• Users Online: 112
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 31-35

An epidemiological study of varicella outbreak in a military training establishment


1 Department of Community Medicine, Station Health Organisation Portblair, Andaman and Nicobar Islands, India
2 Department of Community Medicine, Head Quarters, Central Command, Lucknow, Uttar Pradesh, India
3 Department of Neurosurgery, Command Hospital Southern Command, Pune, Maharashtra, India

Date of Submission28-Sep-2018
Date of Acceptance04-Mar-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Col Rahul K Ray
Community Medicine, Head Quarters, Central Command, Lucknow, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_57_18

Rights and Permissions
  Abstract 


Context: Though incidence of the Varicella has decreased in recent years due to introduction of vaccine; outbreaks continue to occur in closed environments such as those of militaries. The present study describes one such outbreak in a military training establishment. Setting and Design: This cross sectional study was conducted at a Secondary level hospital. Aims: To describe the distribution and characteristics of Varicella infections and to make suitable recommendations for prevention and control. Materials and Methods: All admitted cases of Varicella from a military training establishment during the outbreak were included in the study. Epidemiological data was collected by face to face interview. Statistical Analysis Used: Statistical analysis was performed using Epinfo software version 3.5.3. Results: Total 332 recruits were admitted in the local military hospital in said outbreak. Eight administrative staffs of recruiting center and two medical staffs attending the patient at hospital were also affected. The age of the patients ranged from 18 to 34 years with a mean of 20.3 ± 3.5 years. None of the cases admitted had developed any complication and their hospital stay remained uneventful. Maximum cases (59%) were presented with rash as a first clinical manifestation and 94.3 % of them had history of contact with a case of Varicella. None of them gave a history of vaccination. Conclusions: Though policy to offer vaccination against Varicella to all recruits on entry level exists, it should be implemented on ground to ensure unnecessary interruption in training activities.

Keywords: Outbreak, recruits, varicella


How to cite this article:
Sinalkar DR, Ray RK, Sudumbrekar S M. An epidemiological study of varicella outbreak in a military training establishment. J Mar Med Soc 2019;21:31-5

How to cite this URL:
Sinalkar DR, Ray RK, Sudumbrekar S M. An epidemiological study of varicella outbreak in a military training establishment. J Mar Med Soc [serial online] 2019 [cited 2019 Jul 23];21:31-5. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/1/31/260667




  Introduction Top


Varicella Zoster virus causes varicella among susceptible population and is characterized by pruritic vesicular rash, fever, headache, and malaise.[1] Incubation period ranges from 10 to 21 days. Patients are infectious 1–2 days before the appearance of rash until all lesions are crusted.[2] The virus spreads mainly by respiratory route by direct contact of susceptible personnel with cases.[3] Secondary attack rate among susceptible contacts ranges from 65% to 86%.[1],[4],[5]

Outbreaks of chickenpox in a military training center affect a considerable number of military recruits, leading to a number of hospital admissions and have an adverse effect on training activities.[6]

Outbreaks get reported quite often in countries like India where vaccination is not part of the country's national immunization policy. Varicella outbreaks occur frequently in closed and crowded environments such as military barracks through aerosol spread.[7] Severity and complications are common among adults.[8] Secondary bacterial infections, dehydration, pneumonia, encephalitis, and cerebellar ataxia are few severe complications which may result in death. Hence, varicella is an important health issue among military personnel.[4],[9],[10]

An outbreak of varicella occurred among personnel of a training establishment. All cases were admitted to the nearest military hospital. Based on the information obtained from an inbuilt health intelligence (HI) surveillance section of station health organization and hospital authorities, investigation and control measures were initiated.

The recruits undergo training over a period of 12–18 months.

This study was carried out to describe the distribution and characteristics of varicella among personnel and to make suitable recommendations for the prevention and control of outbreak in a military training establishment.


  Methodology Top


Study setting

This was a cross-sectional study carried out in a secondary care hospital. All varicella cases from the training center who were admitted to the hospital during outbreak were included in the study. Cases started occurring while the recruits were in the first phase of their training. Many contacts of index case developed disease over subsequent days and were admitted.

