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UNDIAGNOSED DISEASE - NEPAL: (SINDHULI) REQUEST FOR INFORMATION
***************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sun 9 Aug 2009
Source: Nepal Republica, social affairs [edited]
<http://www.myrepublica.com/portal/index ... ws_id=8421>


Deaths in Sindhuli not due to diarrhea
--------------------------------------
The Epidemiology and Disease Control Division has on Sunday [9 Aug 2009]
asserted that 5 deaths in Kalpabriksha and Kyaneshwar [Sindhuli district]
VDCs [village development committees] were not caused by diarrhea [that is,
associated with an outbreak of cholera] as was reported by certain sections
of the media.

"These deaths in the last couple of days are due to an as yet to be
identified disease that causes very high fever, severe headache, difficulty
in breathing, and bleeding from the mouth and nose and discharge of blood
in cough, and not due to diarrhea," acting director of the Epidemiology and
Disease Control Division Dr Bishwa Raj Khanal said quoting his district
officers.

Dr Khanal said a team from the district headquarters reached the area on
Saturday [8 Aug 2009] and confirmed that the deaths were not caused by
diarrhea. "We have sent a team (by road) from Kathmandu this morning [to
carry out] laboratory tests to diagnose the disease which looks like
Japanese encephalitis, dengue, malaria, or leptospirosis," Dr Khanal said.

Another team also flew to the area late in the afternoon to control the
situation while the health ministry has also requested the World Health
Organization (WHO) to send its surveillance medical officer based in
Janakpur to Sindhuli.

--
communicated by:
ProMED-mail rapporteur Brent Barrett

[According to the same report, the Epidemiology and Disease Control
Division has stated that a contemporaneous outbreak of cholera in Nepal is
gradually coming under control. The official death toll in this outbreak is
put at 256 with 144 in Jajarkot, 43 in Rukum, 14 in Dailekh, 13 in Achham,
9 each in Baitadi and Surkhet, 4 in Rolpa, 3 each in Dolpa, Salyan,
Dadeldhura, Bajura, and Bajhang, 2 each in Doti and Pyuthan, and one in
Kanchanpur.

The 5 deaths in Sindhuli district are attributed to an outbreak of a
different disease. The symptoms of the disease are not well enough
described to suggest an etiology with confidence, but a hemorrhagic fever
is a possibility. Further information is requested.

The HealthMap/ProMED-mail interactive map of Nepal is available at
<http://healthmap.org/r/00Fm>. Sindhuli District lies in the south of the
central region of Nepal. A map of the Sindhuli district can be accessed at
<http://ncthakur.itgo.com/districtmaps/s ... strict.htm>. - Mod.CP]

ANTHRAX, HUMAN, BOVINE - KYRGYZSTAN (04): (JALAL-ABAD)
******************************************************
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<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: 10 Aug 2009
Source: Akipress.org [edited]
<http://fergana.akipress.org/news:42501/>


The skin form of anthrax has been confirmed in only 6 people out of the 17
hospitalized. All 6 are from Aksi district of Jalalabad. These 6 are
currently under treatment in district hospitals. The remaining 11 people
from the villages of Toktogul, Semet, and Toruk are also under medical
observation.

The Ministry of Health press service also stated that a 20 year old man
from Suzak village of Tula Bulak district who was hospitalized with a
preliminary diagnosis of anthrax is also under treatment in the infectious
disease hospital of Jalalabad.

The Ministry of Health press service said that information campaigns are
being conducted to prevent the further spread of anthrax.

DENGUE/DHF UPDATE 2009 (32)
***************************
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India (Gujarat)
Date: Sun 9 Aug 2009
Source: The Indian Express [edited]
http://www.indianexpress.com/news/Three ... ara/499813

Late on Friday evening [7 Aug 2009], 2 dengue cases from Bharuch were
referred to Sir Sayajirao General Hospital (SSGH) in Vadodara [Gujarat
state]. On Saturday [8 Aug 2009], the blood reports of one [additional]
resident of Sadhali village in Sinor taluka [administrative unit], [was]
confirmed as a positive case of dengue.

--
communicated by:
ProMED-mail rapporteur Brent Barrett

[Although 3 dengue cases hardly constitute a significant outbreak, both
dengue and many chikungunya cases have been reported from Gujarat state
since March 2009, and the 3 cases indicate that dengue virus continues to
be transmitted there.

A HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00FP> and a map showing the location of Gujarat
state in western India can be accessed at
<http://en.wikipedia.org/wiki/Gujarat>. - Mod.TY]

Plague in China
11.08.2009 - WHO

On 1 August, the Ministry of Health (MoH), China reported a cluster outbreak of pulmonary plague cases in the remote town of Ziketan, Qinghai province. The first case was a 32 year old male herdsman, who developed fever and hemoptysis on 26 July. He was referred to a hospital but died en route, and was buried the following day. On 30 July, 11 people who had close contact with the case (mainly relatives who attended the funeral) developed fever and cough, and were all hospitalized. On 1 August, specimens taken from all these 12 people, including the 1st case, tested positive for plague.

On 2 August both the 64 year old father-in-law of the first case and a 37 year old male neighbour of the first case (who helped to bury the corpse) also died. Of the remaining 9 cases, 1 is in critical condition, 1 had acute symptoms of fever and cough, and 7 are in stable condition.

As of August 6, the local health authority has isolated 332 close contacts for further medical observation, and implemented traffic control around affected area. Experts on both disease prevention & control and clinical management have been dispatched to Qinghai province. Protective clothes, X-ray machines and other medical equipment have been sent to the affected area. Prevention guidance pamphlets have also been disseminated.

