Food Borne Outbreak among Sanitary Supervisors during World’s Largest Religious Mass Gathering, Prayagraj, Uttar Pradesh, India-2019

  • Water or foodborne
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Background:
Religious mass gathering held at Prayagraj, India in 2019 attracted approximately 150 million pilgrims globally. Daily disease surveillance was established by state health authority and National Centre for Disease Control, Delhi with objective to identify early warning signals for outbreak prone diseases. On February 19, acute diarrhoeal cases were reported from sanitary supervisor’s residence (camp A). An investigation was conducted to describe outbreak, determine risk factors and provide evidence based recommendations.

Methods:
We defined case as acute onset of ≥3 loose stools within 24 hours or pain abdomen or vomiting from February 18-20, 2019 in a person residing at camp A. We conducted active case search and reviewed hospital records to collect information on symptoms, date of illness onset, and treatment history. Unmatched 1:2 case control study was conducted to identify associated risk factors. Healthy controls were selected from the same camp A. Due to limited laboratory support only one stool sample was collected and tested for Vibrio Cholerabymicroscopy. We interviewed the food handlers about recent illness and preparation of implicated food items. Frequency, OR with 95% CI were calculated using Epi-Info7.

Results:
We identified 16 cases (25% females) with median age 25 years (range 21-38 years). Overall attack rate was 7.6%(16/210). Most common symptom was pain abdomen (81%) followed by diarrhoea (44%). Eight cases (50%) were hospitalized with no death. Median incubation period was 26 hours (range 18-32 hours). Upma (thick semolina porridge) served as breakfast on February 18, was associated with illness (OR=5.57, 95%CI=1.32-23.4). Food handler didn’t report any gastrointestinal symptoms during the month prior to the outbreak. Overnight, non-refrigerated leftover boiled potatoes were used in upma preparation. Stool sample was negative for Vibrio cholera. Food leftover was not available for testing. Food Safety and Standards Authority of India (FSSAI) guidelines were not followed for food preparation and storage.

Conclusion:
Point source outbreak of acute gastroenteritis occurred at camp A associated with consumption of upma with left-over boiled potatoes. The epidemiological, clinical, and environmental findings indicate the most likely etiologic agent to be Bacillus cereus. We recommend to follow FSSAI guidelines and strengthen laboratory capacity during mass gatherings.

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