Incident Action Plan (IAP)

Members
Rattanakorn Somchue Pim
Walaipan Thamjaroensak Lingling
Kullapaporn Trisupakitti Mild
Varunya Visitatimat TiwTiw

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Executive Summary (BLUF)

This project will include the various methods to tackle the spreading of parasites,
Brachylaima cribbi. Brachylaima cribbi is a 2.5 to 6.0 mm long by 0.5 to 0.8 wide parasite
known to have infected humans. It occurred in the rural area, northern part of Thailand, in the
small town with around 10,000 people. The town is surrounded by rivers and streams which
facilitate locals for agriculture. People in this area commonly find their foods near to where they
live. However, the cleanliness and sanitation of the town should be concerned and it could not be
held longer than 3 months. We would start the project as soon as possible or within September to
prevent the rate that increases exponentially in every month.
There are some limitations when doing this project. One of which would be the
residences of the locals that are located near the water, getting a moist environment, allowing the
number of snails to increase rapidly. Another significant factor would be the life cycle of the
Brachylaima cribbi that needs a host for growth and development, especially the snails.
In order to stop and prevent the outbreak, the care about medical, educational, locals, and
environmental issues are needed. In the medical part, the doctors and staff are going to be
responsible for treating patients and returning them health. In the educational part, the
educational staff would be teaching the locals how the procedure of prevention is going to be
done such as sprinkling salt, grounded coffee or making snail traps and the locals are the ones
who have to follow. Furthermore, the environmental staff will be checking the pH of soil after
the steps of prevention that locals did were done. Having concerns about the spreading of this
parasitic disease and the increasing number of patients, these are ways to block and prevent the
infection so that this spreading could have less or no spreading in the future.
However, if all the means are done and cooperated by everybody. It could decrease
approximately 20 cases of infections per month through the positive developments such as local
people’s health are better and people acquire the knowledge throughout the processes. All the
knowledge would be beneficial for the long term outcomes and efficient developments. In
prediction, this outbreak is predicted to end in 3 months.

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Situation

Brachylaima Cribbi is parasite trematode fluke worms, having a terrestrial life cycle
including snails and slugs. It is around 2.5 to 6.0 mm long by 0.5 to 0.8 wide in the adult ages
and discovered in Australia especially the southern part. Moreover, it usually lives in the rural
areas and semi-rural areas. However, it can not live by itself which means it needs a host for
growth and development, such as snails and mammals. Snails are the first and second
intermediate hosts for the parasite because they have a body cercarial chaetotaxy and long
slender adult worms. After that, it will move to mammals, namely humans, and cause the
infection. It is recorded to infect humans by recovering it from human faeces and scanning
electron microscopy. The SEM or scanning electron microscopy is a significant tool for studying
Brachylaima Cribbi’s life cycle.
Since the parasite causes the infection, around 1 month to 2 years are infected in human’s
body. During the 1 or 2 months, it will provide various symptoms depending on the infections.
Trichomoniasis is sexually transmitted, some may cause irritation, redness, or itching. Another
possible infection would be giardiasis, infected in the small intestine, producing diarrhea, gas, or
upset stomach symptoms. Cryptosporidiosis causes humans to have stomach pain, weight loss,
and fever. For the last infection is toxoplasmosis, this infection is not severe, but causes the flu,
muscle pains, or aches lasting over a month. Therefore, people would not prescribe the
medicines unless they are pregnant or prolong infection. Taking medicines for a long time can
cause many side effects since antibiotics can be harmful to an unborn baby, people with eye
problems, people with liver disease or even bone marrow so it is necessary for people who
intake medicines to have frequent medical tests.
The outbreak of a brachylaima cribbi occurred in rural areas of northern Thailand. This
resulted in 34 deaths out of 202 known cases of people infected. The area where the infections
occurred is in interconnected towns with approximately 10,000 people in total. Since there is no
mass transit between these areas, the system of sanitation was hard to control. However, people
over there are still under the law enforcement and the hospitals are still good even though they
are small and can not admit large numbers of people. There are forests surrounding the towns.
Also, a variety of mammal, reptile, and mollusk species living here, such as rats, dogs, and snails
because there are various freshwater rivers and streams running through the area local people
rely on. When there is water, there is life. Having freshwater not only makes people find food
easier: commonly freshwater fish and mollusks but also, leads agriculture to become necessary in
this area. Almost one-third of local people raise farm animals including cows, pigs, and sheep to
transport to major cities as a source of income.
Although this area is lively and fertile, nevertheless, cleanliness and sanitation need to be
concerned. Consuming raw food or cooking food with an unhygienic process can cause people
parasitic diseases. As the report has shown, there was the first infection case in September and
the number of new infection cases begins to rise greatly and exponentially every month. This

