V. cholera

Kelantan Health Conference 2011To’ Puan Dr. Rahmah EliasPublic Health PhysicianTerengganu State Health Department15.06.2011

Introduction Chronology of Events How Did We Do It Epidemiological Investigation Control Measures Communication Epidemiology of the Outbreak Lesson Learnt Conclusion

Acute bacterial enteritis Vibro cholerae serogroup O1 or O139 Sudden onset profuse painless watery diarrhoea Incubation period: Few hours to 5 days (2 - 3d) Symptomatic infection 20% Even in severe epidemic: Attack rate < 2%Untreated case Death within few hours Case fatality rate (CFR) 30 - 50%Proper treatment CFR

Global threat One of 3 diseasesnotifiable to WHOunder IHR Key indicator of socialdevelopment 7 th Pandemic: 1961

Date Time Action10.11.09 10.45pm Syndromic Case Notification fromState Hospital by AEHO o/c7 cases AGE ?Cholera11:00pmState epidemiologist and District MOHwere notified11.11.09 12:30am KT MOH informed outbreak responseteam - meeting @ 8am1:35amAEHO o/c received notification ofanother 4 cases of AGE 11 cases5 female & 6 male

Date / Time11.11.09 @8:00amDistrict Health OfficeBriefing by District MOH to outbreak respond health team -Medical Officers, AEHO, Nurses, Assistant Medical Officer(AMO), Medical Laboratory Assistant (MLA)8:30am Receive notification of another 6 cases 17 cases (4cases in ICU)9:30am10:00amDistrict Investigation team - 6 AEHO headed by M&HO toHSNZBriefing by KT MOH to Terengganu State Health Team ledby Deputy State Health Director (PH)- 82.4% (14) cases were from Kuala Terengganu- Remainder from Marang districtFormation of Outbreak response team: Investigation team,ACD team, Control & Prevention Team

Date / Time District Health Office State HealthDepartment11.11.09 @12:30pm2:30pmNotification of 1 deathPresentation by investigating team4:10pm 3 cases confirmed cholera Opening ofOperations Room5:00pmACD Team headed by M&HO and Control& Prevention Team to the field10:00pm11:30pmDebriefing to district teamReport of outbreakEvaluate response

Date /Time12.11.09 OperationsRoom open7:30pmState Hospital District Health Office State HealthDepartmentDesignatedCholera wards54 cases• 46 adults, 8children• 4 cases in ICUStrengthenInfection ControlActivities• Morning briefing toOutbreak ResponseTeams• Report to TerengganuState Health DepartmentReceived assistance fromState & other districts- Water sampling @ TPO,SRO dan Auxillary Point- Environmentalassessment & sampling: Ice Factory: Keropok FactoryTotal of 10 positive casesIssue directives - Deploystaff from Marang,Dungun, Setiu & HTrg toassist KTInform State ChiefMinister & Health ExcoIssue press statementthrough Berita Harian &NSTAlert all Hospitals & DHO

Date /TimeStateHospitalDistrict Health OfficeState HealthDepartment13 -19.11.09Dailymorning /eveningdiscussion -OperationsRoomReceived assistance from Pahang,Kelantan, EIP fellows & trainees- Case Ix- Case Detection- Premise / Boat Inspection- Environmental Assessment- Wet market, ice factories,eateries- Food & Water sampling- Enforcement activities- Health promotion• Daily morningdiscussion -Operations Room• Discussion withState Secretary(State OutbreakCommittee),Hospital Directors& MOHsDaily report to Terengganu StateHealth Department

Date / Time State Hospital District Health Office State HealthDepartment13 -19.11.09Discussion with otheragencies Fisheries / LKIM /SATU / MBKT / DistrictOutbreak Committee /InformationDepartment / JKKK15.11.09 Confirmation from IMR: 3 samples Vibrio cholera 01 serotypeOgawa

20 - 22.11.091 asymptomatic caseamong fishermen froma Thai fishing boat Subsequently boatsharboured at fishing port -inspected Ice factory at fishing portinspected▪ Water sampling▪ Environmental swabtaken

• Epidemiological Investigation• Control Measures• Communication

Case Detection Case definition▪ All cases presenting with acute diarrhoeain the Terengganu from 5 th till 24 thNovember 2009 Case Finding▪ Passive case finding▪ Notifications from Govt Health Clinics &Hospital’s A+E / Out-Patient Units / PrivateClinics / Private Hospital▪ Active case finding▪ Community screening▪ Contacts of cases Case-Control Study

Investigation Laboratory▪ Rectal swab / Stool▪ Alkaline peptone water -Enrichment medium▪ Culture & Sensitivity▪ Thiosulfate Citrate Bile SaltsSucrose Agar (TCBS Agar)▪ Fingerprinting▪ Pulse Field Gel Electrophoresis(PFGE)

Infection control Health care facilities Health personnel Prophylaxis to contacts /HCW Doxycycline 20.11.2009 - Ciprofloxacin Chlorination Wells / water tanks• Disinfection− Toilets / eateries /waste disposalsites / boats• PremisesInspection andClosureIce Van

