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Indian Journal of Community Medicine

Control of Viral Hepatitis in Cantonments: An Experience

Author(s): V. K. Agrawal

Vol. 31, No. 4 (2006-10 - 2006-12)

V. K. Agrawal

Abstract

Research Question: Investigation and analysis of occurrence of viral hepatitis in troops on day to day basis instead of weekly / monthly basis may help in detection and containment of epidemic in early stage in cantonments. Objectives: To investigate and analyze occurrence of viral hepatitis in troops and suggest remedial measures to prevent further occurrence of cases. Study Design: Cross sectional study. Settings: Troops of four cantonments in central India. Participants: 15000 troops. Study Variables: Incidence of viral hepatitis, types of viral hepatitis (hepatitis B surface antigen (HbsAg) positive or negative), place of infection, likely source of infection. Statistical Analysis: Chi square linear trend Results: Incidence of viral hepatitis varied from 1.60 to 2.80 per 1000 during the study period. 57% to 60% cases were hepatitis B surface antigen (HbsAg) positive. 42.86% to 60.00% HbsAg negative cases acquired infection locally. Clustering of four HbsAg negative cases were observed consuming water from a particular source. Conclusion: Day to day monitoring of viral hepatitis cases helped in detection of clustering of . HbsAg negative cases as well as identification of possible source of infection. Early institution of remedial measures prevented further occurrence of cases.

Key words: Viral Hepatitis, Prevention and Control.

Introduction

Six different types of viral hepatitis are now known. These are hepatitis A, B, C, D, E and G. The last has been discovered as late as 1996. Hepatitis A and E mainly spread through faeco-oral route, usually through water. The other four are usually transmitted parentally, of these, B and C types are most dangerous, and type B is most common1. Hepatitis G virus is widely distributed among people who have received multiple transfusions and among IV drug abusers. It is also found in association with HBV and HCV2. Recently TTVC (transfusion transmitted virus) have been incriminated with some cases of viral hepatitis3,4. At a current estimate, more than 300 million people worldwide suffer from viral hepatitis. Nearly 300 deaths per year are attributed to fulminating acute disease and about 15000 people succumb each year to chronic liver disease. The disease has an enormous impact on health and national economy of many countries including India5. Types A, B, and D can be prevented by use of vaccines. Development of vaccines against types C and E will greatly improve preventive measures against these infections6. By the end of 2001, 142 countries were using HB vaccines in routine immunization schedule. Over 40 of the least developed counties are currently being helped by the vaccine fund for the introduction of HB vaccine in routine schedules. There are more than 350 million chronic carriers mostly all over the world, most of them infected at birth or during childhood7. Prevalence of HAV is high among developing countries, where 80% of the people have evidence of infection by the age of 20 years and 100% by the age of 50, compared to about 40% in developed counties. Future widespread immunization of children would reduce overall prevalence and ultimately help eradication of the disease8. Viral hepatitis remains an important cause of morbidity and loss of trained manpower in armed forces. This study aimed to investigate and analyse the occurrence of viral hepatitis cases in troops located in central India on day to day basis instead of weekly/monthly basis for early detection and containment of epidemic and preservation of trained manpower.

Material and Methods

Viral hepatitis cases occurring in troops (approximate 15000 in numbers) located in four cantonments in central India was investigated from January 2000 to December 2002 to fi nd out type of hepatitis (Hepatitis B surface antigen (HBsAg) positive or HBsAg negative) and place of acquiring infection (fresh local, fresh imported). Instead of waiting for notifi cation, information regarding hospital admission due to viral hepatitis in troops in all stations was collected telephonically, followed by in writing. All cases were investigated by trained health worker and data were analyzed on daily/ weekly/monthly basis to draw inferences and suggest remedial measures to prevent further occurrence of cases. Water supply was monitored by free chlorine and bacteriological analysis. Hygiene and Sanitation survey of all cantonments was carried out twice a year and on need basis. A case acquiring infection within limits of cantonments was labeled as fresh local. A case acquiring infection outside the limit of cantonments (on leave or temporary duty) was labeled as fresh imported.

Results

Year wise distribution: Year wise distribution of cases has been given in table I. Incidence was maximum (2.80 cases per 1000/year) during the year 2000. Distribution of viral hepatitis cases according to type of hepatitis has been given in table II. 57.14 % cases were HBsAg negative during the year 2000, 60.00 % during the year 2001 and 58.33 % during the year 2002. However differences were found nonsignificant.

Table I: Year wise Distribution of Viral Hepatitis Cases

Year Number of cases Incidence/1000/Year
2000 42 2.80
2001 25 1.66
2002 24 1.60

Table – II. Distribution of Viral Hepatitis Cases According to Type of Hepatitis

Year HBs Ag Positive HBs Ag Negative Total
2000 18 (42.86) 24 (57.14) 42 (100)
2001 10 (40.00) 15 (60.00) 25 (100)
2002 10 (41.67) 14 (58.33) 24 (100)
Total 38 (41.76) 53 (58.24) 91 (100)

Chi square linear trend = 0.015 P = 0.9018 Not significant

Month wise distribution: Month wise distribution of viral hepatitis cases is shown in Table III. Highest number of cases (10) occurred in the month of March 2000 followed by in the month of November 2001 (9 cases). During the month of March 2000, out of 10 cases, 6 were HBsAg positive and 4 were HBs Ag negative. Out of these 4 HBsAg Negative cases, 3 were fresh imported and 1 was fresh local. All the cases were scattered and no unit contributed more than two cases.

