title: Investigating a community-wide outbreak of hepatitis a in India.
abstract: BACKGROUND
  There was an outbreak of acute hepatitis in Mylapore village, Kollam district, Kerala, southern India during February to June 2013. An outbreak investigation was initiated with the objective of describing the epidemiological features of the hepatitis outbreak.
  
  
  METHODS
  House-to-house visits were undertaken to identify symptomatic cases. The outbreak was described in terms of person, place and time. Hypothesis was generated based on findings from descriptive study, laboratory investigation of water samples, and environmental observations. A case-control study was designed to test the hypothesis. Chi-square test, univariate analysis, and logistic regression to identify the risk factors associated with hepatitis A infection were done.
  
  
  RESULTS
  Line list generated consisted of 45 cases. Attack rate was the highest among the age group 15-24 years (4.6%) followed by 5-14 years (3.1%). The geographical distribution of the cases suggested a clustering around the water supply through the pipeline and epidemic curve showed a sharp rise in cases suggestive of a common source outbreak. Water samples collected form pipeline showed evidence of fecal contamination and absence of residual chlorine. In the case-control study, having consumed water from the pipeline (odds ratio: 9.01 [95% confidence interval: 2.16-37.61]) was associated with the hepatitis A cases.
  
  
  CONCLUSIONS
  The time frame of disease occurrence, environmental observations, anecdotal evidences, laboratory results and results of the analytical study indicated the possibility of occurrence of hepatitis A outbreak as a result of pipe water contamination supplied from a bore well. The study warrants establishment of an efficient water quality surveillance system.
authors.affiliation: District Surveillance Unit, Integrated Disease Surveillance Project, District Medical Office, Kollam, Kerala, India.
authors.forename: Ps
authors.initials: P
authors.lastname: Rakesh
authors.affiliation: District Surveillance Unit, Integrated Disease Surveillance Project, District Medical Office, Kollam, Kerala, India.
authors.forename: Daniel
authors.initials: D
authors.lastname: Sherin
authors.affiliation: District Surveillance Unit, Integrated Disease Surveillance Project, District Medical Office, Kollam, Kerala, India.
authors.forename: Hari
authors.initials: H
authors.lastname: Sankar
authors.affiliation: District Surveillance Unit, Integrated Disease Surveillance Project, District Medical Office, Kollam, Kerala, India.
authors.forename: Marydasan
authors.initials: M
authors.lastname: Shaji
authors.affiliation: District Surveillance Unit, Integrated Disease Surveillance Project, District Medical Office, Kollam, Kerala, India.
authors.forename: Saraswathy
authors.initials: S
authors.lastname: Subhagan
authors.affiliation: District Surveillance Unit, Integrated Disease Surveillance Project, District Medical Office, Kollam, Kerala, India.
authors.forename: Sreekumar
authors.initials: S
authors.lastname: Salila
keywords: Hepatitis A; Outbreak investigation; Vaccination; Water contamination; Water supply