epidemiology unit, state health department, penang€¦ · not knowing. in addition to sightseeing,...

Epidemiology Unit, State Health Department, Penang

People love to travel


Air travel has become

so affordable

Been there, done that!


Look for new experiences


The intrigue of the unknown lies in

not knowing. In addition to

sightseeing, eating exotic food and

partying in strange places, the draw

of traveling is discovery


Dr Saraswathi Bina Rai

MBBS (Un. Mysore). MPH (Un Malaya) EIP Malaysia

JKN Pulau Pinang

Brucellosis – Lessons

Learnt from our

Outbreak in Penang

Today…

• Brucellosis – the Disease

• Outbreak in Penang

• Lessons Learnt


INTRODUCTION• Brucellosis - Disease of domestic and wild animals (zoonosis):

Transmittable to humans. It has different non-specific symptoms

and signs

• Etiology

• Small non-motile gram-negative coccobacilli

• Many different species, Geographically specific

• Host specific

• Important for humans

• Brucella melitensis

• Brucella abortus

• Brucella suis

• Brucella canis

• Known by many names

Nomenclature

• Also called:

– Bangs disease

– Crimean fever,

– Gibraltar fever,

– Malta fever,

– Maltese fever,

– Mediterranean fever,

– rock fever, or

– undulant fever



EtiologyBrucella melitensis

Goat, sheep, camels

Most widespread

Most virulent


Etiology

Brucella abortus

Cattle and camels

Less virulent


Etiology

Brucella suis

Pigs, swine

Less virulent


Etiology

Brucella canis

Dogs

Least common

Clinical Features

• Systemic bacterial disease with

– Acute or insidious onset, characterised by continued,

intermittent, or irregular fever of variable duration

– Headache

– Weakness

– Profuse sweating

– Chills, arthralgia

– Weight loss and

– Generalised body aches


Brucellosis worldwide

Our Experience in Penang


Chronology of Events

May June

2009 – Mr NAS started goat farm with 4 goats in Air Itam in a durian plantation

July 2010 – surveillance among high risk staff for brucellosis by JPV –Mr NAS negative for BM and BA

Nov 2010 – repeat screening by JPV – 196 screening – 2 goats +

Feb 2011 – 2 goats culled

4th March 2011 – owner of farm Mr NAS – onset of fever,

backache and occipital headache and symptoms

Screening of 211 goats at NAS farm – 2 positive, 1 culled

23rd March – Mr NAS admitted to HPP

29 March – discharged on empirical treatment

for scrub typhus

30th March – diagnosis of

brucellosis received

1st April, notification received

and investigation started

2009 2010 2011

Objectives

• To study the epidemiology of brucellosis in Penang,

• To detect cases early, break chain of transmission and prevent more cases

• To take actions and recommend measures to prevent future incidents

METHODOLOGY• Interview

– Patients / farm owner

– Family members

– Farm worker

– Contacts

• ACD– Family members and contacts

– Mr NAS farm workers

• Case investigations of all cases – both inpatients and outpatients– Physical examination/ results

– Contact tracing

– Lab investigation for brucellosis for all notified cases• IMR, private laboratories or to Hospital Sungai Buloh.

METHODOLOGY

• Environmental inspection– General cleanliness

– Water supply

– Health of workers

• Observation at farm– Process of breeding and feeding animals

– Milking of goats

– Preparation of milk for sale

• Sampling of milk from farm by PKTL, JKN Food unit and Vet dept Timur Laut – Samples sent to Makmal Veterinary Ipoh for analysis for Brucella

• Screening of goats by the veterinary department

Case Definition

(as prepared by ID Unit of HPP)

• Suspected / clinical

• Probable

• Confirmed

Clinical Case Definition

1. Suspect

– An illness characterised by acute or insidious onset

of fever and one or more of the following: night

sweats, fatigue, anorexia, myalgia, weight loss,

headache, arthralgia, arthritis/spondylitis, meningitis,

or focal organ involvement (endocarditis,

orchitis/epididymitis, hepatomegaly, splenomegaly)

With Epidemiological link to a confirmed human or

animal brucellosis case (eg drinking unpasteurized

goats milk)


