A community-wide acute diarrheal disease outbreak associated with drinking contaminated water from shallow bore-wells in a tribal village, India, 2017.

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 multi-variate 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 house-hold latrines and piped-water supply initiated.

Effects of methionine sulfoximine on the enzymes of glutamate metabolism in isolated astrocytes of rat brain.

The enzymes of glutamate metabolism were estimated in astrocytes isolated from brains of normal rats and those injected with the potent convulsant, methionine sulfoximine (MSO), which inhibits glutamine synthetase and induces Alzheimer type II astrocytosis. The wet weight, dry weight; contents of DNA, RNA, protein and the activities of glutamate dehydrogenase and aspartate aminotransferase were elevated following MSO administration. The metabolic effects of MSO were found to be different from those of ammonia wherein a fall in the activity of glutamate dehydrogenase and an increase in the activity of glutamine synthetase was noticed. Based on these results it is suggested that there might be an inverse relationship in the functioning of these two enzymes. Such a relationship would help in preventing the depletion of energy pools in a given cellular compartment during ammonia detoxification.

Acute metabolic effects of ammonia on the enzymes of glutamate metabolism in isolated astroglial cells.

Enzymes of glutamate metabolism were studied in the astrocytes isolated from rats injected with a large dose of ammonium acetate and compared with those isolated from controls. The activities of glutamate dehydrogenase (GDH) and glutaminase decreased while those of glutamine synthetase (GS) and aspartate aminotransferase (AAT) increased both in convulsive and comatose states. The activity of alanine aminotransferase (A1AT) increased only in convulsive state. The results suggested that glutamate required for the formation of glutamine in astrocytes might have its origin in nerve endings and the depletion of citric acid cycle intermediates might occur in nerve endings at least in acute ammonia toxicity.

Acute effects of ammonia on the enzymes of citric acid cycle in rat brain.

Activities of the enzymes of citric acid cycle were determined along with aspartate and alanine aminotransferases and NADP(+)-isocitrate dehydrogenase in the brains of rats treated with an acute dose of ammonium acetate and compared with those of normal animals. Elevation in the activities of pyruvate, ?-ketoglutarate and succinate dehydrogenases and citrate synthase was observed in hyperammonemic animals. The activities of malate, NADP(+)-isocitrate dehydrogenases and aminotransferases decreased under these conditions. The results suggest that ammonia toxicity might not be due to the depletion of ?-ketoglutarate from citric acid cycle.

Differential response of enzymes of glutamate metabolism in neuronal perikarya and synaptosomes in acute hyperammonemia in rat.

Activity levels of the enzymes of glutamate metabolism were determined in the neuronal perikarya and synaptosomes isolated from the cerebral cortex of normal and hyperammonemic rats. In neuronal perikarya, the activities of glutamate dehydrogenase, aspartate, alanine aminotransferases and glutamine synthetase were elevated in hyperammonemic states. In synaptosomes, glutamate dehydrogenase and aspartate aminotransferase were suppressed, while glutamine synthetase and glutaminase were elevated. These results suggested the involvement of neuronal perikarya in ammonia detoxification at least in acute hyperammonemic states.

Suppression of the enzymes of glutamate metabolism in cortical synaptosomes in methionine sulfoximine toxicity.

Enzymes of glutamate metabolism were studied in synaptosomes prepared from normal rats and those treated with acute (300 mg/kg) and subacute (150 mg/kg) doses of the convulsant methionine sulfoximine (MSO). The activities of glutamine synthetase, glutamate dehydrogenase and aspartate aminotransferase were inhibited in the synaptosomes of drug treated animals. It is suggested that MSO would suppress the formation of glutamine and glutamate and consequently the releasable pool of glutamate, aspartate and GABA. These neurotransmitters would be depleted from the nerve endings. It is also indicated that the ammonia accumulated would affect the cerebral functioning by interfering with the maintenance of ionic gradients.

Isolation of astrocytes, neurons, and synaptosomes of rat brain cortex: distribution of enzymes of glutamate metabolism.

A simplified method was developed for the bulk separation of neuronal perikarya and astroglial cells from adult rat brain without the involvement of density gradients. Activities of various enzymes involved in glutamate metabolism were estimated and compared with those of synaptosomes. The activities of glutamate dehydrogenase and aspartate aminotransferase were higher in synaptosomes than in neuronal perikarya or glia. Glutamine synthetase was distributed in all the three fractions while glutaminase activity was higher in astrocytes than in synaptosomes and was not detectable in neuronal perikarya. The significance of these results in relation to metabolic compartmentation was discussed.

Cerebral citric acid cycle enzymes in methionine sulfoximine toxicity.

The activity levels of pyruvate dehydrogenase, enzymes of the citric acid cycle, aspartate and alanine aminotransferases, and NADP+-isocitrate dehydrogenase were determined in the cerebral cortex, cerebellum, brain stem, corpus striatum, hippocampus, and midbrain regions of normal rats and rats injected with acute and subacute doses of methionine sulfoximine (MSI). In both conditions there was an elevation in the activities of pyruvate dehydrogenase and all the enzymes of the citric acid cycle except malate dehydrogenase, whereas the activities of aminotransferases and NADP+-isocitrate dehydrogenase were suppressed in all the cerebral regions. It is suggested that the operational rates of the citric acid cycle would be enhanced in MSI-induced hyperammonemia and that there might be a derangement in the transport of reducing equivalents across mitochondrial membranes. It has been suggested that the convulsant action of the drug is due to its effects on ionic gradients and may not be due to depletion of alpha-ketoglutarate from the citric acid cycle.