, R Bhalwar, VK Wankhede, A Banerjee, D Bhatnagar, H Kumar

Vol. 31, No. 3 (2006-07 - 2006-09)

PMP Singh1, AK Jaiswal2, SK Handa3, R Bhalwar4, VK Wankhede5, A Banerjee6, D Bhatnagar7, H Kumar8

Abstract

Research Question: What are the various epidemiological factors contributing to pneumonia in military recruits? Objectives: To assess the various epidemiological factors contributing to pneumonia in military recruits. Study Design: Cross – sectional descriptive study. Setting: Two military training establishment in India. Study Subjects: Recruits undergoing military training in two training establishments. Statistical Analysis: Proportions. Result: A total of 316 cases of pneumococcal pneumonia occurred from 01 Jan 2004 till 16 Jun 2004. There was no fatality among any case. Detailed epidemiological investigation revealed that the per capita floor and cubic air space was was far below the standards laid down in Manual of Health for the Armed Forces 2003, pages 102, para 239 (a). This was due to unusually higher intake of recruits. X-Ray chest revealed homogenous consolidation of one or move lobes or segments typical of pneumonia. Out of the 316 cases, 233 (73.7%) showed mixed growth with predominant growth of pneumococcus, 44 (13.9%) showed of commensals and remaining 3 (0.9%) showed no growth. In 8 (0.2.5%) cases only saliva could be collected and therefore sputum culture could not be done. The epidemic was controlled by segregation of the affected squads and by reducing overcrowding. All the cases responded to penicillin group of antibiotics, which was also the result of the antibiotic sensitivity test carried out in the laboratory of the local Military Hospital.

Keywords: Pneumonia, Outbreak, Overcrowding, Recruits.

Introduction

Outbreaks of pneumonia in a community tend to be explosive and widespread, with many secondary cases resulting from the short incubation period of several days and the high degree of communicability. Highest incidence is in winter. S pneumoniae is the most common cause of pneumonia1 Epidemcs occur in closed polulation groups2,3,4. This article describes 316 cases of pneumonia which occurred from 01 Jan 2004.

Material and Methods

Epidemiological history was taken from all the 316 cases, e.g. history of movement, camps, history of sleeping on the floor, history of sleeping on double bunk bed, availability reports clothing for protection against cold, etc. Case sheets, laboratory reports and chest X-Rays were perused besides other relevant hospitalization documents. Routine haematological examination, X-Ray chest, sputum Gram stain and sputum culture reports were also examined. The two affected traning establishment were visited at least thrice a week reularly during the period of the outbreak and data was obtained pertaining to strength of recruits, turnover of recruits, and floor and cubic space of the barracks. Besides this hospital OPD and indoor records were also peruded for abnormally high incidence of other respiratory group of diseases bisides pneumonia. Normally recruits of the training establishments do not go to private practitioners or to civil hospital in times of illness. However visits were made to private practitioners and to Government ciivil hospital of the city to search for more cases. Meteorological data was also collected.

Surveillance data obtained from all the above sources for all the cases was reviewed. Detailed information was recorded on an epidemiological case sheet from each reported case.

Any individual typically presenting with high grade fever of sudden onset with chills and rigors, chest pain, difficulty in breathing, a cough productive of “rusty” sputum on clinical examination and found to have leukcytosis and pneumococcus oranism isloated from his sputum on culture or Gram stain or X-Ray chest shows features of pneumonia was labelled as a confirmed case of pneumonia. The diagnosis was arrived at clinically and confirmed radiologically or microbiologically. Any individual typically presenting with high grade fever of sudden onset with chills and rigors, chest pain, difficulty in breathing, a cough productive of “rusty” sputum on clinical examination was labelled as a presumptive case of pneumonia.

Results

Out of the total 316 case, 53 (16.81%) were hospitalized for 10 to 15 days. Two cases (00.6%) were hospitalized for more than 15 days. The remaining 261 cases (82.6%) were discharged after 7 to 10 days of hospitalization without any complications. All the cases survived.