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concern can’t be held any longer since it could increase the rate of infection for more than 10
cases per month and cost more than 1000 baht per person to cure and treat their infection. On the
other hand, if this concern is held longer, the number would continuously increase by
exponential every month. It would also rise up rapidly with 3 months from 202 in April might
grow up to 204 in May. New cases, therefore, would increase by 10 people every month from
April to June, 47, 59, and 67, respectively.
To summarize, this infection should be held within the first month that it occurs because
when it becomes out of control, it would be a huge damage to the town.

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Constraints and Restraints

Constraint
● No killing animals.
● No budget over 1,000 baht per person.

Restraint
● No snails killing.
● Don’t feed snails to animals that we eat until the number of new cases and the number of
old cases decrease for more than half.
● Don’t directly touch the snails.

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Response Procedure

According to the situation, it would be extremely out of control if we don’t do any

approaches to tackle this issue. Due to that, the working process would start in September or start
since the beginning of the infection. However, there are various methods that would provide
some responses for slowing down and preventing the outbreak of parasites, Brachylaima Cribbi.
There are several positive developments if we use various means to slow down and stop
this current rate of infections. One of which would be locals acquired some knowledge about
snails’ prevention and methods to eliminate the snails by using the snail trap and pouring some
coffee grounds and salt to the soil to prevent the comeback of the snails which would be offered
in the educational system for the rural area for the survival skills that might be significant later.
In addition, people would get some knowledge about the sanitizer stuff in everyday lives
including food, kitchen wares, and cooking recipes to avoid the contamination of foods and
goods. As adding the salt and coffee grounds to prevent the snails, the soil would turn to more
acidic or basic which would not be good for farming. We would build up the environmental
teams and researchers to collect the data of the number of snails and the pH of soil, making the
pH suitable for agriculture.
Apart from the knowledge and environmental teams, local people would know more
about how to prevent them by using the natural means to reduce the number of snails, especially
during the rainy season and in the moist environment. They would get more nutrients from each
meal because of their vegetables and animals for consumption including chicken, meat, and fish.
This would decrease the rate of infection by consuming the snails from vegetable or raw ones.
The medical services would be provided for the locals such as the blood test for checking on the
parasites and their eggs, endoscopy to examine the intestinal tract, and X-ray to check for injured
organs that are caused by the parasites. These medical cares would help and cure the infection in
people for decreasing the rate of infection in the town.
To summarize, there are several good developments for the rural town in the northern
part, particularly local people, which would get the positive effects on these various methods for
handling the infection of parasites

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Education

Educating rural people will help stop the spread faster. The most efficient solution to stop
this spreading is to give the locals who are experiencing this outbreak the knowledge of what
they are facing. To reach our aim of giving knowledge to the locals, our team staff will work in
the field and directly teach the locals about the outbreak situation, ways to stop, and what should
be done for the prevention. The expectation of the team toward the villagers are
● Understand the cause of the infection.
● Understand how the symptom and how it will be treated.
● Being able to boil water at the right heat before consuming.
● Being able to sanitise before eating.
● Being able to cook clean food.
● Being able to take the correct care of a patient in the house.
● Being able to give advice to children and be a good example.
The most important knowledge will be about the cause of this disease. Once, we
explained and made it clear to the villager, they can be prepared and ready to stop and prevent
the spread. After the locals know about the general information they will get to learn how to
cook good food and be sanitised. The staff will also provide the information about the
importance of cooking food with heat and cleanliness. Washing hands before cooking and eating
is an initial essential step to avoid infections and contamination. Moreover, this parasite can not
bear or live in high temperature so it is necessary for people to cook the snails properly.
The steps on how to prevent themselves from risky and infected foods is the thing that
educational staff will be responsible for. Eliminating the Brachylaima Cribbi from their hosts is
another important task. Looking at the life cycle of it, this platyhelminthes stays in snails. In
order to prevent people from this parasitic disease, the educational staff needs to provide useful
information about how to prevent and stop this spreading.
In addition, the method of preventing and eliminating snails needs to be taught. Teaching
people the way to prevent snails by pouring salt or coffee grounds on affected areas where the
snails live is the affordable way to prevent infections by themselves. Furthermore, another way
of eliminating snails is to educate people about how to do the snail traps. Making snail traps from
waste materials not only helps reduce the garbage in the area but also helps get rid of the snails.
All of these are the basic steps that people in this area should know and do them in order
to help stop or avoid this spreading. The educational staff will have a responsibility to go to the
affected areas and teach people over there practically in order to prevent the spreading of
parasitic disease as much as possible.

