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© 2016 Indian Journal of Medical Microbiology Published by Wolters Kluwer - Medknow

1 Indian Journal of Medical Microbiology, (2016) 34(2): 233-236

sewage facilities and sanitary conditions. Improvement

in hygienic and socioeconomic conditions decreases the

incidence of HAV infection.[3]

The mean incubation period of the disease is

approximately 30 days (range 2–6 weeks). Approximately,

85% of infected individuals have a full recovery within

3 months and nearly all have a complete recovery

by 6 months. Anti-HAV antibodies can be detected during

acute illness. The early antibody response is predominantly

of immunoglobulin M (IgM) class and is used to establish

the diagnosis of acute infection. During convalescence

and during subsequent life, however, anti-HAV of theimmunoglobulin G (IgG) class becomes the predominant

antibody.[3] The clinical severity of the HAV infection

increases with age and varies from an asymptomatic

infection to a fulminant hepatic failure. Disease is

asymptomatic in only 4–16% of children compared to

75–95% of adults.[6] It is believed that most children acquire

immunity through asymptomatic infection early in life.

The aim of this paper is to describe an outbreak of

HAV among children


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234 Indian Journal of Medical Microbiology vol. 34, No. 2

claimed more than 5700 human lives and thousands of

domestic animals and livestock were feared dead. The focus

of the outbreak was an overcrowded, ood rescue camp

with very poor hygienic conditions, in Rudraprayag district

of Uttarakhand state, India.

Materials and Methods

Study area

In June 2013, a report under infectious disease

surveillance program was received from the local health

authorities regarding the suspected outbreak of acute

viral hepatitis among children in a ood rescue camp in

Rudraprayag District of Uttarakhand State, India. A linkage

was hypothesised between the infected individuals and

the common water sources feared of being contaminated

faecally.

Collection of samples

Blood samples were collected from 28 children

(Age: 2–9 years) clinically suspected of having hepatitis,

over the period of 29 days (21st June to 19th July, 2013)

and were sent to Microbiology laboratory of our hospital,

a Tertiary Care Centre (Veer Chandra Singh Garhwali

Government Medical Sciences and Research Institute,

Srinagar Garhwal) for serological investigations. Water

samples were also collected from common water sources

supplying the camps and were tested for the presence of

faecal coliforms by standard methods.[7]

Serology

Samples were screened for anti-HAV and anti-HEV IgM

and IgG antibodies by using rapid immunochromatographicassay (SD Bioline IgG/IgM rapid Test) and were conrmed

by ELISA (DSI, S.r.l, Varese, Italy) for anti-HAV-IgM

antibodies.

Water analysis

Each water sample was vortexed before dilution and

inoculation to ensure that the organisms present in water

were uniformly distributed. The coliform count was

assessed by the most probable number technique by using

McCrady’s tables.[7] Each sample was diluted 1:10 to give

360 coliforms per 100 ml as the upper limit of accurate

estimation.

Results

Among the 28 samples tested 25 (89.3%) were found

positive for anti-HAV IgG and IgM antibodies by card

test (screening test), and all were negative for anti-HEV

antibodies. Of 25 samples found positive on screening,

23 (92%) were conrmed for Hepatitis A serology by

anti-HAV IgM-ELISA. All the cases were children and

belonged to age group 2 to 9 years, with male: female

ratio of 1:1.3. Mild clinical symptoms were seen, and no

mortality due to the infection was reported. All the eight

water samples collected from the nearby water sources were

found faecally contaminated and had >180 thermotolerant

coliforms/100 ml of water.

Discussion

In this report, we identied 23 cases over a periodof 29 days and due to this sudden increase linked to time

and space we considered this an outbreak of HAV. As all

the cases were identied over a short period of the time

and exhibited nearly identical symptoms, they were part

of an outbreak that probably must have originated from

a common source. This report is noteworthy in that it

describes the emergence of an outbreak in a rescue camp,

after the ash oods and multiple cloud bursts that affected

the Kedarnath valley and the adjacent villages. As this

natural calamity took place at the peak of a pilgrim season,

so a large number of population was affected and this

rescue camp was overcrowded. Moreover, the impact of thisdisastrous calamity was so severe that there was a complete

breakdown of the communication with the affected area.

The general condition of the people and the overall hygienic

conditions in and around this camp were very poor. In

addition, the people residing in the camp were bound to

defecate in the open air. Although the packed food and

drinking water was being supplied to the people sheltered

in the camp but due to bad weather, repeated landslides

and road blocks, the supply could not be maintained

constantly. The people were also dependent on the natural

water sources (Choyaa or Shrot ) which were found faecally

contaminated, and the link between these water sources

and outbreak was hypothesised. The time frame of diseaseoccurrence and the incubation period of hepatitis A infection

also further substantiate this link. The potential for hepatitis

A outbreaks after ood‑related sewage contamination

of water sources has been recognised. Increases in the

incidence of hepatitis A have been noted in association with

natural disasters and attributed to disruptions in water and

sanitation facilities.