Health Education Crucial for continuedcommunity participation▪ Sessions▪ Pamphlets▪ Public announcements

Involvement of multiple agencies District Office Municipality Fisheries Department / LKIM Information Department SATU Other Health Offices / Hospital Communities Coordination Meeting State / District Outbreak Committee MBKT JKKK

Operations Room Need to be activated early Nerve centre▪ Information for dissemination Guidelines Food Water BorneGuidelines Rapid Respond Manual

Documentation Data collection, compilation & analysis▪ Line listing▪ Updating laboratory results Feedback District-State Twice daily meeting▪ Opening meeting to provide guidance▪ Closing meeting to track progress

Outbreak Alert General practitioner, private hospital, health clinics &hospitals Neighbouring states and later nationwide Community Media Alert▪ Radio / Pamphlets▪ Banners / Newspaper Home Visits▪ Active Case Detection▪ Control & Preventive Activities

Inter-State & Inter-Country Terengganu-Kelantan▪ 5-10.11.09: Tok Bali▪ Fishing village in Kelantan, bordering Terengganu▪ Supply fresh fish to Terengganu▪ V. cholerae 01 Ogawa non- local strain▪ 8 of 9 cases from Pattani, Thailand Malaysia-Thailand▪ Mid Oct - 13 /11/2009: Pattani (Thailand)▪ 93 cases V. cholera El Tor Ogawa▪ (R) to tetracycline & otrimoxazole,(S) norfloxacin

• Overall AttackRate23.1/100,000popNo. suspectedcases notified1751• CFR0.53%VC positive239 (13.6%)VC negative1512Symptomatic187 (78.2%)Death - 1Asymptomatic52

DistrictNo. of Cases(%)Attack Rate(per 100000 pop*)Kuala Terengganu 163 (87.2) 48.8Marang 12 (6.4) 12.3Hulu Terengganu 3 (1.6) 4.2Besut 3 (1.6) 2.1Dungun 3 (1.6) 1.9Setiu 1(0.5) 1.6Kemaman 2 (1.1) 1.2Total 187 18.1* Malaysia Basic Population Characteristics by administrative Districts June 2010 Department of Statistics Malaysia

30No. of casesAttack Rate / 100,000 pop16251412No. of cases2015101086AR / 100,000 pop452014 10 8 13 24 26 19 9 18 6 13 12 8 60-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 >64Age group (Years)0

Female, 81,43%Male106 Majority Malays 97.9% Chinese57% 1.1% Others 1.1% Correspond toTerengganu populationdistribution

SymptomsFeverHeadacheAbdominal ColicNausea2023.143.347.4• ALL patients haddiarrhoea: In line withdiagnosis of cholera Profuse diarrhoea Enterotoxin• Vomiting in mostpatients : 68.4%Vomiting68.4Diarrhoea1000 20 40 60 80 100 120Cases Percentagesin Percentage

35302520151050Ice factories (2) closedFood premises closedIce factories (2) closedHealth Education in Kg A.T.Increase chlorine in watertreatment plant• Common sourceoutbreak withpropagation fromperson to person• Via oral feacalrouteEnhancement of HEstate wideCiprofloxacin inhospitalCiprofloxacin amongcommunity contactsNo. of cases01/11/0902/11/0903/11/0904/11/0905/11/0906/11/0907/11/0908/11/0909/11/0910/11/0911/11/0912/11/0913/11/0914/11/0915/11/0916/11/0917/11/0918/11/0919/11/0920/11/0921/11/0922/11/0923/11/0924/11/0925/11/0926/11/0927/11/0928/11/0929/11/0930/11/0901/12/0902/12/0903/12/0904/12/0905/12/0906/12/0907/12/09Date of Onset

Pattani (Thailand) CholeraOutbreak 93 cases V. cholerae Eltor Ogawa - (R) to tetracycline &otrimoxazole, (S) norfloxacinCurrent outbreak in Kelantan:V. cholerae 01 Ogawa non- local strain.Involving 8 of 9 cases from Pattani, ThailandCases amongFishermen in fishingboats (from Patani)(e.g Boat TRF: 25 crew, 1Asymptomatic casewater sample, swab fromtap and toilet bowl +ve)C Fish jettycatch from fishingboats sold at jettyGP Wet MarketRaw chicken +veFish & environmentalsamples -veNO resistant cholera in Malaysia beforeIce factory in CP1 worker +vePak NNasi Lemak + tuna =food handlerPoor hygieneAsymptomatic caseIce factory in Chendering:A Ice : 1 worker + lorrydriver +ve,K Ice: Env. Swab (tap) +veKg. A TMajority of casesin outbreak in thedistrictPak D Food Shop inKg. A TPak D -veNasi Lemak + tunafrom Pak N

Culture & PFGE ofisolates Vibrio cholerae O1 Serotype Ogawa Resistant to Tetracycline,Erythromycin and Bactrim100Dice (Opt:1.20%) (Tol 1.6%-1.6%) (H>0.0% S>0.0%) [0.0%-100.0%]PFGE100PFGELabNoST25VC94VC98VC198VC221VC236VC328VC339VC357VC1723VC194vc 7vc 9vc 19st 23st 29st 31vc 64vc 74rz427rz428rz 429VC224Dendogram Outbreak Terengganu

