Correspondence Address:
Manickam Ponnaiah
Scientist- E, ICMR-National Institute of Epidemiology, R127, TNHB, Chennai - 600 077, Tamil Nadu
India

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Dear Editor

In the South-East Asia, more than 150 million illnesses, 175,000 deaths, and 12 million disability adjusted life years were due to foodborne diseases annually.[1],[2] In India, most foodborne diseases those with high morbidity are often reported by media.[3] Holy food (prasad) which is offered to God does not go through the stringency under the Food Safety and Standards Authority of India. Outbreaks following the distribution of prasad at festivals remain unreported, and hence, only few of them are published in the literature. On April 4, 2018, media reported a cluster of gastroenteritis among the attendees of a religious festival held in Coimbatore District, Tamil Nadu. The next day, a team led by Field Epidemiology Training Program trainee and the District Surveillance Unit officers investigated the cluster to confirm the outbreak, describe cases by time, place, and person, identify the potential exposure, and propose recommendations. We investigated media reported cluster of gastroenteritis (AGE) among festival attendees to confirm the outbreak and identify potential exposures. We defined a case as occurrence of vomiting or loose stools (≥3 episodes). We searched for cases house-to-house and described by time (epicurve), place (spot map), and calculated attack rate by age and gender. We conducted a retrospective cohort study of festival attendees and computed relative risk (RR), 95% confidence interval (95%CI), and Population Attributable Risk (PAR). Of the 61 attendees, we identified 52 AGE cases (Attack rate = 85%). The median incubation period was 12 h (Range: 6–15 h). Attack rate was higher among those who ate rice-flakes-jaggery (96%, [49/51]) than others (30%, [3/10]; RR = 3.2; 95% CI: 1.2 to 8.2; PAR = 74%) [Table 1]. During the interview of the key informants, we learnt that the temple priest prepared the rice-flakes-jaggery sweet by mixing the rice-flakes, jaggery, and ghee, and fruits. The food items were prepared on the night of the previous day (2nd April) with bare hands and were not refrigerated. A group of attendees distributed the food items at 10.30 AM on April 3, 2018. The time interval between food preparation and distribution of rice-flakes-jaggery and fruit salad was 12–13 h. Inspection of the kitchen did not reveal any potential contamination sources. The collected stool specimens, drinking water, and cooking water specimens were negative for pathogenic microorganisms. The results of quality analysis of raw materials used for cooking confirmed the adulteration of ghee with palmolein oil. Although the consumption of rice-flakes-jaggery sweet could explain more than three-fourths of the cases, we could not identify the causative organism. Identifying the causative organism caused the outbreak remains a challenge. The etiology of 71% of the foodborne outbreaks, suspected food vehicle of the 46% outbreaks were not identified, and specimens for laboratory investigations were not collected in 55% of the outbreaks.[4] Considering the incubation period and the clinical presentation, the potential causative organisms that might have caused the outbreak were Bacillus cereus, Staphylococcus aureus, and Clostridium perfringens.[5] We concluded the outbreak of AGE was due to rice-flakes-jaggery distributed during the festival. We recommended fresh preparation and immediate distribution of food during festivals.{Table 1}

Ethics committee approval

This investigation was a rapid response to the public health emergency by the Directorate of Public Health and Preventive Medicine, Government of Tamil Nadu, India. As per the existing Indian norms, such public health practice of outbreak investigations thereof need not go through ethics review process. However, the trainee officer undertook measures to ensure the confidentiality of the information provided during the interview and secure the collected data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References