The district health authorities were informed of the

outbreak, so they could detect possible new cases quickly,

report them urgently, advised to take appropriate measures

to avoid person to person transmission and maintain the

isolation of cases during the infectious period. However, the prevailing situation in the camp was quite poor. The control

measures in such situation were difcult to implement

as when the outbreak was detected the HAV was already

circulating among the population. Besides the hygienic

measures, avoidance of faecal-oral transmission was not

easy to maintain among the population who by force was

bound to defecate in the open air. As the main focus was

to rescue the affected people and save as many lives as

possible, it was very difcult to maintain the hygienic


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Pal, et al .: Hepatitis A virus outbreak in food rescue camp 235April-June 2016

conditions in the camp which may have resulted in faecal

contamination of the water sources. By the time further

control measures like vaccination of children and close

contacts could be implemented most of these cases were

rescued from the area.

With the changing epidemiology of HAV, outbreaks of

hepatitis A have been recorded in India.[8,9] Studies from

northern India indicate that hepatitis A is becoming a major

cause of sporadic hepatitis in children.[10] Earlier reports

also suggest that India is hyperendemic for HAV infection

with very high infection rates in the rst few years of

life.[10] The degree of endemicity is closely related to the

prevailing hygiene and sanitary conditions, socio-economic

level and other developmental indicators.[9] In the present

report, given the poor environmental hygiene, it was

interesting to note that all the affected children were

between 2 and 9 years of age. All these children had a

symptomatic disease which possibly reects the outbreak of

unknown magnitude.

Infectious disease distribution involves complex

social and demographic factors. Meteorological factors

such as temperature, humidity and rainfall patterns may

inuence the infectious disease transmission.[11] The

intergovernmental panel on climate change noted in its

2007 report, that climate change may contribute to the

expansion of high-risk areas for infectious diseases and may

signicantly increase the burden of diarrheal diseases.[12]

The effect of climate change on human health in India is a

broad topic. In South Asia, scientists predict an increased

frequency of oods due to greater intensity of rainfall

events and the glacier lake outburst oods (GLOFs) in

mountainous regions. These trends are already being seen,as seen prior to this outbreak in the Kedarnath valley which

is well known as Himalayan Tsunami. In the Himalayan

region of South Asia particularly in Pakistan, Nepal, India

and Bangladesh, the frequency of GLOFs rose during the

past few years.[11,13]

Floods create conducive environments for disease

transmission as faecally contaminated ood water increases

the rate of faecal-oral disease transmission, allowing

diarrheal disease and other bacterial and viral illness to

ourish. It is of particular concern in Himalayan and

Sub‑Himalayan regions as in the situation of ood the

access to clean water and sanitation is limited.

[11]

Diarrhealdiseases are largely attributable to unsafe drinking water and

lack of basic sanitation; thus reductions in the availability

of fresh water are likely to increase the incidence of such

diseases. Though Rudraprayag and the adjacent villages

are not endemic for Hepatitis A but still the people

visiting Char Dhams (Badrinath, Kedarnath, Gangotri

and Yamunotri) every year may introduce the disease in

this region. A pretravel health advisory should be issued

to travellers, reminding them to follow good personal

and food hygiene, as during travel this is quite difcult to

maintain. Vaccination against HAV is also an important

measure. Several safe and effective vaccines such as

HAVRIX (Glaxo Smith Kline) and VAQTA (Merck and Co.,

Inc.) are available against HAV. A combination hepatitis

A/hepatitis B vaccine consisting of HAVRIX and Engerix

B (Twinrix, Glaxo Smith Kline) is also commercially

available. Post-exposure vaccination is also effective and

can be considered. Shen et al.[14]

demonstrated that theeffectiveness of post-exposure vaccination was 100% in a

common source outbreak.

As the prevailing situation in the camp and overall

environmental and climatic conditions were not favourable,

so an epidemiological investigation of this outbreak

was not possible at that particular moment of time and

this is a primary limitation of our report. However, this

report exemplies the basic problems encountered after

a natural calamity and we believe it can be helpful in the

development of control strategies for effective management

of such situations.

Conclusion

Despite great advances in medicine over the past

decades, complications arising from natural calamities

are still common. Such situations are more problematic

for developing countries like India, where resources are

limited. It is obvious that improved sanitation will lead

to more success in controlling the spread of HAV and

vaccination of susceptible population is the cornerstone

of outbreak control. However, it should also be kept in

mind that it is quite difcult to achieve the ideal control

measures in the extreme situations like discussed in the

current report. Preplanning and a core outbreak management

team trained to deal with such situations should be formed.

Furthermore, the long-term prevention of outbreaks will be

achieved through implementation of high vaccination rate in

schools and day care centres. Detection of conrmed HAV

infections (with or without symptoms) should be a statutorily

reportable situation for clinical laboratories, to allow a quick

investigation of sources of infection and contacts for further

appropriate and timely intervention. Our report can serve

as a template for the development of local guidelines for

prevention and appropriate management of such outbreaks.

Financial support and sponsorship

Integrated Disease Surveillance Programme, New Delhi,India.

Conicts of interest

There are no conicts of interest.

References

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P u b l i c a t i o n s & M e d i a P v t . L t d . a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s

o r p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r ,

u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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