According to the epidemiological investigation, the source of this outbreak was a wild marmot, which had contact with the dog of the index case. Ziketan is in an area of natural plague bacteria circulation amongst animals and at the present time it is the active season for plague transmission amongst animals. No drug resistance of the bacterium has been found so far and the 3 death cases have been attributed largely to delayed treatment.

China has established a national surveillance network for plague, and has prepared necessary supplies in high-risk areas. After this outbreak, special funds, supplies and experts were quickly dispatched to the affected area.

UNDIAGNOSED DISEASE - NEPAL (02): (SINDHULI)
********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Tue 11 Aug 2009
From: David Thomson <david.thomson@global.net.pg> [edited]


A comment
---------
The undiagnosed disease reported in the ProMED-mail post entitled
"Undiagnosed disease - Nepal: (SI) RFI 20090810.2842", sounds remarkably
like the undiagnosed condition reported via ProMED-mail and recorded in
several remote villages in Nepal back in about March or early April 2009
(can't quite recall the dates or references of the initial and at least one
follow-up post).

From memory it reportedly killed at least 16 (most from one village) and
had spread to at least 2 other nearby villages. I seem to recall that it
occurred there about 3 weeks before poultry started dying from H5N1 in
Tibet and wild birds started dying in Quinghai lakes and then in Mongolia.
At that time I don't think clinical reports included severe headaches, but
did include fever, SARI [symptoms associated with respiratory illness], and
haemorrhagic expectoration.

Could possibly have been a very aggressive influenza originally, but with
the strong headache added, now sounds a bit more like a haemorrhagic fever
of some type (as pointed out by the Moderator). A spot to watch, I believe.

--
David Thomson
Sub-regional Animal Health Specialist
Secretariat of the Pacific Community
<david.thomson@global.net.pg>

[David Thomson's comments are welcomed and ProMED-mail awaits with interest
the outcome of the investigation now under way in Sindhuli District. The
ProMED-mail posts cited by David Thomson are those listed below, I believe.
There is certainly some similarity in the descriptions of the disease, but
the outbreaks occurred in different districts of Nepal. - Mod.CP]

JAPANESE ENCEPHALITIS - INDIA (02): (UTTAR PRADESH, NAGALAND, ASSAM)
*************************************
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ProMED-mail is a program of the
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<http://www.isid.org>

In this update:
[1] Uttar Pradesh
[2] Nagaland
[3] Nagaland, Upper Assam

******
[1] Uttar Pradesh
Date: Mon 17 Aug 2009
Source: Indian Express [edited]
<http://www.indianexpress.com/news/what- ... ul/502895/>


More than 200 cases and 40 deaths have taken place in eastern UP
[Uttar Pradesh state] in the past one month due to encephalitis, the
disease which has a mortality rate between 30 to 40 percent. In the
same period, only 20 cases of mild flu have been reported. According
to Dr K P Kushwaha of the BRD Medical College, 8-10 patients are
being admitted daily at BDR Medical College. However, while all
government attention is focused on swine flu [influenza (H1N1) 2009],
few seem to be bothered about encephalitis. For swine flu, all
hospitals have been put on alert, whereas there is no such alert for
encephalitis. Tests for detection of swine flu, each of which is 3
times costlier, are being done daily, while encephalitis-detection
tests are being conducted at a maximum of thrice a week.

"The reason is simple: swine flu is an imported disease where the
victims are either people who have returned from abroad or belong to
the middle class. Encephalitis is affecting children of poor people
in eastern UP. We have to find ways to draw attention towards
encephalitis deaths and cases," said Dr R N Singh, who heads
Encephalitis Eradication Movement, a private initiative.

[Byline: Maulshree-Seth]

--
Communicated by:
HealthMap Alerts via ProMED-mail
<promed@promedmail.org>

[These encephalitis cases are likely due to Japanese encephalitis
virus (JEV) infections. The state of Uttar Pradesh (UP) is endemic
for JEV. A report of 9 May 2009 (see ProMED archive number
20090513.1789) indicated that there were 38 fatalities and 170
hospitalized encephalitis cases suspected JEV infections in UP. This
current report above indicates that the hospital receiving the
patients is doing laboratory tests, but does not indicate if the
tests are confirming JEV as the etiological agent involved. ProMED
would appreciate receiving additional information. It would also be
of interest to know if the national JEV vaccination program has been
operating in this area this year.

A map showing the location of Indian states including Uttar Pradesh
in northeastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>
A HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/promed/en?v=22.9,79.6,5>
- Mod.TY]

******
[2] Nagaland
Date: Mon 17 Aug 2009
Source: New Kerala.com [edited]
<http://www.newkerala.com/nkfullnews-1-93740.html>


Japanese encephalitis, a communicable [mosquito transmissible, not
transmissible from person-to-person - Mod.TY] disease, has entered
Nagaland and so far 4 cases have been detected throughout the state.
State Nodal Officer Dr Kevichusa Medikhru here today said samples of
5 patients were sent for testing, out of which 4 were confirmed to be
suffering from Japanese encephalitis. The patients were from Dimapur
and Tuli area of Mokokchung district. The cases were referred to the
National Vector Borne Control Programme (NVBCP) officials to initiate
necessary follow up action.

Japanese encephalitis [virus] is endemic to the state along the
foothill areas. However, no report of such cases have so far been
received from other districts of the state.

--
Communicated by:
HealthMap Alerts via ProMED-mail
<promed@promedmail.org>

******
[3] Nagaland, Upper Assam
Date: Sat 8 Aug 2009
Source: Eastern Mirror [edited]
<http://www.easternmirrornagaland.com/in ... 1:top-news>


While the spreading H1NI virus (swine Flu) has been creating jitters
within the state medical department and the local populace, another
viral disease -- Japanese encephalitis [JE], also transmitted through
mosquitoes via pigs [and wild birds. - Mod.TY] -- is posing a more
immediate threat with 5 confirmed cases of mortality within 2 months.
The impact of this viral disease here in the state cannot be fully
gauged at the moment because no survey has been conducted yet.

