During August 1996 (month five, 1417H), the Infectious Disease Department of the Ministry of Health (MOH) received reports of an acute hemorrhagic conjunctivitis (AHC) outbreak from the coastal city of Jeddah. There were 974 cases in both male and female schools within 25 days. As a response to the outbreak in Jeddah, a team from the Field Epidemiology Training Program (FETP) was sent to Jeddah to investigate the outbreak and to implement and enhance the preventive control measures, improve reporting of AHC from schools, evaluate the effect of improved control measures, and identify the causative organism.
Methodology
A case of AHC was defined as a person who developed sudden onset of red eye, with conjunctival edema, pain, or sub-conjunctival hemorrhage in either or both eyes and diagnosed by a physician as AHC. A list of all patients was obtained, the log books (records) of the school health units were reviewed, and preventive actions taken. Based on the districts with the highest reports, we selected all the primary schools with the highest number of cases in those districts. From that group we randomly selected six boys' and six girls' primary schools for our study. Patients with AHC were interviewed directly. A presentation about the signs and symptoms of the disease and preventive measures was given to the students during the morning meeting. The teachers were asked to give a simple presentation about the disease daily for one week after the interview. We arranged with the Ophthalmology Hospital and the virology lab at the Dr. Fagih Hospital to provide the media and to isolate the causative organism. These were taken to King Khalid University Hospital (KKUH) in Riyadh for serotyping.
Results
A total of 744 school children were interviewed, 433 (58.2%) males and 311 (41.8%) females. The mean age of patients was 10.4 years (range: 6-16 years). Most of the identified cases (64.8%) were Saudi nationals. It was found that the incidence of disease decelerated faster in schools with extra health education (HE). The RR (relative risk) of the selected schools with extra HE (0.18; 95% CI = 0.14 - 0.25) was lower than that for schools with standard HE (0.29; 95% CI = 0.23 - 0.36) and the PF (preventive fraction) was higher in schools with extra HE (81%; 95% CI 56.5 - 91.4) than schools with standard HE (68.3%; 95% CI = 42.8 - 82). Enterovirus 70 was isolated from 11 of 20 specimens of conjunctival scrapings from patients with AHC which was cultured in human skin fibroblast (HSF) at KKUH in Riyadh city.
Conclusion
Early detection is essential for control of many infectious diseases. Detection of early signs and symptoms of the first few cases plays a major role in controlling the spread of infection. The only way to reach this purpose is to educate teachers about the clinical presentation of the infection, mode of transmission and preventive measures. Starting HE at the beginning of the outbreak is more effective. Monthly reporting for AHC is recommended, especially in coastal cities.