All cases were interviewed on the day of admission by trained health personnel after informed consent. Data was collected by means of a semi-structured questionnaire based on the study objectives. The data included personal details, clinical features including travel history, movements for camps/outdoor training, and immunization details. An epidemiological case sheet and line listing was done. Contact tracing was carried out for close contacts.

Data thus collected were analyzed using Epi-info software version 3.5.3 (Centers for Disease Control, Atlanta, United States of America) and IBM SPSS Statistics for Windows version 24 (IBM Corp., Armonk, NY: USA). Secondary attack rate was calculated by dividing the number of cases with the number of susceptibles within the incubation period of index case.

Case definitions

Clinical case was defined as the one with acute onset of diffuse (generalized) maculopapular vesicular rash with fever among personnel in a training establishment admitted in local military hospital with no prior history of varicella.[11] The case definition was based only on the clinical diagnosis, and the cases were not laboratory confirmed.

Probable case was the one that meets the clinical case definition and was not epidemiologically linked to another probable or confirmed case.[11]

Confirmed case was the one that meets clinical case definition and was epidemiologically linked to another probable or confirmed case.[11]

Outbreak was confirmed by comparing the weekly incidence of varicella with similar period of previous 3 years' data as available in the establishment.

Close contacts were defined as recruits/personnel who had direct contact indoor or outdoor, defined as being within a distance of <1 m from a case and/or had discussion of more than three words with a case and/or had face-to-face contact with the case.

Susceptibles were those recruits/personnel with no known history of varicella or vaccination against varicella and who came in close contact with cases.

Overcrowding was defined using the American Public Health Association Centers for Disease Control and Prevention criteria.[12] Maximum occupancy of any dwelling unit/room should not exceed lesser than the requirements of the first (at least 150 sq. foot floor area) and the second and subsequent occupants (at least 101 sq. foot floor area). If dwelling of two or more rooms was occupied, then it should have at least 70 sq. foot of floor area for the first occupant and at least 50 sq. foot floor area for subsequent occupants.

Control measures

All close contacts were immediately quarantined in separate accommodations/temporary tents. Separate messing facilities and training facilities were established for segregated recruits. Awareness drives were conducted for instructional staff for sensitizing the recruits about the importance of frequent handwashing, cough etiquettes, use of face mask, restriction of movement, avoiding mass gathering, to increase space between beds, head-to-toe pattern of sleeping, wet mopping of floors, early reporting of symptoms, etc. Additional tents were established for accommodating recruits. Personnel with a previous history of varicella were tasked for taking care of quarantined recruits. Vaccination of all recruits was initiated after availability of vaccine. Vaccination was initially given to close contacts; health personnel and subsequently all recruits were vaccinated in batches. Surveillance was continued till next four weeks after the last case was diagnosed.


  Results Top


A total of 342 cases of varicella from a military training center were admitted in the Military Hospital during the study period. Out of these, 332 (97%) were young recruits, eight (2.4%) were administrative staff and two (0.6%) were medical staff of the center attending the patients.

Overall attack rate among the recruits during this outbreak was 4.8%, whereas the corresponding attack rates of the last 3 years were 0.5%, 1.5% and 0.8% respectively.

An epidemic curve for time distribution of cases was prepared, which showed that 22 cases occurred within the incubation period of the index case which later propagated the disease among the other recruits [Figure 1]. In our study, out of 26 susceptible recruits, 22 recruits had developed the disease. Secondary attack rate was found to be 87% among susceptible close contacts.
Figure 1: Epidemic curve with multiple peaks

Click here to view


Subunit-wise distributions of the admitted recruits are shown in [Figure 2] and [Figure 3]. In our study, attack rate was maximum (5.3%) among recruits of Subunit III. The Subunit II had attack rate of 4.4%, while the same for Subunit I was 3.9%.
Figure 2: Distribution of Varicella cases as per subunits