The common symptoms of JE [virus infections] are headache, stupor,
fever, disorientation, coma and paralysis -- loss of co-ordination.
There is no specific treatment or cure for JE. However, supportive
treatment and good nursing care can significantly reduce case
fatality rate. It is, therefore, important that encephalitis cases
should be referred to a hospital as early as possible, doctors insisted.

The Japanese encephalitis virus has a complex life cycle involving
domestic pigs and a specific type of mosquito, _Culex
tritaeniorhynchus_ [and other closely related _Culex_ species -
Mod.TY], that lives in rice-growing and pig-farming regions. The
animal hosts mainly include pigs and amongst birds are the water
birds, poultry birds and ducks. Pigs are the major vertebrate hosts
and are considered as amplifying hosts. Infection in man appears to
be correlated with living in close proximity with animal reservoirs,
especially pigs. The virus in an infected person invades the central
nervous system, including the brain and spinal cord, causing brain
damage, including paralysis and also death.

Zion Hospital has reported clinically confirmed death of 5 patients
from around 17 suspected cases. Most of the cases reported till now
are from various areas in Dimapur including Purana Bazar, Thlixu
village, Diphupar, Notun Basti, Supply Colony and Ao Kashiram. One
isolated case from Tenning under Peren district and around 2 from
Tuli have been reported so far.

In slight contrast, Dr Neiketou Angami, Joint Director NVBDCP
informed that 11 cases have been reported. Among the 11 reported
cases, 4 out of 5 samples sent to National Centre for Infectious
Disease (NCID) for blood test have been confirmed positive. And 2 of
the patients who tested positive, have reportedly succumbed. The
joint director informed that 3 more blood samples, 2 from Referral
hospital and another from Dimapur Hospital have been sent to NCID for
blood test. With no proper testing facilities in the state, about one
week is wasted in sending the samples to Delhi for testing and
confirming the results.

Efforts are being made to identify the outbreak areas of the disease
so that fogging and impregnation of bed-nets would be carried out
along with sensitization, Dr Imcha, DMO, Malaria department informed.
Meanwhile, outbreak of JE from Tuli in Mokokchung district has been
reported, with one confirmed death and 2 other positive cases. 2
places namely Teyong Mopu at Tzudikong and Longpong ward, Tuli have
also been identified for protection measures. Residents of Tuli and
Tzudikong town also expressed suspicion that 3 patients, whose deaths
were suspected to have been caused by malaria, might actually have
been infected with JE.

The state malaria department has alerted all district malaria
officers with regard to JE and has been in the process of going about
with control measures like fogging, distributing insecticide treated
bed-nets, introducing Larvivorous fish in water bodies and
sensitizing the citizens on the disease.

It may be mentioned that in 2007, 11 cases of JE were reported with
one death. During 1985-86, the 1st reported outbreak of JE in
Nagaland, 50 cases were confirmed with 60 percent mortality (30
deaths), according to reports.

Japanese Encephalitis (JE) poses a serious threat in Nagaland,
particularly with unmonitored rearing of pigs in residential areas.
And with the late onset of monsoon this year, it would only mean more
density of mosquitoes and so chances of more cases of JE disease.
Even in developed towns like Dimapur, pigsties can be found in
backyards of many homes, in close proximity to living quarters of
people. Dr Imcha, while stressing that pigs should normally be reared
5 kilometers away from human inhabitation, said enforcement of such
laws has been found practically impossible in Nagaland. Added to
that, the town and municipal councils are yet to wake up from their
slumber, to monitor rearing of pigs in residential areas.

Most doctors, when asked about the magnitude of threat posed by JE,
expressed concern over possibility of many undetected cases,
particularly with pig-rearing being a common practice among Nagas.
The only option to battle the spread of the fatal infection, Dr.
Imcha says, would be to adopt preventive measures as directed by the
malaria department. And though, National Vector Borne Disease Control
Programme, Nagaland under malaria department has been making efforts
to take preventive measures, awareness of the viral disease is found
to be still lacking among the citizens, with many confusing it for
malaria or typhoid.

Officially, 34 people have died of encephalitis in Upper Assam in
July [2009], according to newspaper reports, while the unofficial
number has been pegged beyond 50. More than 100 people are now
battling the disease in hospitals across Upper Assam.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[These JE reports indicate the need for a well organized and
integrated prevention, control and treatment approach to JE in areas
where the virus is endemic. Sentinel pig and _Culex_ mosquito
monitoring would provide an indication of the time and places where
transmission is becoming active. This requires rapid laboratory
support. Ongoing public education reduce mosquito breeding and avoid
mosquito bites would reduce human cases. Public education is also
important for timely visits to health centers and hospitals to
improve early provision of treatment of JE virus infected patients
and reduce case fatality rates. India has an active JE virus
vaccination program, and it would be of interest to know its extent
in Nagaland and Upper Assam. All of these measures require
considerable financial support, and would compete with other
important public health programs.

General information on Japanese encephalitis can be accessed at
<http://www.who.int/water_sanitation_hea ... alitis/en/> and
<http://www.cdc.gov/ncidod/dvbid/jencephalitis/qa.htm> - Mod.TY]

[The interactive HealthMap/ProMED map for India is available at:
<http://healthmap.org/r/008o> - CopyEd.EJP]

JAPANESE ENCEPHALITIS - INDIA (03): (UTTAR PRADESH) REQUEST FOR INFORMATION
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Date: Tue 18 Aug 2009
Source: CNN.com [edited]
<http://edition.cnn.com/2009/HEALTH/08/1 ... pstoryview>


Doctors say an encephalitis outbreak has killed 130 people -- mostly
children -- in northern India since January [2009]. The outbreak of
acute encephalitis -- an inflammation of brain tissue -- is mostly
concentrated in eastern parts of Uttar Pradesh, said VS Nigam, the
state's nodal officer for tackling the disease. He told CNN that 640
patients had tested positive for the infection, including 30 with
Japanese encephalitis, which is spread by mosquitoes.