Environmental FactorsAssessment of premise (score < 50or violation at food handling criticalpoint)% (No. of at risk premises orsamples)7.2% (54 / 752)(50 food premises, 0 ice factory,4 fish cracker factories)Premises with Food handlers +ve VC1.7% (13 premises / 752)rectal swab or stool or hand swabEnvironmental swab or water sample(+ve VC) including fishing boats &water for external useFood (+ve VC) including ice for fishstorage(7 food premises, 6 ice factories)1.5% (21 samples / 1416)(7 food premises, 3 ice factories, 4 fishcracker factories, 7 fishing boats)0.7% (7 samples / 1031)(nasi lemak, laksam, ice,boiled egg, raw chicken)Drinking water in boat (+ve VC) 4.8% (3 samples / 62)

Water supplied by TerengganuWater Company (SATU) No violations in water quality▪ monitored by KKM and▪ water treatment plant No interruptions in water, electricaland chlorine supply in treatmentplants Water supplied by treatment plantsdid not follow distribution of cases

From eating local nasilemak (with fish) Supported by case controlstudy Nasi lemak supplierConsumption of ice Unhygienic practices ofmaking and handling ice NO ice sample were +ve +ve for V. cholerae Nasi lemak samples No +ve Late sampling NO samples of water sourceused for making ice +veV.cholerae Ice factory worker & lorrydriver +ve V.cholerae +ve environmental swabs

Related to fish andfisherman fromThailand Outbreak history incountry of origin▪ Mid October 2009 Fishermen▪ Asympomatic cholera Boat environmentalsamples▪ +ve for v. cholerae Fishes sampled▪ -ve for v.cholerae Unhygienic practices offishermen contaminationof fishes▪ outflow from bathing andself-cleaning activities byfishermen directly orindirectly into fish storageareaUnhygienic practices &handling of food by foodhandlers Food premises implicatedwith cholera cases andworkers at food premises

Early Detection- Rapid Verification & Response Send a multidisciplinary team to the field inorder to Confirm the outbreak and Take the first measures for controlling the spread ofthe disease.

Investigation to determine cause “vehicles of transmission” must beinvestigated for appropriate control measures:▪ Drinking-water contaminated at source / duringtransport and storage / ice made with contaminatedwater▪ Food contaminated during or after preparation▪ Seafood▪ Fruits and Vegetables

Surveillance Information for action– DESCRIPTIVE EPIDEMIOLOGY Hold twice daily update meetings with team Sharing all formal communications (tohealth care providers, to media, to schools,etc.) with team

Work closely with laboratories and localhealthcare providers to assure “collection” andreporting of all suspected patients and to obtainrapid results Specific time and mode for communications withState & Ministry to support easy information flow

Statewide cholera outbreak 239 cholera cases Vibrio cholerae O1 Ogawa▪ Resistant to Tetracycline, Erythromycin and Bactrim 187 (78.2%) symptomatic Attack rate was 23.1/100,000 pop. Suspected source of infection Linkage with the cholera outbreak in Thailand▪ Pattani fishermen▪ V. cholera El Tor Ogawa▪ (R) to tetracycline & otrimoxazole, (S) norfloxacin▪ Tok Bali▪ V. cholerae 01 Ogawa non- local strain▪ Among Thai fishermen

Other possibilities Cholera smoulder unrecognised▪ Asymptomatic cases (21.8%) Faecal contamination of cooked food throughsecondary transferPersist longer in environmentMultiply more rapidly after inoculation into food

Good routine surveillancesystem AGE surveillanceTo be done diligentlyProxy for food and waterbornedisease outbreak Early outbreak management Initiation of State and districtRapid Response Team Sought assistance early

Effective Outbreak Communication Partnership with media▪ Open flow of information▪ Prevent misleading rumours Communication at various levels▪ Co-operation▪ Collaboration Health Education Continued participation Sharing of Information

Control of communicable diseases in man 18 th editionWHO Report on Global Surveillance of Epidemic-prone Infectious DiseasesWHO/CDS/CSR/ISR/2000.1 Chapter 4 Cholera pp 39-43 Garispanduan Pengendalian Wabak Kolera di Malaysia Jilid 3FWBD/CHO/GP/001 (pindaan 2006) Pasakorn Karasewi. Cholera - Thailand: Southern. published 18.11.2009http://www.promedmail.orgA Mini Review: Cholera Outbreak via Shellfish, R. Suzita, A.S Abdulamir,Fatimah Abu Bakar, R. Son, American Journal of Infectious Diseases5(1):40- 47, 2009. 6.Malaysia Basic Population Characteristics by administrative Districts June2010 Department of Statistics MalaysiaRanjit, K., and Nurahan M., (2000) Tetracycline Resistant Cholera inKelantan. Medical Journal of Malaysia, 55 (1). pp. 143-145