A Fatal Waterborne Outbreak of Pesticide Poisoning Caused by Damaged Pipelines, Sindhikela, Bolangir, Orissa, India, 2008

Introduction. We investigated a cluster of pesticide poisoning in Orissa. Methods. We searched the village for cases of vomiting and sweating on 2 February 2008. We described the outbreak by time, place, and person. We compared cases with controls. Results. We identified 65 cases (two deaths; attack rate: 12 per 1000; case fatality: 3%). The epidemic curve suggested a point source outbreak, and cases clustered close to a roadside eatery. Consumption of water from a specific source (odds ratio [OR]: 35, confidence interval [CI]: 13–93) and eating in the eatery (OR: 2.3, CI: 1.1–4.7) was associated with illness. On 31 January 2008, villagers had used pesticides to kill street dogs and had discarded leftovers in the drains. Damaged pipelines located beneath and supplying water may have aspirated the pesticide during the nocturnal negative pressure phase and rinsed it off the next morning in the water supply. Conclusions. Innapropriate use of pesticides contaminated the water supply and caused this outbreak. Education programs and regulations need to be combined to ensure a safer use of pesticides in India

Injection use in two districts of Pakistan: implications for disease prevention

Objective. To estimate the annual number of injections per person in Sindh province of Pakistan and to describe their distribution with regard to prescribers, settings, and safety. Design. A population-based cross-sectional study in July-September 2001. Setting. Lyari, an urban town in Karachi district; and Digri, a rural subdistrict in Mirpur Khas district. Study participants. We selected a population-based cluster sample of 1150 individuals aged ≥3 months. We interviewed one person per household for the number of encounters they had with health care providers, number and types of injections received, safety circumstances, and cost of injections during the past 3 months. Main outcome measure. The number of injections per person per year. Results. After adjusting for age and sex, 68% of participants had received at least one injection in the previous 3 months (13.6 injections/person/year). The majority of the respondents received injections at the clinics of qualified general practitioners (n = 571, 67%) by dispensers (644, 76%). Most of the injections (n = 3446, 96%) were for curative purposes. A freshly opened syringe was used for only 454 (53%) of the injections. The average fee for receiving an injection was Rs. 51 (US$0.8). Conclusion. Injections are overused in Pakistan's Sindh province and the ratios of injection per capita that we found are among the highest ever reported. Interventions are needed to substantially reduce injection prescription among private health care providers who prescribe most of the injections received by the populatio

A malaria outbreak in Naxalbari, Darjeeling district, West Bengal, India, 2005: weaknesses in disease control, important risk factors

An outbreak of malaria in Naxalbari, West Bengal, India, in 2005 was investigated to understand determinants and propose control measures. Malaria cases were slide-confirmed. Methods included calculation of annual blood examination rates (ABER, number of slides examined/population), collection of water specimens from potential vector-breeding sites, sorting of villages in categories depending on the number of abandoned wells within two kilometers radius and review of the DDT spray coverage. Cases were compared with matched neighbourhood controls in terms of personal protection using matched odds ratios (MOR). 7,303 cases and 17 deaths were reported between April 2005 and March 2006 with a peak during October rains (Attack rate: 50 per 1,000, case fatality: 0.2%). The attack rate increased according to the number of abandoned wells within 2 kilometres radius (P < 0.0001, Chi-square for trend). Abandoned wells were Anopheles breeding sites. Compared with controls, cases were more likely to sleep outdoors (MOR: 3.8) and less likely to use of mosquito nets and repellents (MOR: 0.3 and 0.1, respectively). DDT spray coverage and ABER were 39% and 3.5%, below the recommended 85% and 10%, respectively. Overall, this outbreak resulted from weaknesses in malaria control measures and a combination of factors, including vector breeding, low implementation of personal protection and weak case detection

Five Pond-centred Outbreaks of Cholera in Villages of West Bengal, India: Evidence for Focused Interventions