Acute encephalitis can be spread in various ways, including a
bacterial or viral infection; the ingesting of toxic substances; and
complications of a disease.

The disease has mostly struck children up to 15 years old, Nigam added.

--
Communicated by:
HealthMap Alerts via ProMED-mail
<promed@promedmail.org>

[The outbreak of encephalitis in eastern Uttar Pradesh continues to
grow. The etiology (etiologies?) of the encephalitis outbreak
reported above is somewhat confusing. Clearly, Japanese encephalitis
virus is involved in some of these cases. That is not surprising as
Uttar Pradesh is endemic for Japanese encephalitis virus. The open
question concerns the remaining 610 patients that were reported as
"testing positive." Positive for what? ProMED-mail would appreciate
receiving additional information as it become available.

A map showing the location of Indian states including Uttar Pradesh
in northeastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
A HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00Hk>. - Mod.TY]

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2009 (21)
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
Asia
[1] Cholera - Nepal
[2] Cholera - India

*****
[1] Cholera - Nepal
Date: Sun 16 Aug 2009
Source: Republica [edited]
<http://www.myrepublica.com/portal/index ... ws_id=8709>


The Ministry of Health has put the latest death toll due to the
diarrhea-cholera epidemic at 301, including 151 in Jajarkot.

Organizing a press conference on Sunday [16 Aug 2009], senior health
administrator at the Epidemiology and Disease Control Division Dr
Bishwa Raj Khanal said 46 diarrhea deaths have been confirmed in
Rukum, 20 in Dailekh, 17 in Achham, 14 in Surkhet, 8 each in Baitadi
and Doti, 7 in Dolpa, 6 each in Salyan and Bajhang, 4 each in Rolpa,
Dadeldhura and Kailali, 3 in Bajura, 2 in Pyuthan and one in Kanchanpur.

Dr Padam Bahadur Chand, who returned to the capital recently after
serving in Jajarkot for around a month, shared his experience while
working in the district and blamed lack of awareness and sanitation
and difficult terrain for the severity of the outbreak.

Talking about the death tolls, Chand admitted that there are bound to
be differences in numbers because no one has a foolproof mechanism to
verify the cause of deaths, and they have to rely on the accounts of
villagers. "We don't entertain any deaths as caused by cholera on
mere insistence of villagers, who generally say that the deceased
also had a bout of diarrhea," Chand explained.

--
Communicated by:
ProMED-mail <promed@promedmail.org>

[The Jajarkot district, where the outbreak is centered, is located in
the Mid Western Region and can be found on a map at
<http://ncthakur.itgo.com/map04.htm>. The HealthMap/ProMED-mail
interactive map of Nepal is available at
<http://healthmap.org/r/00BY>. - Mod.LL]

******
[2] Cholera - India (Punjab)
Date: Fri 14 Aug 2009
Source: The Tribune [edited]
<http://www.tribuneindia.com/2009/20090815/ldh1.htm#2>


A 50-year-old resident of Maharaaj Nagar was tested positive for
cholera this morning [14 Aug 2009]. He had been admitted to a
hospital at Gurdev Nagar yesterday, 13 Aug 2009. With this case, the
confirmed cholera cases have gone up to 18. The district health
officer, Dr SS Dhir, said the previous cases had been reported from
private hospitals in various localities.

Two out of the 3 persons who died recently at Sunet village near BRS
Nagar had cholera. Expressing concern that the cholera patient lived
among 22 families living in a "vehra" at Maharaaj Nagar, he said a
team of health officials would collect water samples and assess the situation.

Dr GS Garewal, medical director of the hospital where the patient was
admitted, said: "Consumption of contaminated water is the apparent
cause of infection. He has been kept in isolation. He was in a
critical condition yesterday [13 Aug 2009], but is stable now."

--
Communicated by:
ProMED-mail <promed@promedmail.org>

[The area mentioned is in the state of Punjab, India. Maps of India
showing the northern state of Punjab can be found at
<http://www.mapsofindia.com/maps/punjab/ ... on-map.gif> and
the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/00BV>. - Mod.LL]

JAPANESE ENCEPHALITIS - INDIA (04): (UTTAR PRADESH)
***************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Mon 24 Aug 2009
Source: BBC News [edited]
<http://news.bbc.co.uk/2/hi/south_asia/8217453.stm>


At least 200 children have died in an outbreak of Japanese
encephalitis in northern India, health officials say. So far, 900
affected children have been admitted to hospitals in Uttar Pradesh
state. Some patients have come from neighbouring Bihar state and
Nepal.

There is no specific cure for the mosquito-borne disease, which has
killed thousands in India since 1978. Health experts complain that
red tape has prevented development of an effective vaccination
programme. The disease occurs regularly during India's monsoon.

Doctors say children between the ages of 6 months to 15 years are
worst affected and most of the victims are poor people from rural
areas. "The attack of the encephalitis virus is extremely ferocious
this year [2009]," says Dr Rashmi Kumar, an expert on Japanese
encephalitis at Lucknow Medical College hospital. "Children are
developing a serious condition within a day or 2 of getting
infected," she says.

Health officials in the state capital, Lucknow, say cases of acute
encephalitis are being reported mostly from 14 districts of eastern
Uttar Pradesh in the foothills of the Himalayas. The low-lying areas
are prone to annual floods, and severe water-logging and a lack of
sanitation provide a breeding ground for mosquitoes.