Table-III: Month Wise Distribution of Viral Hepatitis Cases

Year 2000 2001 2002
January 4 1 5
February 7 1 4
March 10 1 3
April 6 1 1
May 5 - 4
June 5 1 -
July 1 - 3
August - 4 -
September 1 1 -
October 1 5 2
November - 9 1
December 2 1 1
Total 42 25 24

HBsAg negative and 4 were HBsAg positive. Distribution of these cases according to cantonments and unit has been shown in Table IV. Unit 1 located in cantonment A contributed to 4 cases. All these cases were fresh local and occurred in a span of 10 days in first half of November.

Sanitary survey of unit 1 was carried out to find out possible source of exposure. At one place sewage overfl ow was observed but there was no water pipe line nearby. Free chlorine was detected in 96 percent water samples during the month of Oct. 2001. Bacteriological analysis of water sample was found satisfactory. On further investigation it was found out that all these four cases were consuming water from a water tap located at the junction of unit and civil area. The source of water supply to this tap was from civil. Water sample from this tap was found bacteriologicaly unsatisfactory. Water tap was closed permanently and no more cases of viral hepatitis were reported subsequently. Sporadic cases of viral hepatitis were also reported in adjacent civil area.

Place wise distribution: Table-V shows distribution of HBsAg negative cases according to place of acquiring infection. 45.83% cases acquired infection within the cantonments during the year 2000, 60.00% during the year 2001 and 42.86% during the year 2002. Difference was statistically not significant.

Table-IV. Unit Wise Distribution of Viral Hepatitis Cases in November 2001

Unit Cantonment HBs Ag Positive HBs Ag Negative Total
I A - 4 4
II A 1 - 1
III B 1 - 1
IV B 1 1 1
V C 1 - 1
VI D 1 - 1
Total   4 5 9

Table- V. Distribution of Viral Hepatitis (HBs Ag Negative) Cases According to Place of Infection.

Year Fresh Local Fresh Imported Total
2000 11 (45.83) 13 (54.17) 24 (100.00)
2001 9 (60.00) 6 (40.00) 15 (100.00)
2002 6 (42.86) 8 (57.14) 14 (100.00)
Total 26 (49.06) 27 (50.94) 53 (100.00)

Discussion

Sporadic cases of viral hepatitis are common in armed forces. Hospital admission rate for viral hepatitis was 2.80 cases per 1000 per year in armed forces during the year 20009. In this study, hospital admission rate due to viral hepatitis was from 1.60 to 2.80 cases per 1000 per year from 2000-2002, which is similar to overall morbidity rate due to this disease in armed forces. 40.00% to 42.86% admission was due to hepatitis B emphasizing the requirement of introduction of hepatitis B vaccine in armed forces.

Possibility of explosive outbreak of viral hepatitis A and E can not be ruled out in armed forces in some of the old cantonments due to old, rusted and leaking water pipe lines, old sewerage system and nonfunctioning Chloronomes or Bleaching dozers. One such explosive outbreak of viral hepatitis E has taken place in one of regimental center in UP in the year 2002 due to cross-connection of water pipe line and overfl owing sewage10.

Outbreak of viral hepatitis (A&E) can be prevented by monitoring of water supply, proper sewage and solid waste disposal and by observing hygiene and sanitation in cookhouses. Water supply should be monitored by free chlorine, bacteriological analysis and sanitary survey. Regular surveys should be done for early detection of sewage overflow. Military Engineering Services should be advised to rectify the defect in water supply and sewerage system as early as possible. Sometimes early rectification of defect in water supply and sewerage system remain difficult due to logistic constraints.

Monitoring of hospital admission and OPD cases should be done regularly for early detection of an outbreak. At present units are required to report occurrence of all communicable diseases including viral hepatitis to higher authorities on weekly basis unless it is an outbreak. Golden hour may be lost in weekly reporting and analysis of data, since outbreak of viral hepatitis is explosive in nature due to faeco – oral transmission. Hospital admission can be easily monitored and analyzed in this era of communication.

In this study, all hospital admission of troops and families of study areas were collected daily in the morning telephonically. All cases of communicable diseases including viral hepatitis were investigated to fi nd out source of infection and mode of transmission. If from a unit more than two cases of HBsAg negative (fresh local) were reported in a week, hygiene and sanitary survey was done to find out possible sources of infection and mode of transmission and suggest remedial measures. Day to day monitoring of viral hepatitis cases helped in detection of clustering of HBsAg negative cases in a unit as well as in identifi cation of possible source of infection. Early institution of remedial measures prevented further occurrence of cases in unit.

Conclusion

Surveillance of communicable diseases is the key for early detection and containment of epidemic. Communicable diseases cases detected during surveillance should be investigated as early as possible and analyzed to fi nd out clustering in time, place and person and source of exposure so that epidemic can be detected and contained early. Golden hours may be lost if communicable diseases cases are investigated / analyzed late and may be not of a much help as peak may have already reached.

References

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  8. Batra Y, Bhaatkal B, Ojha B. Vaccination against HA virus may not be required for school children in northern India: results of seroepidemiological survey. Bull. WHO 2002; 80:277-81
  9. Director General, Armed Forces Medical Services. Report on the health of Armed Forces 2002.
  10. Editorial. Outbreak of viral hepatitis at Jat Regimental Center Bareilly. Dept of PSM AFMC, Pune News letter 2004: 3 (1): p3.

Deptt. of PSM, Armed Forces Medical College, Pune 411040
E-mail: [email protected]
Received: 2.9.04

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