In rural West Bengal, outbreaks of cholera are often centred around ponds that is a feature of the environment. Five investigations of laboratory-confirmed, pond-centred outbreaks of cholera were reviewed. Case-control odds ratios were approximated with relative risks (RRs) as the incidence was low. The environment was investigated to understand how the pond(s) could have become contaminated and could have infected villagers. The five outbreaks of cholera in 2004-2008 led to 277 cases and three deaths (median attack rate: 51/1,000 people; case fatality: 1.1%; median age of case-patients: 22 years; median duration: 13 days, range: 6-15 days). Factors significantly (p<0.05) associated with cholera in the case-control (n=4) and cohort investigations (n=1) included washing utensils in ponds (4 outbreaks of cholera, RR range: 6-12), bathing (3 outbreaks of cholera, RR range: 3.5-9.3), and exposure to pond water, including drinking (2 outbreaks of cholera, RR range: 2.1-3.2), mouth washing (1 outbreak of cholera, RR: 4.8), and cooking (1 outbreak of cholera, RR: 3.0). Initial case-patients contaminated ponds through washing soiled clothes (n=4) or defaecation (n=1). Ubiquitous ponds used for many purposes transmit cholera in West Bengal. Focused health education, hygiene, and sanitation must protect villagers, particularly following the occurrence of an index case in a village that has ponds

The global prevalence of hepatitis D virus infection:systematic review and metaanalysis

Background and Aims There are uncertainties about the epidemic patterns of hepatitis delta virus (HDV) infection and its contribution to the burden of liver disease. We estimated the global prevalence of HDV infection and explored its contribution to the development of cirrhosis and hepatocellular carcinoma (HCC) among hepatitis B surface antigen (HBsAg)-positive people. Methods We searched Pubmed, EMBASE and Scopus for studies reporting on total or IgG anti-HDV among HBsAg-positive people. Anti-HDV prevalence was estimated using a binomial mixed model, weighting for study quality and population size. The population attributable fraction (PAF) of HDV to cirrhosis and HCC among HBsAg-positive people was estimated using random-effects models. Results We included 282 studies, comprising 376 population samples from 95 countries, which together tested 120,293 HBsAg-positive people for anti-HDV. The estimated anti-HDV prevalence was 4.5% (95% CI 3.6, 5.7) among all HBsAg-positive people and 16.4% (14.6, 18.6) among those attending hepatology clinics. Worldwide, 0.16% (0.11, 0.25) of the general population, totalling 12.0 (8.7, 18.7) million people, were estimated to be anti-HDV positive. Prevalence among HBsAg-positive people was highest in Mongolia, the Republic of Moldova and countries in Western and Middle Africa, and was higher in injecting drug users, haemodialysis recipients, men who have sex with men, commercial sex workers, and those with hepatitis C virus or HIV. Among HBsAg-positive people, preliminary PAF estimates of HDV were 18% (10, 26) for cirrhosis and 20% (8, 33) for HCC. Conclusions An estimated 12 million people worldwide have experienced HDV infection, with higher prevalence in certain geographic areas and populations. HDV is a significant contributor to HBV-associated liver disease. More quality data are needed to improve the precisions of burden estimates

Persistence of Diphtheria, Hyderabad, India, 2003–2006

During 2003–2006, diphtheria rates in Hyderabad, India, were higher among persons 5–19 years of age, women, and Muslims than among other groups. Vaccine was efficacious among those who received >4 doses. The proportion of the population receiving boosters was low, especially among Muslims. We recommend increasing booster dose coverage

Five Pond-centred Outbreaks of Cholera in Villages of West Bengal, India: Evidence for Focused Interventions

In rural West Bengal, outbreaks of cholera are often centred around ponds that is a feature of the environment. Five investigations of laboratory-confirmed, pond-centred outbreaks of cholera were reviewed. Case-control odds ratios were approximated with relative risks (RRs) as the incidence was low. The environment was investigated to understand how the pond(s) could have become contaminated and could have infected villagers. The five outbreaks of cholera in 2004-2008 led to 277 cases and three deaths (median attack rate: 51/1,000 people; case fatality: 1.1%; median age of case-patients: 22 years; median duration: 13 days, range: 6-15 days). Factors significantly (p&lt;0.05) associated with cholera in the case-control (n=4) and cohort investigations (n=1) included washing utensils in ponds (4 outbreaks of cholera, RR range: 6-12), bathing (3 outbreaks of cholera, RR range: 3.5-9.3), and exposure to pond water, including drinking (2 outbreaks of cholera, RR range: 2.1-3.2), mouth washing (1 outbreak of cholera, RR: 4.8), and cooking (1 outbreak of cholera, RR: 3.0). Initial case-patients contaminated ponds through washing soiled clothes (n=4) or defaecation (n=1). Ubiquitous ponds used for many purposes transmit cholera in West Bengal. Focused health education, hygiene, and sanitation must protect villagers, particularly following the occurrence of an index case in a village that has ponds