Doctors say Gorakhpur town is the epicentre of the disease. Last year
[2008], the government said it would spend 60 million rupees (USD
1.24m) to upgrade facilities at Gorakhpur Medical College hospital.
But, doctors say, the hospital does not have adequate numbers of
medical staff to deal with the large numbers of patients. Doctors say
the children who survive will have to face lifelong problems as the
disease has a crippling effect.

While there is no specific cure for the disease after it has been
contracted, 3 vaccines are in use worldwide that have reportedly been
successful in preventing the disease. But India has so far failed to
develop an effective vaccination programme. After the disease killed
1500 children in 2005, a public outcry forced the government to
import vaccines from China and a mass vaccination project was
started. However, doctors say the vaccine coverage has not been
satisfactory this year [2009], with many parents of affected children
saying no vaccination was done in their areas.

Japanese encephalitis, which causes high fever, vomiting, and can
leave patients comatose, usually hits Uttar Pradesh state in
July-August. The disease has recurred annually in eastern regions of
the state since 1978.

[Byline: Ram Dutt Tripathi]

--
Communicated by:
HealthMap Alerts via ProMED-mail
<promed@promedmail.org>

[The Japanese encephalitis (JE) outbreak continues to spread and
intensify in Uttar Pradesh and neighboring areas. One wonders if most
of the previously reported cases of unspecified "encephalitis" in
this area (see previous ProMED-mail 2009 posts, below) are mostly
cases of JE virus infection.

A map showing the location of Indian states including Uttar Pradesh
in northeastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
A HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00Hk>. - Mod.TY]

ENCEPHALITIS - INDIA: (UTTAR PRADESH) REQUEST FOR INFORMATION
*************************************************************
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ProMED-mail is a program of the
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[1]
Date: Sat 22 Aug 2009
Source: The Times of India (TOI), Times News Network (TNN) [edited]
<http://timesofindia.indiatimes.com/news ... 920904.cms>


A 4-member team of the National Institute of Virology (NIV), Pune, is
in Gorakhpur, hoping to crack the code of the mystery virus that has
killed over 100 people in Uttar Pradesh. The team has been assigned
the job of ascertaining the nature and characteristics of the virus,
how it is spreading, and eventually to find a way to control it so as
to provide guidelines to the state government that will implement
them as preventive measures.

Speaking to TOI on Friday [21 Aug 2009], AC Mishra, director, NIV,
Pune said, "Our team has been working in Gorakhpur for a long time,
particularly to study this virus. They are doing a surveillance of
the environment and the breed of mosquitoes and trying to understand
which family the virus hails from."

Since January [2009], UP has recorded 665 cases of acute encephalitis
syndrome (AES) a severe neurological condition associated with
significant morbidity and mortality. Around 137 people have already
succumbed to the viral infection.

When contacted, Milind Gore, who is leading the NIV team in
Gorakhpur, told TOI, "Since the virus is not entirely known and we
are still unable to distinctly classify it, we are finding out the
percentage of its presence in the environment and its transmission
into the body. We have noticed that most times it is found in
children. We know that it is an enterovirus."

This mystery virus has been causing brain fever and killing people in
UP since last year [2008] but no breakthrough has been made regarding
the virus's identity and nature. Gore said, "Right now we are trying
to figure out how many people have been infected by the virus, what
is the mode of spreading and in what other diseases is the virus or
its characteristics found."

Initially, a 4-member team went to Gorakhpur and started work on the
study. However, a full-fledged centre will soon be established and
more people will be recruited for this study. The NIV team is closely
working with experts from the Centre for Disease Control and
Prevention (CDC) Atlanta. "We are sharing the results of our finding
with the American team and vice-versa. We are working together and
the aim of both these teams is to know more about the virus," Gore
added.

Once the case of the mystery virus is solved, the team will be
recommending guidelines to the Uttar Pradesh government as well as
the preventive measures that can be implemented to curb the spreading
of virus.

[Byline: Swati Shinde, Umesh Isalkar]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[2]
Date: Fri 21 Aug 2009
Source: The Times of India (TOI), Times News Network (TNN) [edited]
<http://timesofindia.indiatimes.com/news ... 916125.cms>


It's a virus that has already claimed over 100 lives but Indian and
American scientists seem to have no clue about what it is. Since
January [2009], the state has recorded 665 cases of acute
encephalitis syndrome (AES) -- a severe neurological condition
associated with significant morbidity and mortality. Around 137
people have already succumbed to the viral infection.

Lab investigations have revealed that only 34 of the cases and 4 of
the deaths were caused by Japanese encephalitis [virus infection] --
a known scourge in the state. However, scientists have no clue what
caused the rest of the 133 encephalitis deaths and 631 cases.
According to officials, this mystery virus has been causing brain
fever and killing people in UP since last year [2008] but no
breakthrough has been made regarding the virus's identity and nature.

Experts from Centre for Disease Control and Prevention (CDC) Atlanta
had picked up 150 samples from UP to help identify the virus. But
they too have failed to make any headway. Speaking to TOI, director
of National Institute of Virology (Gorakhpur) Dr Milind Gore said,
"We are working on identifying the virus and its origin. At present
we don't know what's causing these cases of AES and deaths. We
suspect it could be a type of enterovirus."

Dr Gore added, "It is clear that JE [virus] alone isn't causing AES.
We recently checked 450 stool swabs and found that 68 percent of them
were positive for enteroviruses. However, we don't know exactly which
one from this family of viruses is the dominant one behind the
deaths. Even CDC experts haven't figured it out." Officials said the
search for the "real culprit" behind the AES cases had taken a
beating in the last few months with scientists in NIV Pune drowned
with H1N1 samples.