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Environmental Issue

We would build up the environmental staff and researchers for reporting the quality of
the water in the river which is a villagers resource and the team will also be responsible for
checking the number of snails in every month. For intense, the water quality is impossible to
control because it is natural and wild, so the most accurate way will be to prevent and stop the
villagers from using the natural water during the outbreak. On the other hand, with the snail issue
the team will fix by measuring the number of snails per unit area or clump which means it will
provide the average for each month. If the number is too high or higher than the average, we
would use various methods to eliminate them, including snails’ trap. As the snails are primary
and secondary hosts for the parasites, we should record and check the amount of snails for
limiting the growth of Brachylaima cribbi when there is no host available for them. When the
number of snails decreases, we would apply some ​Coffee grounds or salt to prevent the snails
from growing and increasing the population of the snails again.
Due to the application of coffee grounds and salt, the researchers and environmental staff
would measure the pH in every month after offering those to the ground. It would be beneficial
for farmers because when putting those, the soil might change their pH to become more acidic or
basic and it would not be good for planting and doing farming stuff. Also, we would wash the
soil surface and drain water frequently to prevent saline soil.

Villagers Issue

The locals would be educated by the education team and they must use the knowledge
that they have and apply it to their daily life to the prevention of snails. For example, they can
make the snail traps and use salt and coffee grounds to prevent the number of snails in their own
land. If every household follows the instructions, the number of snails will decrease sooner as
well as the number of the Brachylima. Furthermore, local people should eat well cooked food,
the education team and local leaders will educate people on the importance of cooked food and
why they shouldn’t eat raw food. There are various ways to eat safe and clean food such as
boiling and consume meats from the farming such as beef, pork, and fish. This knowledge is the
way to prevent locals from eating contaminated food. For instance, this will reduce the rate of
infection because locals don’t consume the snails that have the Brachylaima cribbi in the body
system and secretes out by feces, so the locals won’t have a fluke in their system either.
Apart from this, people should sanitise the kitchen wares frequently and eat with clean
flatwares and silverwares which would prevent the locals from eating ​contaminated​ food and
reduce the rate of infections.

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Medical Issue

Symptoms
- Trichomoniasis; sexually transmitted, producing no symptoms; some may cause
irritation, redness, itching.
- Giardiasis: diarrhea, gas, upset stomach, dehydration.
- Cryptosporidiosis: stomach cramps, stomach pain, nausea, vomiting, dehydration,
weight loss, and fever.
- Toxoplasmosis: like flu, swollen lymph nodes and muscle pains or aches lasting
over a month. (Not prescribing medicines unless pregnant or prolonged infection)

Treatment for infected patients

1. Blood test, fecal exam (stool examination)- check for parasites and their
eggs
2. Endoscopy or colonoscopy- passing a thin flexible tube through the mouth
or rectum into the digestive system to examine the intestinal tract.
3. X-rays, MRI (magnetic resonance imaging) or CAT (computerized axial
tomography); check for signs of lesion or injury to the organs caused by
parasites.
4. Medication depends on specific diagnosis, doctors will prescribe
medicines (antibiotics) to infected people depending on symptoms.