• Probable

– A clinically compatible illness with definitive laboratory evidence

of Brucella infection

– Presumptive laboratory evidence , but without definitive

laboratory evidence of Brucella infection. Brucella total antibody

titre > or equal to 160 by standard tube agglutination test (SAT)

or Brucella microagglutination test (BMAT) in one or more serum

specimens obtained after onset of symptoms

• Confirmed

– A clinically compatible illness with definitive laboratory evidence

of Brucella infection

1. Culture and identification of Brucella spp from a clinical specimen, or

2. Evidence of 4-fold or greater rise in Brucella antibody titre between acute

and convalescent –phase serum specimens obtained 2 or more weeks

apart

3. Single Brucella total antibody >320 by SAT


RESULTS AND ACTIONS

TAKEN


Cases Notified

(84)

Laboratory confirmed positive

(68)

Singapore

(1)

Taiwan

(3)

Penang Cases

(64)

Laboratory test negative

(16)

Fit case defintion/epid

linked

(8)

Not fit case defintion / not

linked

(8)

No further

information

available

Analysed here – 72 cases that fit case definition

of confirmed or probable

Summary of Brucellosis Cases Notified in Penang in 2011


Air Itam area (39 cases)

Bayan Lepas (1)

Bukit Jambul (2)

Georgetown (12)

Jelutong (4)

Simpang

Empat (1)

Tanjung Bungah/Tanjung

Tokong (4)Sungai

Petani (4)

Gelugor (3)

Location of Cases of

Brucellosis in Penang

Total of 72 cases

Brucella cases by date on Onset in Penang, 2011


Cases by Gender and Ethnicity.

Age group of Brucellosis cases, Penang

Main presenting signs and symptoms of brucellosis

cases.

Place Where cases were admitted sought

treatment

Number %

Hospital Pulau Pinang 43 68.3

Gleneagles Medical centre 9 9.8

Loh Guan Lye 6 7.3

Lam Wah Ee 4 4.9

Island Hospital 3 4.9

Penang Adventist Hospital 7 4.9

Inpatients – 35 cases (48.6%) Govt hospital – 43 (59.7%)

Outpatients – 37 cases (51.4%) Private Hosp - 29 (40.2%)

Fresh goat’s Milk Drinking Habits

(All give history of drinking fresh goats milk)

Location of farm

Location of farm in Air Itam

Environmental

Assessment• Farm

– On the way up the hill in a 4 acre durian plantation

– Goats include Boers, Sheehan, Anglo Nubir and Alpine

– Also rears some chickens and turkeys

– 8 goat sheds

• Overall cleanliness poor

• Farm unlicensed

Goats are in 8 sheds

General poor cleanliness


Observations at farm

• Process of milking goats:

Done by the workers who also tend to the goats – milked into

plastic cups at the barn itself. No sterilization done of udders etc


Milk is then collected into these cold boxes


• Bottling of the milk for sale

Milk is prepared in the kitchen area of the farm using containers and

cups. Manually poured into bottles for sale alter


• Daily produce kept in chiller and after 3 days transferred into the freezer

• Regular buyers that he delivers to their homes

• Some are sold at the farm itself.

• Buyers as far as KL

• Goats may be sold for meat –but tagged by vet dept before being sold.


• About 60 – 70 bottles of milk produced daily and sold :– in 500 ml packing for

RM13.00 each

– or 1 litre packing for RM25.00 each.