One case (0.3%) relapsed after one week of discharge from the hospital. He was readmitted and treated again before being discharged.

X-Ray chest revealed homogenous consolidation of one or more lobes or segments typical of pneumonia. Of 233 (73.7%) cases diplococci / pneumococci were seen in their sputum culture. 28 (8.91%) showed mixed growth predominantly pneumococcus, 44 (13.9%) showed growth of commensals and remaining 3 (0.9%) showed no growth. In 8 (02.53%) case only saliva could be collected. All cases responded to penicillins for which antibiotic sensitivity test was positive.

Noon of the cases gave any history of movement outside unit line. No special event was revent was reported in the one week prior to the onset of disease. All cases of pneumonia were local.

All except 2 cases were amongst recruits. Two cases were amongst Non Commissioned Officers / Other Ranks. There was no case amongst Officers / Junior Commissioned Officers. Most cases were aged 17 – 23 years (95.91%). 111 (35.12%) cases were in training establishment A and 205 (64/91%) case were in training establishment B.

The first two cases of pneumonia occurred on 01 Jan 2004. This was followed by a gradual rise in the number of cases. The maximum number of admissions on any single day was 10 cases (3.25% of the total cases) on 29 Mar 2004, and 9 cases (2.8% of the total cases) each on 22 Mar 2004 and 24 Mar 2004.

In both the training establishments the floor space available to the recruits was only in the range of 1.4 to 1.6 m2 per capita while the air space was in the range of 4.27 m3 to 4.88 m3 per capita. The distance between the center of two adjacent beds was 0.6 to 0.9 m. The total strength of recruits present in both the training establishments put together was approximately 13500 during the period of the epidemic. The total strength of recruits in both the training establishments during the monthly enrolement of new recruits and the strength of recruits had increased in the year 2004 as compared to last year, in both the training establishments.

The population of both the establishment comprised mainly of young recruits who come from various branch recruiting officers all over the country who come from various branch recruiting offices all over the country and also those direclty from rural background and may be slightly underweight at the time of recruitment. Besides being from poor rural background they have very poor sense of personal hygiene and preventive measures of various communicable diseases. They follow a very hectic training schedule in the training establishmnets which subjects them to severe physical and mental stress and strain. Besides the hectic training schedule leaves them little time to consume their nutritious diet further causing them to become undernourished during their training. This reduces the immune respinse of their bodies to any infection. The low immunity current outbreak. Both the training establishments have their winter months from Dec to Mar. the maximum temperature during the months of Jan to Jun 2004 was 35°C to 43°C. The minimum temperature during the same period was 10°C to 26°C.

In the years 2002 and 2003 there were 103 and 118 cases of pneumonia respectively. The incidence per 1000 for the previous two year was 12.12 and 9.83 respectively. However no bacteriological confirmation could be established in the previous years. The incidence per 1000 for the year 2004 was 23.4. No such increased incidence of Pneumonia or any other communicable disease was observed in the civil population of the Cantonment and the city as was evident from local newspaper reports, local TV channels and liaison with local Cantonment General Hospital and local Civil Hospital. In order to control the outbreak the following preventive measures were taken immediately:

Adequate number of tents were procured and pitched and provisions made for ensuring optimum space per recruit. all available accommodation in the form of stores, sheds etc were used with suitable modifications to provide adequate ventillation, privacy and protection from inclement weather. Overcrowding was avoided at dining halls, cinema halls, cantens, recreation room, information rooms and barracks etc.

Windows, doors of all living, sleeping or working rooms were kept open, and the sides of all tents were rolled up by day. Efficient ventilation was also ensured by mechancal menas, in canteens, recreation room, schools and cineman.

