Investigation Of a CKD Outbreak In Western Odisha

Dr Rajesh Kumar LudamP.G Student

V.S.S.M.C.H ODISHA

Background-:

• One person in every ten people is suffering from kidney related diseases

• Approx 1.50 lakh new kidney patients every year• Third biggest non-communicable disease after hyper-

tension and diabetes• More than half of the patients won’t even know until

damaged by more than 60%. • About five lakh kidney transplants are needed each

year, but a few thousands of the patients could eventually get it.

• Definition-: CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health.

Criteria for CKD (either of the following present for > 3 months)

A.) Markers of kidney damage (one or more)-Albuminuria (AER >30 mg/24 hours;ACR >30 mg/g [>3 mg/mmol])

-Urine sediment abnormalities-Electrolyte and other abnormalities-Abnormalities detected by histology-Structural abnormalities detected by imaging- H/o kidney transplantation B.) Decreased GFR - GFR <60 ml/min/1.73 m2

• CKD is classified based on cause, GFR category, and albuminuria category (CGA)

GFR categories in CKD

Albuminuria categories in CKD

GFR Category GFR ( ml/min/1.73 m2 ) TermsG1 >90 Normal or HighG2 60-89 Mildly decreasedG3a 45-59 Mild to Moderately decreasedG3b 30-44 Moderate to Severely decreasedG4 15-29 Severely decreasedG5 <15 Kidney failure

Category AER(mg/24hr)

ACR ( mg/mmol ) (mg/g)

Terms

A1 <30 <3 <30 Normal to Mildly decreasedA2 30-300 3-30 30-300 Moderately decreased

A3 >300 >30 >300 Severely decreased

Risk Factors-:

• Diabetes • Hypertension• Acute kidney injury • Cardiovascular disease (IHD, CHF, peripheral vascular

disease or CVD) • Structural renal tract disease, recurrent renal calculi or

prostatic hypertrophy • Multisystem diseases with potential kidney involvement –

e.g. SLE • Family h/o end-stage kidney disease (GFR category G5) or

hereditary kidney disease • opportunistic detection of haematuria. [new 2014] • CKDU & CKDNT

Why we are so much Concerned???

Silent Epidemic…….

• Outbreak-:- The occurrence of more cases of disease than expected

in a given area or among a specific group of people over a particular period of time.

- E.g.- In 2013 In Narasinghpur Panchayat of Cuttack reported 29 out of 33 villages are reported to have sizeable number of cases of CKD between June and Sept.

- It was found that 8 to 12 per cent of the people surveyed had CKD amounting to 400.

- Late reports suggest high prevalence of CKD have been reported from Bolangir,Jharsuguda,Koraput,Sundergarh area of Odisha.

CKD Outbreak investigation1. Prepare for field work2. Establish the existence of an outbreak3. Verify the diagnosis4. Construct a working case definition5. Find cases systematically and record information6. Perform descriptive epidemiology7. Develop hypotheses8. Evaluate hypotheses epidemiologically9. Reconsider, refine, and re-evaluate hypotheses10. Compare with laboratory and/or environmental studies11. Implement control and prevention measures12. Initiate or maintain surveillance13. Communicate findings

1.Prepare for field work• The preparations can be grouped into two broad

categories: (a)Scientific and Investigative (b) Management and Operational.

A. Scientific and Investigative-: - Appropriate scientific knowledge, supplies, and

equipment to carry out the investigation before departing for the field.

- In previous similar outbreaks, what have been the sources, modes of transmission, and risk factors for the disease?

- Develop a toolkit for the proper laboratory material and know the proper collection, storage, and transportation.

- A plan of action with clear objectives of this investigation

B.Management and Operational-:- The team members are selected with their clear role and

responsibility.e.g.Epidemiologist,Medicine/Nephrology ,laboratorian,computer specialist, Driver etc….

- Contacting the local staff of the area- A communications plan must be established.- laptop/computer, cell phone or phone card, camera,

and other supplies.- Travel, lodging, and local transportation arranged- Take care of personal matters before leaving….!!!!!

2.Establish the existence of an outbreak-:- The expected number is usually the number from the

previous few weeks or months, or from a comparable period during the previous few years based on locally available data.

- Reporting should be checked for-:- changes in local reporting procedures- changes in the case definition- increased interest because of local or national awareness- improvements in diagnostic procedures.- diagnostic procedures- laboratory error- sudden changes in population size

3. Verify the diagnosis-: - (a) to ensure that the disease has been properly

identified (b) to rule out laboratory error as the basis for the increase in reported cases.

- Talking and examining directly with some patients - Lab confirming by-: Serum Creatinine, e-GFR estimation,

Urine testing for-Micro-albuminuria/Proteinuria

- Summarizing the clinical features using frequency distributions - spectrum of illness and verifying the diagnosis.

