Twenty-Three Cases in Six Days

Working case definition: any person in the village with three or more loose or watery stools in 24 hours since 3 July, with or without vomiting. A severe case is one with any sign of dehydration - sunken eyes, slow skin pinch, restlessness or lethargy, inability to drink. This definition includes the mild cases that are still transmitting infection and excludes routine stools of other causes, so it does not inflate the count.

Why this is an outbreak and not a coincidence: 23 cases in 42 households in six days, a clustering in under-fives, one death, and a plausible common source - a tube well 15 metres from a pit latrine after heavy rain. The single death already makes this a grade-one public health event.

First 48 hours, in priority order:

1. Treat first. Set up an ORS corner at the sub-centre and give ORS and zinc to every case. A child who dies of dehydration while the investigation is being planned is a failure of priorities.
2. Active house-to-house case search to find cases the family has not reported, and start a line-list with name, age, sex, date of onset, symptoms and outcome.
3. Stop harmful treatment. Speak to the private practitioner about stopping antimotility drugs (they keep the toxin in the gut and can cause ileus) and unnecessary injections and antibiotics. This requires diplomacy, not confrontation, because he is the family's trusted provider.
4. Notify immediately - verbal report the same day to the block medical officer of health and the district surveillance unit under IDSP, followed by the written outbreak report.
5. Investigate the water: collect a sample for bacteriological testing and check the free residual chlorine; test the tube well and any alternative source.
6. Risk communication - begin household messaging on boiling and handwashing the same day.

Assessment: thirsty, drinks eagerly, sunken eyes, but no lethargy or inability to drink - this fits some dehydration, not severe dehydration. That distinction decides everything: some dehydration is treated with oral rehydration, severe dehydration needs intravenous fluids and transfer.

Plan B calculation: ORS at 75 ml per kg over 4 hours.

• 11 kg × 75 ml = 825 ml over 4 hours, which is roughly 200 ml per hour, or about one small cup given by spoon or small sips every 1–2 minutes.
• Continue breastfeeding throughout, between ORS feeds. Do not stop feeds, and do not give plain water instead of ORS.
• Zinc: 20 mg daily for 14 days (10 mg if under six months) - this shortens the episode and reduces recurrence over the next few months, which matters in a child who may be undernourished.
• Reassess at 1 hour (to check that he is actually drinking and keeping it down) and again at 4 hours (to reclassify hydration status).
• Show the mother how to make ORS with one litre of safe water and teach her the signs that mean return at once.

Refer immediately if: vomiting prevents any fluid from staying down, he becomes lethargic or unconscious, the skin pinch becomes very slow, he stops passing urine, blood appears in the stool, or there is high fever or poor feeding. In a village with a recent death, the threshold for referral should be lower, not higher - send early when in doubt.

Water and sanitation measures:

• Protect the source. Repair the apron and drainage around the tube well so that rainwater and latrine seepage run away from it, and stop washing, bathing or tethering animals at the wellhead.
• Chlorinate and verify. Disinfect the well with bleaching powder according to its volume, then test the free residual chlorine after about 30 minutes (target around 0.5 mg/L) and test the water repeatedly with H2S vials or a field kit until the counts fall.
• Protect the latrine: check for cracks, ensure it is not sited uphill or within 15 metres of the well, and repair the ground around it.
• Household level: boil or chlorinate drinking water, store it in a covered container with a tap or a ladle that is never dipped by hand, and wash hands with soap at the five critical times - after defecation, after cleaning a child, before preparing food, before eating, before feeding a child.
• Food hygiene: cover food, reheat leftovers thoroughly, and keep cooked and raw separate.

Handling the belief that clear, tasteless water is safe: do not argue the point head-on - it is a reasonable belief and contradicting it loses the audience. Instead, put a demonstration in front of them: show the water sample under a simple field kit or the H2S vial result, and explain with a concrete comparison that germs are invisible and have no taste, odour or colour, which is exactly why we protect the source rather than rely on our senses. Use the ASHA and anganwadi workers, hold the session in the local language at the panchayat meeting, involve the tube well caretaker and the mothers of the affected children, and end with a demonstration of ORS preparation and handwashing. Report the line-list daily to the block and submit the written outbreak report with the environmental findings.