Prescription
Anthelmintics; Albendazole
- Doses are based on weight. (At least 21 days)
- Skipping doses can increase the risk of bleeding or infection. (frequent
medical tests needed.)
- Must be stored at room temperature, away from moisture and heat.
- May harm an unborn baby, people who have eye problems, liver disease
and bone marrow suppression.
- Liver function needed to be checked every 2 weeks.
- Common side effects: headache, fever, nausea and dizziness.

Prescription for Symptomatic Medication.

- For Trichomoniasis
Redness, itchiness reducing cream.
- For Giardiasis
Oral rehydration salts, activated charcoal.
- For Cryptosporidiosis

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 Paracetamol
- For Toxoplasmosis
Paracetamol, Vitamin C.

Procedure
1. Separate the villagers into 2 groups.
a. Infected
b. Uninfected
2. Give out Anthelmintics for the villagers who are infected with the beginner
dose for 7 days.
3. Operate a fecal exam for villagers who are in the risky place.
4. Determine the patients who got infected by the Brachylaima Cribbi.
5. Indicate symptoms the patients have and give out the symptomatic medicines.
6. Frequently have the medical tests such as liver or kidney checking for
patients.
7. Treat the patients and return them to health.

Projections

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 As shown above, The number of infected patients will increase almost a hundred cases if
the locals have a delay in treatment and prevention. Our team decided that the outbreak should
be treated as soon as possible.

Cost

Rough table to predict the cost that will cost for one patient

Treatment Pice (baht)

Albendazole 2 pills/day*7days 7

Blood test 200

Fecal exam 40

Anti-itch cream 150

Activated charcoal capsule/panel 30

Paracetamol/panel 50

Vitamin C 100

Total 577

Therefore the approximate cost for the outbreak will be

● Now - total of 202 cases, the cost will be 116,554 baht.
● Delay- total of 263 cases, the cost will be 151,751 baht.

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Finance

The Finance includes medical cost, education and environment, and meals for staff.

List Price (baht) Amount Cost

Medical

Blood test 200 / person 202 40,400

Fecal exam 40 / person 10,000 40,000

Albendazole 0.5 / capsule 202Person* 1,414

2times/day*
7days
=2828 capsules

Anti-itch cream 150 / person 202 30,300

Activated charcoal capsule/panel 30 / person 202 6,060

Paracetamol/panel 50 / person 202 10,100

Vitamin C 100 / person 202 20,200

Education & Environmental

Transportation fee for staffs

Bus 30 / person / day 15 450

Gas 500 / day 2 1,000

Booklet with an information about 1 / book 10,000 10,000

the disease

Meals for staffs

Meal per day (including lunch and (100 20 2,000

snacks) baht/person)

Total cost for medical 148,474

Total cost 161,924

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Prevention Steps

To prevent this outbreak from occurring again, the locals need to improve their utilities
and public facilities. Unfortunately, the village is small and the budget is low, so to benefit the
locals their best the budget needs to be managed wisely. In order to reach the aim the village
should have
● Latrine
● Water ​purifier or plumping system to the village.
● Educational cooking
● Sanitation behavior
● Good dietary
These are all the prevention steps that can prevent people in this area from being infected
and outbreak again. By following these rules, people in this area are going to be more hygiene
and safe from this parasitic disease.

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Conclusion

Brachylaima cribbi can cause people to get infected, which increases numbers who need
a treatment. These fluke worms can’t live by themselves, it needs a host to live and grow, for
example, humans and snails, especially the snails. Due to the fact, this problem occurs in a rural
area and no mass transit, it is hard to control sanitation around this area. Large water source is a
good place for snails, which means that we need to control the amount of snails that are living by
having environmental staff and researchers to report and predict the number of snails. For the
plan, staff will be educating people to know more about snails, make a snail trap, grounding salt
and coffee, and keep their village to have good sanitation. To treat people who got infected,
villagers need to separate between the people who got infected and not infected. The one not
infected will get to be educated and after that, they will need to make a snail trap and grounding
soil. On the other side, the one who got infected will need to take antibiotics and check their
symptoms, if that person has complications they need to stay in hospitals, others stay at home
and take care of themselves. This separation for the infected will control and not have large
numbers of infected hospitals. If this plan is no delay and starts this plan in September, this
parasitic disease may end in 3 months.

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