Althaf Setyawan 1, Citra Indriani 2, Erlin Setianti 3, Nyoman Sujaya 4, Lenny  Oktriana 5, Pramono6, Dibyo Pramono 7, Haripurnomo Kushadiwijaya8

Background: On 24th July, 2007, a District Health Office in Central Java reported 25 cases presenting to hospital and primary health care with gastrointestinal symptoms. The illness had a rapid progression and resulted in many fatalities. Due to ongoing international concern regarding emerging diseases such as avian influenza in Indonesia, this cluster attracted intense media attention resulting in public panic. An epidemiological investigation was mounted to determine the extent of the epidemic, the etiology and adopt the appropriate measures to control it.

Methods: We collected epidemiological, clinical and environmental data to investigate the epidemic. Samples were sent to five laboratories to screen for infectious, chemical and toxic agents. A questionnaire was administered to patients or family members to investigate the source of illness and pathways associated with the epidemic.

Results: Thirty-one cases were identified with ten fatalities (case fatality rate 32.3%), where most fatalities occurred within one-day of symptom onset. Twenty-one cases were female (68%) and ten were male (32%). Case ages ranged from 7 – 65 years, where the median age was 40. Clinical presentation showed acute toxic symptoms (100%), impairment of hepatic cell function (81%). Autopsies and laboratory analyses found carbamate in gastric lavage fluid in five patients. The environmental investigation found organic phosphates in two affected households, but carbamate was not detected in food, water or other samples collected from the affected village.

Conclusions: The likely cause of the epidemic was carbamate poisoning, where the patients’ clinical presentation and laboratory findings support this hypothesis. However, despite extensive epidemiological and environmental investigation, the source and vehicle for the poisoning could not be determined. Public health education should focus on communicating the risks associated with insecticide usage, such as the importance of thoroughly washing and preparing fresh produce before consumption. Future investigations for epidemic that attract media attention should be coordinated carefully to avoid confusion and unnecessary public panic.  

Key Words:
epidemic, hepatic failure, acute poisoning, Indonesia