Click here to view
Figure 3: Spot Map depicting placewise distribution of cases

Click here to view


As shown in [Table 1], the most common clinical manifestation observed among cases was rash (100%) followed by fever (83%) and body ache (36%). The first site of appearance of rash was the trunk in the majority (85%) of the patients. Maximum cases (59%) had presented with rash as a first clinical manifestation, whereas fever was the first clinical manifestation in 40% of cases. Nearly 94.3% of the patients (confirmed cases) had a history of contact with a case, whereas 5.7% of the patients (probable cases) were not known to have any contact with any case. None of them gave a positive history of varicella infection and vaccination against varicella in childhood. None of the cases developed any complications and recovered completely from the disease. The age of the patients ranged from 18 to 34 years, with a mean of 20.3 ± 3.5 years. The mean hospital stay of the cases was 8.4 days, with a standard deviation of 1.4.
Table 1: Clinical profile of cases

Click here to view


Overcrowding was observed in the barracks with corresponding reduction in available floor area per recruit. Area available per recruit was only 36.5 sq. feet.

As shown in [Figure 1], the number of cases steadily increased from M Month to M+3 Month and then started to decline. After M+5 month, the number of cases was at preoutbreak level.

Epidemiological linkage between the cases was studied and is depicted in [Figure 4].
Figure 4: Epidemiological Linkage between Varicella Cases

Click here to view



  Discussion Top


In the present outbreak, the index case was a recruit of 18 years with 15 days of military service. He had traveled in train from North to South along with two other newly selected candidates from the same Army Recruiting Office (ARO). All of them had contact with a co-passenger in the train who had varicella. Soon after reporting to the center, they were accommodated in the barracks along with other recruits from various AROs. All of them had developed varicella subsequently and were admitted to the hospital. These recruits in turn had spread the disease to their close contacts in the barracks. After one month of the initial phase, the recruits were transferred for trade-wise training to different subunits as per their trades and relocated to the respective subunits' accommodation.

The epidemic curve demonstrates a propagated epidemic, with multiple peaks indicating transmission of infection to successive clusters of recruits. The interval between the peaks was less than the incubation period of varicella (10–21 days), which implies that cases were infectious during the incubation period.

All the newly inducted recruits were sheltered in same barracks. This led to overcrowding and compromise in the ventilation and hygiene sanitation of recruits. Furthermore, mixing of recruits in the classes, dining halls, sports ground, and auditorium prior to the implementation of preventive measures resulted in the further spread of varicella.

Almost all quarantined close contacts were deployed as working parties along with other recruits for the preparation of incoming major event to be held in the first half of fourth month of reporting of recruits. This deployment was from last week of third month and first week of fourth month at various locations of the center. This defeated the purpose of segregation and resulted in multiple peaks of cases in epidemic curve and was an important cause for prolongation of an ongoing epidemic.

Known high secondary attack rate of disease also contributed to the spread. The secondary attack rate in our study (87%) was comparable with that of other studies.[4],[5]

Another reason for spread among the recruits was transmission occurring among close contacts during the period of infectivity, especially the period of communicability extending 1–2 days before the onset of rash.[3] None of the close contacts were either vaccinated or had any previous infection with varicella.

Being winter season, lower temperature might have accelerated the transmission of varicella among susceptible recruits as seen in the study conducted among mobile troops by Chatterjee et al.[13],[14]

This outbreak occurred among military recruits residing in close proximity, making them vulnerable to the spread of highly communicable diseases like varicella. A similar outbreak was also reported among military troops at Singapore.[7]

Limitations of the study

Laboratory confirmation of cases and serosurveillance among the recruits for determining the immunity among close contacts could not be carried out due to lack of laboratory facility in the study area.


  Conclusions Top


This outbreak of varicella in a military training center affected young recruits coming from various parts of the country leading to their hospital admission and an adverse effect on training activities.

