Highlights At Kumbh Mela 2019, disease surveillance was established for 22 acute diseases and syndromes. Among the reported illnesses, 95% were communicable diseases such as acute respiratory illness (35%), acute fever (28%), and skin infections (18%). The incident command centre generated 12 early warning signals from indicator-based and event-based surveillance: acute diarrheal diseases ( n = 8, 66%), vector-borne diseases ( n = 2, 16%), vaccine-preventable disease ( n = 1, 8%), and thermal event ( n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled. Implementation of disease surveillance facilitated early outbreak detection and response.

Background: In 2016, India reported 709 acute diarrheal disease (ADD) outbreaks (> 25% of all outbreaks). Tribal populations are at higher risk with 27% not having accessibility to safe drinking water and 75% households not having toilets. On June 26, 2017 Pedda-Gujjul-Thanda, a tribal village reported an acute diarrheal disease (ADD) outbreak. We investigated to describe the epidemiology, identify risk factors, and provide evidence-based recommendations. Methods: We defined a case as ≥3 loose stools within 24 h in Pedda-Gujjul-Thanda residents from June 24-30, 2017. We identified cases by reviewing hospital records and house-to-house survey. We conducted a retrospective cohort study and collected stool samples for culture. We assessed drinking water supply and sanitation practices and tested water samples for faecal-contamination. Results: We identified 191 cases (65% females) with median age 36 years (range 4-80 years) and no deaths. The attack-rate (AR) was 37% (191/512). Downhill colonies (located on slope of hilly terrains of the village) reported higher ARs (56%[136/243], p < 0.001) than others (20%[55/269]). Symptoms included diarrhea (100%), fever (17%), vomiting (16%) and abdominal pain (13%). Drinking water from five shallow bore-wells located in downhill colonies was significantly associated with illness (RR = 4.6, 95%CI = 3.4-6.1 and population attributable fraction 61%). In multivariate analysis, drinking water from the shallow bore-wells located in downhill colonies (aOR = 7.9, [95% CI =4.7-13.2]), illiteracy (aOR =6, [95% CI = 3.6-10.1]), good hand-washing practice (aOR = 0.4, [95%CI = 0.2-0.7]) and household water treatment (aOR = 0.3, [95%CI = 0.2-0.5]) were significantly associated with illness. Two stool cultures were negative for Vibrio cholerae. Heavy rainfall was reported from June 22-24. Five of six water samples collected from shallow bore-wells located in downhill colonies were positive for faecal contamination. Conclusion: An ADD outbreak with high attack rate in a remote tribal village was associated with drinking water from shallow downhill bore-wells, likely contaminated via runoff from open defecation areas after heavy rains. Based on our recommendations, immediate public health actions including repair of leakages at contaminated water sources and alternative supply of purified canned drinking water to families, and as long-term public health measures construction of household latrines and piped-water supply initiated.

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D iphtheria is a vaccine-preventable disease of the upper respiratory system caused by toxigenic strains of Corynebacterium diphtheriae. Global casefatality rate (CFR) is estimated at 5%-10%; higher CFRs of up to 20% are reported in children <5 years of age (1). In 2016, with 78% national coverage for third-dose diphtheria-tetanus-pertussis (DTP) vaccine, India reported 48% of diphtheria cases and half of 350 deaths worldwide (2,3). In India, the 3 primary DTP doses are administered at 6, 10, and 14 weeks of age, and booster doses are given at 16-24 months and 5-6 years of age. Numerous states across India have reported diphtheria outbreaks, including Assam in 2010, Karnataka in 2011, and Andhra Pradesh in 2014 (4). In December 2017, the Integrated Disease Surveillance Program of Telangana state reported a rise in diphtheria cases. We investigated to describe the epidemiology of the outbreak, identify risk factors, assess trends in immunization coverage, and provide evidence-based recommendations. The Study For this study we defined a diphtheria case as an upper respiratory tract illness with an adherent pseudomembrane in the nasal cavity, pharynx, or larynx and C. diphtheriae isolated from a clinical specimen from a Telangana resident during January 1-December 31, 2017. Clinical specimens were cultured initially on blood tellurite medium followed by selective culture on cystinase medium. We identified 124 laboratory-confirmed diphtheria cases, for an annual incidence of 3.5 cases/1 million residents; the 19 deaths represented a CFR of 15%. This incidence was more than the mean incidence (+2 SD) of 2.9 cases/1 million residents during 2014-2016, which confirmed the 2017 cases as an outbreak. Age range for case-patients was 4-26 years (median 12 years). Adolescents 10-14 years of age had the highest annual incidence rate, 15/1 million residents. CFR decreased by age from 24% among children 4-9 years of age to no deaths in persons 20-29 years (odds ratio [OR] 1.9, 95% CI 1.1-3.4; p = 0.03). Only 11% (14/124) of laboratoryconfirmed samples had an Elek test for toxigenic strain; 12 (86%) of those 14 samples were positive. Female patients accounted for 50% of cases but 63% of deaths. Children identified as Muslim, a religious minority in Telangana, accounted for 60% of cases, but 74% of deaths. Most cases (81%) and deaths (89%) occurred in the last half of 2017 (Figure 1). Urban Hyderabad makes up only 11.2% of the population of Telangana (https://www.telangana.gov. in/PDFDocuments/Statistical-Year-Book-2017. pdf) but accounted for 53% of diphtheria cases and 47% of deaths in the state; annual incidence in Hyderabad was 19 cases/1 million population, the highest among all geographic areas of Telangana.

We report a diphtheria outbreak mostly among children (median 12 years; range 4–26 years) of a religious minority in urban India. Case-fatality rate (15%, 19/124) was higher among unimmunized patients (relative risk 4.1, 95% CI 1.5–11.7). We recommend mandating and integrating immunization into school health programs to prevent reemergence.