Date: Tue 7 Nov 2017
Source: Kuensel [edited]

Sephu Primary School (PS) in Wangdue reported 8 cases of chicken pox among students yesterday [Mon 6 Nov 2017], taking the total number of infected to 26 since [Thu 2 Nov 2017].

The school health in-charge, Rinchen Om, said 5 students complained of the sickness on [Thu 2 Nov 2017].and were sent to Sephu basic health unit (BHU). It was later confirmed that the students were suffering from chicken pox.

Infected students were sent home on medication. The school again reported another 6 cases on [Fri 3 Nov 2017].

The school received another 4 girls and 4 boys suffering from chicken pox yesterday [Mon 06 Nov 2017]. Most of the students infected are below 14 years of age. The school has total of 112 students from pre-primary to class VI.

"This is the 1st time the school has seen outbreak of chicken pox," she said, adding that at least 2 cases keep coming [per] day. No students, however, have been admitted in the BHU.

Rinchen Om added the school sends students home when they are found to have contacted the disease to prevent from spreading. "The BHU health officials have already come and created awareness to students on the prevention of the disease. We call their parents and advise them to visit BHU, which is 4km [2.48 mi approx.] from the school."

Health assistant, Tashi Pelden, said that although it is not confirmed, the outbreak was likely spread from a student from Nobding Lower Secondary School who was in Sephu village after he was sent home for treatment.

"Looks like that the student had visited Sephu PS and that was how the disease was spread," she said. "Since some of the students recovered in a few days the outbreak is not so alarming."  [Byline: Yangchen C Rinzin]
[It is not clear whether these students had been vaccinated. According to CDC, 2 doses of the vaccine are about 90 percent effective at preventing chickenpox. The 1st dose is recommended at age 12 through 15 months old and the 2nd at age 4 through 6 years. Some people who are vaccinated against chickenpox may still get the disease. However, it is usually milder with fewer blisters and little or no fever.

A Healthmap/ProMED of Bhutan can be found at
<>. - ProMED Mod.LK]
Date: Thu 3 Aug 2017
Source: Kuensel [edited]

About 40 people suspected of food poisoning from salmonellosis were treated at Punakha district hospital and the national referral hospital in Thimphu last week [week of 24 Jul 2017].

On [26 Jul 2017], some 18 people including children visited the emergency unit at the national referral hospital in Thimphu complaining of vomiting, diarrhea, and abdominal cramps. The family had a birthday celebration the previous day [25 Jul 2017]. Of the 25 people at the celebration, 17 who ate the birthday cake, and one who did not eat the cake fell sick. The cake was bought from a bakery in Thimphu. The hospital informed the Royal Centre for Disease Control (RCDC) of the suspected food poisoning case, which then informed the Bhutan Agriculture and Food Regulatory Authority (BAFRA).

Another 7 people with similar symptoms were admitted to the hospital on [27 Jul 2017] when BAFRA and RCDC officials were questioning the patients of the earlier incident. On investigation, it was found that these 7 people had also eaten cakes from the same bakery on [26 Jul 2017]. Of the 8 in the family, the one who did not eat the cake did not fall sick.

BAFRA's deputy chief regulatory and quarantine officer, Sithar Dorjee, said the authority investigated the food items that members of both families had consumed: "Other food items were not found to have significance on their illness." Besides the samples of cakes consumed by the 2 families, samples of cakes on sale and those left by the customers in the bakery were sent to RCDC and the National Food Testing Laboratory in Yusipang on [27 Jul 2017] for testing.

Sithar Dorji said that although the laboratory did not confirm that the families fell ill because of the cake, BAFRA temporarily closed the bakery to prevent further cases since the clinical epidemiological evidence is linked to the bakery. The authority has seized the cakes from the bakery and disposed of them. A notification was served to rectify some non-compliance issues on the requirements regarding food hygiene and safety.

BAFRA's director general, Namgay Wangchuk said, "When it comes to food safety, we cannot compromise."

The results from the samples confirmed the presence of the bacterium salmonella, which was also found in the stool and vomit of the patients, Sithar Dorjee said. "Salmonella bacteria might have come from the egg used in cakes or contaminated from a person." Sithar Dorjee said the RCDC might send the result abroad for serotyping since there is no facility in the country to test if the bacteria were from the eggs or contaminated by food handlers.

