Outbreak of Oral Ulcers (Glossitis) among the students of three Central Schools under Tsirang District in Bhutan, 2018

Abstract Background In the early weeks of September 2018, clusters of oral sores mostly affecting the tongue were reported in three central schools under Tsirang district, Bhutan. All the three central schools have both boarding and day schooling facilities. A total of 243 students were affected in total as aggregated by the schools in all three central schools. Almost all the affected students’ complaint of burning sensation of the mouth followed by redness depapillation of the tongue. All the affected students have been assessed on the outbreak and nutritional survey was conducted in the schools. Methods Descriptive cross sectional study among the affected three central schools is conducted. The descriptive statistics are presented as findings from the outbreak investigations. Results Almost all the affected students in all the three schools had complaints of Burning Sensation (n=158) followed by Pain (n=153), Impaired Taste Sensation (n=100) and Intolerance to Spicy Food (n=95). Other complaints such as Fissured Tongue and Depapillation of the dorsum of the tongue accounted to about 16.6% of the total affected students.Nutritional Survey on school diet revealed the school diet not meeting the Recommended Dietary Allowance (RDA) for Vitamin B1 (Thiamin), B2 (Riboflavin), B3 (Niacin), B5 (Pantothenic Acid), B6 (Pyridoxine), B9 (Folic Acid), B12 (Cyanocobalamin) and Iron. Conclusions While some recommendations are provided, the strongest and most effective measures to prevent the outbreak is to improve the school diet with extended green fruits and vegetables in the school’s dietary menu. Laboratory investigation on the content of currently supplied fortified rice in the schools and the Hazard Analysis of the manufacturers of the fortified rice supplied to Bhutan is also suggested with importance to Bhutanese authorities in school feeding program under the Ministry of Education, Royal Government of Bhutan.