An Outbreak of Fever and Death in a Training Camp for Young Men – Kohat, Pakistan 2018

  • Occupational and environmental health
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Background:
On 1st June 2018, an 18-year-old from a males’ training camp in Kohat developed fever which rapidly progressed to coagulopathy, respiratory distress, and death. Three days later, another 4 members of the same new cohort of trainees living in the same hostel of that camp presented with similar clinical picture; one also died. Considering the possibility of a serious infectious disease outbreak, an investigation was initiated.

Methods:
A case was defined as a resident of the hostel developing fever from mid-May onward. Cases were asked about known causes of fever like systemic infection, inflammatory disorder, malignancy, drugs, physical exertion, heat exposure, animal contact, and recent travel. A retrospective cohort study was done to verify association of risk factors with fever.

Results:
The training camp hostel comprised 3 blocks; each having separate floors for new and old cohorts. From 1-13 June, 36 cases occurred including 2 deaths (Attack Rate=6.1%, Case Fatality Rate=5.6%). Thorough clinical and laboratory work-up could not identify the cause / source of outbreak. Microbiological tests conducted for all possible endemic infections were also negative. Descriptive analysis of cases showed that all 36 cases were from the new cohort; none among the old cohort. Thirty-two cases were from blocks 1 and 2 of the hostel while 4 cases were from block 3. The new cohort gave history of un-acclimatized strenuous outdoor physical exercise (≥6hrs/day). Prevailing temperature of Kohat was 40-45OC. Attack Rates (AR) for blocks 1 (AR=6.8%) and 2 (AR=7.6%) were twice compared to block 3 (AR = 2.6%) where routine exercise was limited to 2 hrs/day. Occurrence of disease was associated with outdoor physical exertion (≥6hrs/day; RR=4.3; 95% CI= 3.3-5.3), sleep deprivation (≤5hrs/day; RR=3.3; 95%CI=2.4-4.2), inadequate hydration (<8 glasses/day; RR=3.2; 95%CI=2.7-3.6), and overcrowding (RR=3.0; 95%CI=2.5-3.4).

Conclusion:
The outbreak of fever and deaths was probably heat related, precipitated by unaccustomed physical exertion of the new cohort in hot weather aggravated by overcrowded living conditions, insufficient water intake, and lack of sleep. Modification of exercise routine and appropriate re-hydration effectively checked the outbreak. Findings of investigation allayed prevailing panic about an infectious disease outbreak and led to an acclimatization policy for incoming cohorts.

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