He said the bakery had sold 13 cakes of the same kind to the 2 families over the 2 days. "The 2 cakes might have not been properly stored for longer period of time before consuming, which resulted in the multiplication of the bacteria or maybe people did not report the illness." He also said that the cake topping is most likely to be contaminated since raw egg white is used for toppings. If there is infection in poultry, then the eggs will also be infected thereby contaminating the cake. Eggs from the same farm are also being tested for the bacterium.

Food poisoning can be caused by bacteria, viruses, or parasites at any stage such as when they are growing, packaged, stored, shipped, or cooked. Certain food like raw eggs and uncooked meat are more likely to harbour harmful agents. The chances of getting food poisoning are higher in summer and food can start to spoil within an hour when exposed to extreme heat.

BAFRA has taken some corrective and precautionary measures to prevent contamination. The workers at the bakery were also provided food handler's training that includes food hygiene and proper storage. "The bakery will be allowed to reopen once they comply with all required corrective measures because it is contamination," he [sic] said. "However, we will increase the frequency of inspection of the bakery." The authority inspected the bakery about a month ago.

Sithar Dorjee said the frequency of inspection depends on the risks. "If a restaurant or bakery has a history of non-compliance to the authority's requirement on food hygiene and safety, we will frequently inspect."

The bakery owner said he is yet to know the findings of the test so he couldn't comment. However, he said that if people fall ill after eating cake from his bakery then he could be at fault. But, since the cakes were taken out of the bakery, improper storage or keeping the cake in a vehicle for a longer time could also contaminate the cake. He said that since the affected families had a birthday celebration, other food items could also have caused food poisoning. "We maintain proper storage of our products."

Meanwhile, on [28 Jul 2017], about 15 monks of Talo monastery in Punakha [district] visited the Punakha district hospital after suffering from vomiting, diarrhea, fever, and stomach cramps. Of the total, 10 monks were admitted to the hospital then. Currently, there are 2 monks admitted in the hospital.

Punakha [district] health officer, Dechenmo, said the monks said that they started falling ill after they ate a cake offered to the monastery by some devotees during the 1st Sermon of Lord Buddha on [27 Jul 2017]. According to the monks, 2 cakes were offered to the monastery and those who ate the small cake fell ill while those who consumed the other cake did not fall sick.

Dechenmo said that the 2 monks who are still in the hospital are recovering and will be discharged from the hospital in a few days. "We cannot investigate the source of the cake because we don't know who offered the cake to the monastery."

The health assistant of Nubgang BHU visited the monastery and disinfected all toilets. The monks were also educated on the prevention of the disease. "The monks came to the hospital at the right time and everything was under control," Dechenmo said. "If we are not careful and not treated on time, then food poisoning can be fatal."  [byline: Dechen Tshomo]
[By definition, baked goods by being baked should be free of bacterial risk but the products can still be the reservoir of foodborne illness. This can occur if the product is undercooked or if icing or filling, which might be placed after baking, is the contaminated substance. The contamination may be from a component of the icing or filling or be contaminated from a bakery worker.

It is not clear if the monastery outbreak is due to salmonellosis, but certainly could have been. - ProMED Mod.LL]

[Maps of Bhutan can be seen at
<> and
<>. - ProMED Sr.Tech.Ed.MJ]
22nd July 2017

- National. 14 Jul 2017. More than 100 cases reported since last month [June 2017]. Phuentsholing hospital 33 dengue fever cases; Samtse hospital 46; and Samdrupjongkhar hospital, 42 cases as of yesterday [13 Jul 2017].

[Maps of Bhutan can be seen at
<> and
<>. - ProMED Sr.Tech.Ed.MJ]
Date: Fri 30 Jun 2017
Source: Kuensel [edited]

With 13 cases reported to the hospital, the Royal Centre for Disease Control (RCDC) concluded that there is a [para]typhoid outbreak in a private apartment building in Changzamtok, Thimphu. The affected people, aged 3.5 to 50 years, were mostly students and housewives. They complained of suffering from fever and headache.

A microbiologist, Tshering Dorji, said that on [21 Jun 2017], RCDC was notified that 3 patients were diagnosed with _Salmonella [enterica serotype] Paratyphi B_ and one suspected in the Jigme Dorji Wangchuk National Referral Hospital (JDWNRH). All patients confirmed that they live in the same building in Changzamtok.