"H1N1 has proved to be a setback for the work on encephalitis in UP.
Improved methods of diagnosis and new primers were to be tested
against the unknown virus. But everybody at NIV Pune is busy with
H1N1," an official said.

AES is characterised by inflammation of the brain, seizures, and
convulsions among children.

International NGO PATH's senior programme officer for JE Dr Pritu
Dhalaria told TOI, "Usually, around 4-5 enteroviruses work in tandem,
in clusters in particular areas. It is therefore difficult to
identify exactly which virus is the deadly one. By this time last
year [2008], UP had recorded 435 AES cases of which only 15 were
caused by JE [virus]. This year [2009], the cases have increased, and
we don't know which virus is behind it."

Non-polio enteroviruses are very common across the globe. They are
2nd only to the common cold viruses, the rhinoviruses, as the most
common viral infectious agents in humans. Although infection often
has no symptoms and goes unnoticed, these viruses are also associated
with occasional outbreaks in which a larger-than-usual number of
patients develop clinical disease, sometimes with fatal consequences.
Transmission of enterovirus infections is increased by poor hygiene
and overcrowded living conditions. Measures that can be taken to
avoid getting infected with enteroviruses include frequent hand
washing.

Enteroviruses can be found in the respiratory secretions and stool of
an infected person. Other persons may become infected by direct
contact with secretions from an infected person or by contact with
contaminated surfaces or objects.

According to some experts, UP has seen a nearly 40 percent increase
in AES cases this year [2009], majority of them not belonging to the
enterovirus category.

[Byline: Kounteya Sinha]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Clearly, some of these cases of encephalitis were cause by JE virus
infections. The 1st report above states that the non-JE cases were
caused by an enterovirus. The 2nd report is confusing, stating that
unidentified enteroviruses are involved but ending by saying the
majority were not. The basis on which these statements were made
would be of interest.

ProMED-mail requests further information about the etiology of these
encephalitis cases as it becomes available.

Encephalitis of enterovirus etiology has occurred previously in this
area, as reported in the following reference:
Sapkal GN, Bondre VP, Fulmali PV, Patil P, Gopalkrishna V, Dadhania
V, et al. 2009: Enteroviruses in patients with acute encephalitis,
Uttar Pradesh, India. Emerg Infect Dis. 15: 295-8 (full article
available at <http://www.cdc.gov/eid/content/15/2/pdfs/08-0865.pdf>)

Abstract
--------
An outbreak of viral encephalitis occurred in northern India in 2006.
Attempts to identify an etiologic agent in cerebrospinal fluid by
using reverse transcription-PCR showed positivity to enterovirus (EV)
in 66 of 306 patients. Sequencing and phylogenetic analyses of PCR
products from 59 of 66 specimens showed similarity with EV-89 and
EV-76 sequences.

A map showing the location of Indian states including Uttar Pradesh
in northeastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
A HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00Hk>. - Mod.TY]

JAPANESE ENCEPHALITIS - INDIA (05): (UTTAR PRADESH)
***************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Tue 25 Aug 2009
Source: Xinhua News Agency [edited]
<http://news.xinhuanet.com/english/2009- ... 940936.htm>


The Press Trust of India on Tuesday [25 Aug 2009] reported that 3
more Indian children have died of Japanese encephalitis in the
northern Indian state of Uttar Pradesh, taking the toll due to the
viral infection in the state since January [2009], to 180. The
children belonging to Kushinagar, Siddharthanagar, and Mahrajganj
districts of Uttar Pradesh died in the last 2 days at the BRD Medical
College in Gorakhpur, where a total of 20 people suffering from the
viral fever were being treated, said the report.

The deadly Japanese encephalitis fever is caused by a virus found in
pigs and transferred to humans by mosquito bites. The disease affects
the brain and causes high fever and respiratory distress.

[Editor: Li Xianzhi]

--
Communicated by:
HealthMap Alerts via ProMED-mail
<promed@promedmail.org>

A map showing the location of Indian states including Uttar Pradesh
in northeastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
A HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00Hk>. - Mod.TY]

JAPANESE ENCEPHALITIS - INDIA (06): (UTTAR PRADESH)
***************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Wed 26 Aug 2009
From: Deborah Phillips <dphillips@path.org> [edited]


To offer some clarity regarding the recent reports of encephalitis
outbreaks in Uttar Pradesh (UP), Assam, and Nagaland, we would like to
share information we have gathered through our collaboration with the
Government of India.

Since January 2009, UP has recorded 665 acute encephalitis syndrome (AES)
cases. Samples were collected and tested for all cases, and 34 cases and 4
deaths were laboratory-confirmed as Japanese encephalitis (JE) All 4 deaths
occurred in unvaccinated children, 2 children among the surviving cases had
received JE vaccine. The National Institute of Virology continues to
investigate the cause(s) of other AES cases.

From 2006-2008, JE vaccination campaigns for children 1-15 years of age
were held in 27 districts in UP. This year [2009], campaigns in UP were
held in May in 7 additional districts: Allahabad, Pratapgarh, Fatehpur,
Kanpur (urban), Ghazipur, Jaunpur, and Shahjahanpur. The reported coverage
for the 2009 campaigns was 84.6 per cent.

In Assam, according to the Government of India, 109 AES cases were reported
from July-August 2009. Of these, 33 were JE cases, of which 10 adults and 5
children (all unvaccinated) died. Non-JE AES samples are being tested at
the Regional Medical Research Center to determine other etiologies, and
results are expected soon.

A total of 6 districts of upper Assam were covered in JE vaccination
campaigns held in 2006-2008, targeting children 1-15 years of age
(Dibrugarh, Jorhat, Tinsukia, Sivsagar, Golaghat, and Dhemaji). This year
[2009], campaigns were held in May in Lakhimpur (upper Assam), Sonitpur
(middle Assam), and Kamrup (lower Assam), with an overall reported coverage
of 74 per cent.