Rapid assessment of injection practices in Cambodia, 2002

BACKGROUND: Injection overuse and unsafe injection practices facilitate transmission of bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Anecdotal reports of unsafe and unnecessary therapeutic injections and the high prevalence of HBV (8.0%), HCV (6.5%), and HIV (2.6%) infection in Cambodia have raised concern over injection safety. To estimate the magnitude and patterns of such practices, a rapid assessment of injection practices was conducted. METHODS: We surveyed a random sample of the general population in Takeo Province and convenience samples of prescribers and injection providers in Takeo Province and Phnom Penh city regarding injection-related knowledge, attitudes, and practices. Injection providers were observed administering injections. Data were collected using standardized methods adapted from the World Health Organization safe injection assessment guidelines. RESULTS: Among the general population sample (n = 500), the overall injection rate was 5.9 injections per person-year, with 40% of participants reporting receipt of ≥ 1 injection during the previous 6 months. Therapeutic injections, intravenous infusions, and immunizations accounted for 74%, 16% and 10% of injections, respectively. The majority (>85%) of injections were received in the private sector. All participants who recalled their last injection reported the injection was administered with a newly opened disposable syringe and needle. Prescribers (n = 60) reported that 47% of the total prescriptions they wrote included a therapeutic injection or infusion. Among injection providers (n = 60), 58% recapped the syringe after use and 13% did not dispose of the used needle and syringe appropriately. Over half (53%) of the providers reported a needlestick injury during the previous 12 months. Ninety percent of prescribers and injection providers were aware HBV, HCV, and HIV were transmitted through unsafe injection practices. Knowledge of HIV transmission through "dirty" syringes among the general population was also high (95%). CONCLUSION: Our data suggest that Cambodia has one of the world's highest rates of overall injection usage, despite general awareness of associated infection risks. Although there was little evidence of reuse of needles and syringes, support is needed for interventions to address injection overuse, healthcare worker safety and appropriate waste disposal

Measles transmission following the tsunami in a population with a high one-dose vaccination coverage, Tamil Nadu, India 2004–2005

BACKGROUND: On 26 December 2004, a tsunami struck the coast of the state of Tamil Nadu, India, where one-dose measles coverage exceeded 95%. On 29 December, supplemental measles immunization activities targeted children 6 to 60 months of age in affected villages. On 30 December, Cuddalore, a tsunami-affected district in Tamil Nadu reported a cluster of measles cases. We investigated this cluster to estimate the magnitude of the problem and to propose recommendations for control. METHODS: We received notification of WHO-defined measles cases through stimulated passive surveillance. We collected information regarding date of onset, age, sex, vaccination status and residence. We collected samples for IgM antibodies and genotype studies. We modeled the accumulation of susceptible individuals over the time on the basis of vaccination coverage, vaccine efficacy and birth rate. RESULTS: We identified 101 measles cases and detected IgM antibodies against measles virus in eight of 11 sera. Cases were reported from tsunami-affected (n = 71) and unaffected villages (n = 30) with attack rates of 1.3 and 1.7 per 1000, respectively. 42% of cases in tsunami-affected villages had an onset date within 14 days of the tsunami. The median ages of case-patients in tsunami-affected and un-affected areas were 54 months and 60 months respectively (p = 0.471). 36% of cases from tsunami-affected areas were above 60 months of age. Phylogenetic analyses indicated that the sequences of virus belonged to genotype D8 that circulated in Tamil Nadu. CONCLUSION: Measles virus circulated in Cuddalore district following the tsunami, although there was no association between the two events. Transmission despite high one-dose vaccination coverage pointed to the limitations of this vaccination strategy. A second opportunity for measles immunization may help reducing measles mortality and morbidity in such areas. Children from 6 month to 14 years of age must be targeted for supplemental immunization during complex emergencies