4. A working case definition-: A case definition includes clinical criteria and particularly in the setting of an outbreak investigation restricticted by time, place, and person.

- e.g. 100 new cases of pedal edema has been reported in Chudapali area among males of 20-60 yrs. H/o hypertension and proteinuria, increased serum creatinine and shrunken kidneys on USG for > 3 months.

- So as per the criteria for CKD Case definition could be-:People >18 yrs having the feature for > 3 months i) Males

ii) B.P= >150/90 mm Hg iii)Proteinuria= in dip stick +1 or more

iv) Serum Creatinine level > 1.5 mg/dl

5. Find cases systematically and record information-: for additional cases to determine the true geographic extent of the problem and the populations affected by it.

- identify cases is directed at healthcare practitioners and facilities

- passive surveillance or active surveillance

Data Collection must include-: - Identifying information-: name, address, and telephone

number etc - Demographic information-:Age, sex,caste, occupation, etc. - Clinical information-:Signs and symptoms to verify that the

case definition has been met.

- Risk factor information-: Previous H/O-Diabetes, HTN, family history, surgical procedure etc… - Reporter information-: reporter or source of the

report- a physician, clinic, hospital, or laboratory.

Ask case-patients if they know anyone else with the same condition.

Line-listing of cases is done.

6. Perform descriptive epidemiology-: - Comprehensive characterization of the outbreak —

trends over time, geographic distribution (place), and the populations (persons) affected by the disease.

- Identify or infer the population at risk for the disease. - Begin intervention and prevention measures.By Time-:By Place-: Area map/ Spot map to illustrating where

cases live, work, or may have been exposed.By Person-: Host characteristics (age, race, sex, and

medical status) and • Possible exposures (occupation and use of medications,

tobacco, and drugs).

7. Develop hypotheses-:

“Round up the usual suspects.”- Capt. Renault 1942

-e.g.- Suppose out of 100 CKD cases around 80 cases are agricultural workers, exposed to pesticides.

Hypothesis-: “Use of pesticide is related to CKD development”

- e.g.- Suppose out of 100 CKD cases around 70 cases have a positive h/o Diabetes and HTN

Hypothesis-: “Long term Diabetes and HTN is related to CKD development”

8. Evaluate hypotheses epidemiologically-:- Either by comparing the hypotheses with the established

facts or by using analytic epidemiology to quantify relationships and assess the role of chance.

I) If previous report of epidemic is available-: the clinical, laboratory, environmental, and/or epidemiologic evidence obviously support the hypotheses.

II) If not -: A Case Control study can be carried out.Cases -: All 100 casesControls -: (Can be taken 200 if available)

- Neighbours of case-patients - Patients from the same physician practice or hospital who do not have the disease in question - Friends of case-patients.

9. Reconsider, refine, and re-evaluate hypotheses-: - When analytic epidemiology is unrevealing, hypotheses

rethink - Consider convening a meeting of the case-patients to

look for common links

10. Compare and reconcile with laboratory and environmental studies-:

• Epidemiologic, environmental, and laboratory arms of the investigation complements one another, and leads to an inescapable conclusion

11. Implement control and prevention measures-:Lifestyle Changes-:- Keep blood pressure at the target set by health care

provider- If diabetic, control blood glucose level to normal- Keep blood cholesterol in target range.- Quit smoking,alcohol- Get or become more active. - Lose weight if you are overweight.- Meditation can help a lot- Avoid a stressful life……..

Diet Changes-: - Choose and prepare foods with less salt and sodium. - Eat the right amount and the right types of protein. - Choose foods that are healthy for your heart e.g.-Poultry without the skin,Fish,Beans,Vegetables,Fruits, Low-fat

milk, yogurt, cheese etc…- Choose foods with less phosphorus.- Choose foods having the right amount of potassium.- Drink as much waterTreatment Changes-: - Regular follow-up of confirmed cases - Take medicines the proper way - Regular check-ups of at risk people - Renal Transplant if necessary……

12. Initiate or maintain surveillance-: - If active surveillance was initiated as part of case finding

efforts, it should be continued or else should be started at the earliest.

Helps to-:- determine whether the prevention and control measures are working.- Is the number of new cases slowing down or, better yet, stopping?-know whether the outbreak has spread outside its original area

13. Communicate findings-: The final task where the investigation, its findings, and its outcome summarized in a report and communicated in an effective manner.

- i) An oral briefing for local authorities. - ii) A written report -: In the usual scientific format of-

introduction, background, methods, results, discussion, and recommendations.

Serves as-:- a blueprint for action- a record of performance- a document for potential legal issues- a reference- the broader purpose of contributing to the knowledge base of epidemiology and public health.

Thank You…