Nagaland was not included in the national government's initial plan to
target high-risk districts throughout the country. However, given the
recent outbreak situation, the Government of India is considering whether
to include additional states, such as Nagaland, Manipur, and Uttaranchal
for next year's [2010] JE vaccination campaigns.

--
Deborah Phillips
Communications Officer
PATH
USA
<dphillips@path.org>

[ProMED-mail thanks Deborah Phillips for this report, confirming Japanese
encephalitis (JE) virus as the etiologic agent responsible for some of the
AES cases, and providing information about the status of the Indian
government's JE vaccination campaign in this area. ProMED awaits with
interest information on the etiological agent responsible for the remaining
AES cases.

A map showing the location of Indian states including Uttar Pradesh in
north eastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>. A
HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00Hk>. - Mod.TY]

JAPANESE ENCEPHALITIS - INDIA (07): (ASSAM)
*******************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Fri 28 Aug 2009
Source: Sindh Today [edited]
<http://www.sindhtoday.net/news/1/46310.htm>


Japanese encephalitis, a mosquitoborne disease, has killed 78 people in 8
districts of eastern Assam since April [2009] and the health department has
sounded a high alert to check its spread, an official said on Friday [28
Aug 2009]. A health department spokesperson said close to 1000 people have
been affected by the disease.

"We have alerted health officials across the state to take preventive
measures to stop Japanese encephalitis [virus] from spreading to newer
areas," Parthajyoti Gogoi, a senior health department official, said.

The disease, transmitted from pigs through mosquitoes, strikes during the
peak [mosquito] breeding period from April to September. Encephalitis
causes inflammation of the brain tissue, producing symptoms of high fever,
headache, rigidity of the neck, loss of voice, and involuntary movement of
the body.

Authorities in some areas have conducted an encephalitis immunisation
drive, besides fogging and spraying mosquito repellents to kill the
vectors. "People in Japanese encephalitis prone areas in the age group of
one to 15 should take vaccination available at all government hospitals."
Gogoi said, adding: "Prevention is the best way of dealing with Japanese
encephalitis."

--
communicated by:
ProMED-mail rapporteur Susan Baekeland

[If the above figures are laboratory-confirmed Japanese encephalitis (JE)
cases, the numbers have increased significantly since the 26 Aug 2009
report (cited in ProMED-mail archive number 20090827.3015). The situation
in Assam and Uttar Pradesh is not clear currently, as there have been a
large number of "acute encephalitis syndrome" cases of suspected
enterovirus etiology in this area, which substantially exceed the numbers
of JE cases. ProMED-mail archive number 20090827.3015 reported, "In Assam,
according to the Government of India, 109 AES cases were reported from
July-August 2009. Of these, 33 were JE cases, of which 10 adults and 5
children (all unvaccinated) died. Non-JE AES samples are being tested at
the Regional Medical Research Center to determine other etiologies, and
results are expected soon."

A map showing the location of Indian states including Assam in north
eastern India can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>. A
HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/00Hk>. - Mod.TY]

HEPATITIS B AND HEPATITIS C - INDIA: (UTTAR PRADESH), CONTAMINATED BLOOD
**************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sun 30 Aug 2009
Source: Prokerala.com, Indo-Asian News Service (IANS) report [edited]
<http://www.prokerala.com/news/articles/a75710.html>


Contaminated blood could have caused hepatitis
----------------------------------------------
More than a week after police busted a massive racket in adulterated
blood in Uttar Pradesh, another report on the quality of blood seized
reveals that it was infected with the highly contagious hepatitis B
and hepatitis C viruses -- painting an alarming picture of the
possibility of patients having contracted [hepatitis].

The Sanjay Gandhi Post Graduate Institute of Medical Sciences
(SGPGIMS), in another report to the government on Friday [28 Aug
2009], said the hepatitis viruses were found in the adulterated blood.
The report was also submitted to the Food and Drug Administration
(FDA), an FDA source said on Sunday [30 Aug 2009].

A detailed examination of the blood, seized by the authorities from a
private nursing home run illegally by a government doctor had revealed
that very poor quality blood with extremely low levels of haemoglobin
was being supplied to patients in different hospitals. Over a period
of 2 years, 100 000 units of the contaminated blood were sold.

Uttar Pradesh Police arrested 6 people, including an anesthetist from
the state-run Balrampur Hospital, in connection with the racket on 22
Aug 2009. The racket was allegedly being run with the connivance of
several well-known private blood banks and doctors. "We have received
the report but the details cannot be revealed now because it will be
presented in the court as evidence against the accused on Monday [31
Aug 2009]," FDA commissioner Lalit Verma told IANS. The blood seized
by the police with fake labels of the state's largest blood bank at
King George's Medical College (KGMC) were sent for detailed
examination to the SGPGIMS.

Earlier, a report by the SGPGIMS revealed that saline water was being
mixed with the blood to increase its quantity, which led to further
dilution of the already low haemoglobin level in the blood. Lucknow
superintendent of Police (City) Paresh Pandey, who busted the racket,
had initially said he suspected animal blood was being mixed with
human blood. Later, it was found that the blood was being diluted with
saline water.

Last week a joint team of the FDA and police raided a number of
private hospitals and blood banks across the city and a [show cause]
notice was served to 3 blood banks. "Charak Pathology, Indira
Diagnostic Centre, and Kohli Blood Bank were found to be functioning
without proper facilities for blood collection and storage. They were
also not carrying proper certificates," an FDA official said.