• Labeling of milk– Not compliant with Food Act

– No Labeling / no expiry date

– No batch number

• Milk sold is not pasteurised

Other observations

• Farm workers – not vaccinated against

typhoid

– No proper attire

– Poor personal cleanliness

Washing area not sanitaryWater source from hill and

not treated

Analysis of Goats Milk samples from Mr NAS

Farm, Penang 2011

Date Type of sample No

taken

Volume Results By whom

4 April Fresh milk 10 500ml negative PKTL

25 April Fresh milk 10 500ml negative PKTL

25 April Frozen milk 10 500ml negative PKTL

9 May Boiled milk (chiller) 1 500 ml 1+ JKN FQC

16 May Fresh milk 4 30 ml 2+ JKN FQC

18 May Boiled milk 1 500 ml negative JKN FQC

18 May Fresh milk 4 30 ml negative JKN FQC

25 May Boiled milk 4 500 ml negative JKN FQC

25 May Fresh milk 29 30 ml 2 + JKN FQC

1 June Boiled milk 2 500 ml negative JKN FQC

1 June Fresh milk 6 30 ml negative JKN FQC

Actions taken• Opened operations room

• State meetings with vet to work out issues

• Inform MMA and PMPS (to the private and Govt doctors) – alert sent out

• Closure of farm under the CDC Act– Closed on 24th April, 2011 and orders

renewed on 11th May, 2011

• Seize milk samples and milk stored in fridge– 24th April – 405 bottles

– 4th May – 480 bottles

– 12 May – 22 bottles

– 20th May – 20 bottles

– 2nd June – 455 bottles• Some destroyed

Actions Taken• Monitoring of farm to see that he

complies with closure and not selling milk– Up till 10th June, 21 visits by PKTL

• Guidelines on management of brucellosis prepared by HPP and sent out.

• Plan of action for Brucellosis prepared for the State and distributed.

• CME on brucellosis – to private hospitals/ Govt and Health CME.

• Brucellosis flyers

Actions Taken

• Health education to farm workers, owner, family and contacts

• Advice to farm owner on recommendations and actions needed to be taken to improve process of milk production in his farm

• Vet department culled 69 goats and another 57 on 10th June, 2011 when out of 188 goats screened, 58 positive for brucellosis

Discussion

• Not the first incident in Penang. Case of 7 year old boy in 2010 notified through IHR

• B. melitensis and B. suis, more virulent than B. abortus and B. canis.

• Infection with any B. species, including attenuated vaccine strains can cause serious human disease.

• Spread is by contact with infected animals– Body fluids / tissues, urine, vaginal discharges esp placentas,

Carcasses or unpasteurized milk. Large numbers shed in milk

– Here all cases gave history of drinking unpasteurised milk (with 2 exceptions)

Discussion

• Disease determined by:

- Host nutritional and immune status.

- Size of infectious inoculum.

- Route of transmission.

Ex: -Low gastric juice PH, more effective in

preventing B. abortus than B. melitensis

infection when administered by oral route.

• Many people obviously drunk the milk unknowingly but not all got sick

• Long incubation period of 5 days to 5 months results in more cases being discovered even though we have removed the source.

• Some had onset a long time ago but only now heard of it so seeking treatment

Discussion

• Goats were screened late last year and were

negative so his farm affected is a fairly recent

phenomenon

• But goats he had purchased were from within state

so there may be other farms positive – part of our

POA to test these farms

• In 2010, 98 goats were positive in Penang –

magnitude of problem worrying.

Lessons Learnt and Problems

faced

• Another emerging zoonotic disease in Penang

not to be taken for granted

• Early in outbreak, so many unknowns –

– who licenses farms?

– Who sees to GHP in farms?

• Knowledge amongst doctors poor

• Not notifiable so most not sure how to notify

• Always to be prepared

• We don’t want to kill the industry

• Relapses – also common

• Very severe outcome

• Why do people consume fresh goats

milk?

– Benefits - easily digestible, boost immune

system, more nutritionally wholesome, more

fatty acids, less bloating, lower fat, calcium

rich etc.



faced


faced• Goats still positive

• Cows also positive in 2015

• Still insufficient knowledge, but other

states with more cases …


CONCLUSION

• This is an outbreak of brucellosis in Penang

associated with the drinking of fresh goats milk

from 1 particular infected farm.

• Lessons learnt from here …not to make same

mistakes elsewhere

RECOMMENDATIONS

• Complete and thorough screening of goats for brucellosis in the state

• Town council to look seriously into licensing of farms

• Brucellosis not yet a notifiable disease – but doctors need to know.

• Proper guideline on fresh milk production and sale from farms, on pasteurization of milk

Brucellosis – where are we now?

• Many states have reported cases – are we

looking

• People coming back from exotic places,

(been there tried that) including drinking

milk from all sources.

• In process of amending sale of raw milk


THANK YOU

FOR YOUR

ATTENTION!

epidemiology unit, state health department, penang€¦ · not knowing. in addition to sightseeing,...

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