Overcrowding, higher secondary attack rate of varicella among susceptibles, no history of vaccinations prior to entry, nonavailability of vaccines at the training center for administration to recruits on entry, and deployment of segregated recruits for the preparation of incoming major event by executive authorities despite medical advice have played a supportive role in the transmission of varicella.

Early initiation of preventive measures as advised by medical authorities is of paramount importance. Executive authorities should strictly institute the measures as advised. Permanent solution for reducing the overcrowding may be considered by increasing the infrastructure for recruits. Occurrence of even a single case of varicella has the potential of rapid spread among recruits and outbreak, and hence, vaccination of all recruits on entry on the very 1st day of reporting to the training center should be considered to prevent such outbreaks in future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Heininger U, Seward JF. Varicella. Lancet 2006;368:1365-76.  Back to cited text no. 1
    
2.
Macartney K, Heywood A, McIntyre P. Vaccines for post-exposure prophylaxis against varicella (chickenpox) in children and adults. Cochrane Database Syst Rev 2014;6:CD001833.  Back to cited text no. 2
    
3.
Park K. Park's Textbook of Preventive and Social Medicine. 22nd ed. Jabalpur: M/s Banarsidas Bhanot; 2013.  Back to cited text no. 3
    
4.
Lopez A. Strategies for the Control and Investigation of Varicella Outbreaks 2008. National Center for Immunization and Respiratory Diseases. Atlanta: Centers for Disease Control and Prevention; 2008.  Back to cited text no. 4
    
5.
World Health Organization. Weekly Epidemiological Record: WHO Position Paper on Varicella Vaccines. Vol. 73. Geneva: World Health Organization; 1998. p. 241-8.  Back to cited text no. 5
    
6.
Eijaz G, Mahmood R, Muhammad AR. Outbreak of chickenpox in a military center in Northern Pakistan. Pak Armed Forces Med J 2016;66:147-50.  Back to cited text no. 6
    
7.
Goh JJ, Ho M, Koh WM, Lee VJ. An economic analysis of varicella immunization in the Singapore military. Mil Med Res 2016;3:3.  Back to cited text no. 7
    
8.
Lee BW. Review of varicella zoster seroepidemiology in India and Southeast Asia. Trop Med Int Health 1998;3:886-90.  Back to cited text no. 8
    
9.
Dawood FS, Ambrose JF, Russell BP, Hawksworth AW, Winchell JM, Glass N, et al. Outbreak of pneumonia in the setting of fatal pneumococcal meningitis among US Army trainees: Potential role of chlamydia pneumoniae infection. BMC Infect Dis 2011;11:157.  Back to cited text no. 9
    
10.
Gray GC, Palinkas LA, Kelley PW. Increasing incidence of varicella hospitalizations in United States Army and Navy personnel: Are today's teenagers more susceptible? Should recruits be vaccinated? Pediatrics 1990;86:867-73.  Back to cited text no. 10
    
11.
Council of State and Territorial Epidemiologists. Position Statements. CSTE Annual Meeting, Madison, WI. Position Statements ID-9; 1999. Available from: http://www.cste.org/dnn/AnnualConference/PositionStatementTemplates/PositionStatements/tabid/191/Default.aspx. [Last accessed on 2018 Nov 15].  Back to cited text no. 11
    
12.
Wood EW. Housing and Health. APHA CDC Recommended Minimum Housing Standards. Washington, DC: American Public Health Association; 1995. p. 37-8.  Back to cited text no. 12
    
13.
Chatterjee K, Kunwar R, Taneja G, Mitra S, Srinivas V. An outbreak of varicella among troops on the move: A challenge in field epidemiology. J Mar Med Soc 2018;20:38-43.  Back to cited text no. 13
  [Full text]  
14.
Singh MP, Singh G, Kumar A, Singh A, Ratho RK. Epidemiologic lessons: Chickenpox outbreak investigation in a rural community around Chandigarh, North India. Indian J Pathol Microbiol 2011;54:772-4.  Back to cited text no. 14
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed61    
    Printed0    
    Emailed0    
    PDF Downloaded11    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]