The gang used to buy blood from professional donors like drug addicts,
rickshaw pullers, and beggars and would [dilute] it with saline water
to make 3 units from one unit of blood, police said. This was sold at
INR 1000-1500 [USD 20.50 to 30.75] per unit.

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[The state of Uttar Pradesh and its capital Lucknow can be located on
the maps of the Indian states at
<http://rulers.org/indmap.html>
and the HealthMap/ProMED-mail map at
<http://healthmap.org/r/00K3>.

The extent of the illegal supply of this contaminated blood is
alarming. Apart from the circumstance that saline dilution of the
blood is likely to reduce its therapeutic value, the inclusion of
unscreened blood would allow transmission of many infections agents in
addition to hepatitis viruses, not least HIV -- see PromED archive for
2004 below. Information on the known consequences of the sale and
distribution of this contaminated blood should be made public as soon
as it is ascertained. - Mod.CP]

DENGUE/DHF UPDATE 2009 (34)
***************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:

[1] India (Gujarat)
[2] Pakistan


*****
[1] India (Gujarat)
Date: Mon 31 Aug 2009
Source: Times of India [edited]
<http://timesofindia.indiatimes.com/NEWS ... 952136.cms>


The dengue outbreak in the city is refusing to die down, with 15 cases
reported in the city in the past 48 hours. With 3 fresh cases reported
on Sunday [30 Aug 2009], the total number of patients being treated
for the disease in the city has gone up to 55. One person has died of
the disease till date. The patients were admitted from Sukhnathpara,
Sardarnagar and Baharwadi areas. On Saturday [29 Aug 2009], there were
7 new cases reported.

"We are doing our best to tackle the situation in the city. The
district collector PR Sompura has formed a special team to root out
the virus from the city. Daily, 10 teams under this special team are
conducting door-to-door surveys along with officials from Amreli
municipality, to find out cases," a district health official said.

Apart from health officials, teams from the municipality are also
conducting cleanliness drives throughout the city. "We are fumigating
all streets of the city every evening to kill mosquitoes carrying the
dengue virus and cleaning any water-logged areas. However, our job
will get more challenging with the 2nd spell of rainfall that has
begun since the past 72 hours," an official from Amreli Nagar Palika
said.

--
Communicated by:
HealthMap Alerts via
ProMED-mail <promed@promedmail.org>

[Fumigating the streets will be of only temporary value. Eliminating
the vector mosquito breeding sites in and around houses and other
buildings will provide more effective control of the outbreak.

An interactive map of Gujarat, India showing the location of Amreli
and vicinity can be accessed at
<http://www.maplandia.com/india/gujarat/amreli/amreli/>. A
HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/promed/en?v=22.9,79.6,5>. - Mod.TY]

******
[2] Pakistan
Date: Wed 26 Aug 2009
Source: The News [edited]
<http://www.thenews.com.pk/print1.asp?id=195030>


Out of 18 patients of a locality admitted to Holy Family Hospital
Saturday [22 Aug 2009] evening, 5 were declared positive for dengue
fever by the National Institute of Health (NIH), Islamabad. The
confirmation of 5 cases as positive, the 1st in this season in this
region of the country, has convinced a number of health experts in
town to fear an outbreak of the infection.

"The confirmation of 5 cases proved the existence of _Aedes aegypti_,
the female mosquito that causes dengue fever [transmits dengue
viruses] in town. The deaths of 2 children on Friday night and
Saturday morning [21 and 22 Aug 2009] due to fever in the area from
where 18 patients have been taken might be attributed to dengue fever
or DHF," said NIH.

A special team of the District Health Department headed by District
Health Officer Dr. Khalid Randhawa has shifted some 16 children and 2
adults to the HFH after suspecting them cases of dengue fever on
Saturday evening [29 Aug 2009] from a village not more than 25 km from
here. The team was constituted after the Executive District Officer
(Health) received reports of deaths of the 2 children. The deceased as
well as all the suspects admitted at HFH have been living in a cluster
of nearly a dozen families settled near the village Larr in Dhoke
Jhando, located in union council Thatta Khalil of Taxila.

All the 5 cases confirmed so far for the infection range between 3 and
8 years of age. The HFH has sent blood samples of a total of 18
suspected patients of dengue fever to NIH for dengue serology, of
which 5 have been confirmed positive, 9 negative, while results of 4
cases have not been finalised as yet.

Experts do believe that with the detection of 5 confirmed cases in the
outskirts of twin cities of Islamabad and Rawalpindi, a rising threat
of an outbreak of dengue and DHF seems to be lurking, as the disease
has a tendency to occur in epidemics and outbreaks and spreads like
wild fire.

Head of Pathology Department at Rawalpindi Medical College Professor
Dr. Abbas Hayat has repeatedly expressed to "The News" that the spikes
of dengue fever, if they occur repeatedly, might be more deadly and
might result in severe complications, including hemorrhagic
manifestations. Two months back, he said that the situation might be
alarming after the monsoon, as the climate after monsoon is considered
to be the most suitable for the breeding of the mosquito _Aedes
aegypti_ that causes [transmits the viruses that cause] DF and DHF.
DHF is a cause of disease and death primarily among children in
tropical Asia.

Studies have revealed that people at a higher risk for dengue
transmission are children, travellers and tourists, whereas adults
residing in endemic areas are also susceptible to contracting the
disease.

The District Health Department has already claimed that it has
performed fogging and sprinkled insecticidal spray in and around Larr;
however, experts believe that a continuous surveillance is needed at
this time to avert a possible outbreak of dengue fever.

[Byline: Muhammad Qasim]

--
Communicated by:
HealthMap Alerts via
ProMED-mail <promed@promedmail.org>

[A HealthMap/ProMED-mail interactive map of Pakistan can be accessed
at <http://healthmap.org/promed/en?v=30,69.4,5>. - Mod.TY]