The potential candidates reporting from Branch Recruiting Offices were isolated. They were kept in separate barracks away from the other recruits. They were not allowed to mingle with recrits undergoing training. They were not allowed to mingle with recruits undergoing training. They were forbidden from utilising the facilities and entertainment made available for recruis et. Canteen, cinema, dining halls, harracks meant for recuits etc. Early detection of cases/illness was ensured through ecucation and responsibility of squad leader, Non Commissioned Officer/Junior Commissoned Officer instructor incharge of the squad. Timely reporting of cases was ensured. Extensive health education of Officers, Junior Commissioned Officers, Non Commissioned Officers, other ranks and recruits was carried out.

Discussion

Most pneumonias arise form the aspiration of oropharyngeal flora, normally a complex assortment of aerobid and anaerobic bacteria. Which of these oraganism causes the pneumonia seems to depend upon the type of the microbes present and the quantity of material aspirated. Streptococcus pneumoniae, H influenzae, S pyogenes, Mycoplasma pneumoniae, and Moraxella catarrhalis are found in the oropharynx of healthy adults1.

5-10% of healthy adults may carry pneumococci in their nasopharynx which in certain groups may rise to 40 – 60 % as is evident from nasal smear culture5. The incidence of cases in the present study was 23.4 per 1000, while community studies carried out the would over indicate the overall rate of ivasive pneumococcal disease to vary from about 0.15 per 1000 population per year to 7 per 10004,6,7.

Streptococcus pneumoniae is known to be associated with upto 70% of pneumonia cases in which a pathogen is isolated8,9. In the present study also Streptococcus pneumoniae was isolated in more than 70% of cases. Factors that might contribute to increased susceptibility to respiratory infections in this population include cold weather; a precursor of airborne infections, complemented with manmade overcrowding; which exposes nonimmune pesons to several pathogens, and the physical and psychological stress of training. The per capita recommended standards for floor space and air space is 5 m2 and 18 m3 respectively.

The recommended standard distance between the centers of two adjacent beds is 1.8 m10. In both the training establishments, the standards for floor space, air space and distance between center of two adjacent beds was far below these recommended standards. In fact they were even below the standard of 4 m2 recimmended by WHO11. Correlation is known to exist between overcrowding and incidence of pneumonia12. Moreover the stress to which the recruits are subjected during the course of their training may suppress their immunity thus further predisposing them to infections13,14.

Various Governmental and professional groups have advocated pneumococcal vaccination in populations at risk15. Preventive strategies for pneumococcal infection include targeted use of the 23 valent polysaccharide vaccine for individuals older than 2 years of age16. The current vaccine is designed to elicit protective antibodies antibodies against 23 of 83 known capsular serotypes. These serotypes cause 90% of the invasive pneumococcal disease and include most penicillin resistant strains17. Vaccination can prevent about 50% of deaths from pneumococcal disease18.

Conclusion

The spread by droplet infection was due to gross overcrowding. Majority (95.99%) of the cases were 17-23 years of age. Such overcrowding puts tremendous pressure on the infrastructure and favours transmission of various diseases. Outbreaks of pneumonia and other communicable diseases have occurred in both these training establishment in the past and occur every year.

The Station Health Committee in each station should periodically review the progress in improvement of living accommodation during their quarterly meetings where it should invariably get top priority among all the agenda points. Routine surveillance by medical authorities for various respiratory infections be strengthened to prevent outbreaks of respiratory infections. Azithromycin or erythromycin prophylaxis may be resorted to as one of the preventive measures as the same has been found to be effective in reduction in pnemococcal carriage rates as well as reduction in pneumonia rates3. Administration of polyvalent pneumonia vaccine to recruits may be considered after research on prevalent serotypes in our military population.

References

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1 State Health Organization, Devlali.

2 Command Hospital, Pune.

3 Army Head Quarters, Lucknow Road, New Delhi

4 Deptt. of PSM, AFMC, Pune.

5 HQ 9 CORPS, C/o 56 APO.

6 HQ 101 Area, C/056 APO.

7 HQ 39 Mountain Division, C/o 56 APO

8 Station Health Organization, Mumbai-5

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