A team, comprising a public health professional, clinical officer and laboratory personnel from RCDC, then investigated to check whether the same water source may lead to transmission of the disease to other residents and determine the risk factors of the outbreak for implementing evidence-based prevention and control measures. It was found out that it occurred from [5 to 23 Jun 2017]. The team also found out that the building was supplied with water from both a private source and City Corporation.

A report issued by RCDC stated that laboratory testing found out the water supplied from the private water source was polluted. "The drinking water should be free of an indicator of bacteria to be safe for consumption." The report also stated that it recommended the house owner to refrain from drinking water from the private source and to shield the reservoir tank with a tight lid to protect it from litter, sewer, and waste water. "The tenants must drink boiled water and refrain from drinking water directly from the tap," the report recommended. "City Corporation should reinforce the water supply regulation in the city and monitor its compliance."

RCDC, the report states, should scale up water quality surveillance and provide health education on knowledge awareness of the paratyphoid fever and its prevention and control measures.

Meanwhile, the residents of the building said the owner had to provide water from a private source because the water provided by City Corporation was not enough. A woman, who did not want to be named, said they boil water, but, because it is contagious, they also fall sick. The 1st patient was her 6-year-old son, and it spread to her father and husband. She said 2 people staying in the building are still in the hospital.  [Byline: Tashi Dema]
[Although not specifically stated, the serotype here may be the d-tartrate-fermenting variant _S. enterica_ subspecies _enterica_ serovar Paratyphi B dT+ (sometimes referred to as _S._ Java). This organism has well-characterized animal reservoirs and has been involved in several outbreaks reported in ProMED-mail as noted below.

The organism has been linked to human salmonellosis acquired from ornamental aquaria (Levings RS, Lightfoot D, Hall RM and Djordjevic SP. Aquariums as reservoirs for multidrug-resistant _Salmonella_ Paratyphi B. Emerg Infect Dis. 2006 Mar;12(3):507-10; available at <>). - ProMED Mod.LL]

[A HealthMap/ProMED-mail map can be accessed at:
Date: Tue 31 May 2016
Source: Kuensel [edited]
15 of the 33 people from Serthi gewog in Samdrup Jongkhar [district] who grew sick after consuming beef suspected to be infected by anthrax have recovered and are now in stable condition. Health officials said the situation is under control and no human casualties have been reported so far.

But health officials are still waiting for test results from Thimphu to confirm if the cause is anthrax. All 33 people were treated for anthrax based on clinical symptoms and those not displaying the symptoms were provided with prophylaxis.

The incident occurred on 22 May [2016] when the entire community of Deptsang village had come together to construct a lhakhang [temple]. Lunch consisted of meat from a dead cow. The farmer sold the remaining meat and took home the rest.

Health officials said since the cow had died while grazing, the farmer thought the cow had died a natural death. However, the entire community including children who consumed the meat suffered fever, nausea, headaches, abdominal cramps, pain and dehydration. Officials said the meat was found discoloured and foul smelling. The kidney and pancreas of the dead cow were also found damaged.

An official said that those people who had consumed the liver and internal organs were reported to have suffered more severe symptoms as compared to those who consumed only the meat.

A field investigation has already been conducted. While food poisoning is suspected, based on the clinical symptoms, people were treated for anthrax.  [Byline: Yangchen C Rinzin]
Communicated by:
Sabine Zentis
Castleview English Longhorns
Gut Laach
D-52385 Nideggen, Germany
[Anthrax in Bhutan is frankly sporadic and seen usually in cattle, though sometimes in pigs; an outbreak in 2013 involved 4 pigs. So it is rather to be expected that a small village coming together in a community-wide activity to build a temple took advantage of this dead cow for food for the participants, with the results as reported. "Anthrax" has yet to be confirmed. As it was a community event, 33 falling ill is not unexpected.

Samdrup Jongkhar is in the south west corner of the country, near the Indian border and state of Assam; see <>. Thimphu is on the western side of the country and became the capital in 1961; see <>. Thanks to Sabine for this report. - ProMed Mod.MHJ]

[A HealthMap/ProMED-mail map can be accessed at:
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