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CHIKUNGUNYA (34): INDIA (ORISSA)
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Date: Sat 18 Dec 2010
Source: Orissa Diary [summarized, edited]
<http://orissadiary.com/CurrentNews.asp?id=23208>


Panic has gripped the people of different costal villages of Kujang
and Erasama blocks after detection of chikungunya [virus or antibody?
- Mod.TY] from the blood samples of affected people.

Sources said that hundreds of people from Chauta, Pokharipada under
Erasama and Sahada village under Kujang block have been suffering
from an unknown fever and disease. A medical team collected blood
samples of 15 suspected cases from these villages. Blood samples were
sent to SCB [Shri Ramachandra Bhanj] Medical College and hospital,
Cuttack for examination, which has detected chikungunya virus [or
antibody?] in these patients. Meanwhile, many villagers have been
admitted in different Primary Health Centers (PHCs) for the treatment
of chikungunya [virus infections].

"Chikungunya [virus] is spreading in the village as the authorities
have failed to provide potable water to the people. Due to shortage
of unsafe drinking water, many costal villagers are being compelled
to drink polluted water from the ponds and rivers, causing spread of
dengue and chikungunya [virus infections] in these villages.
[Consuming polluted water from ponds and rivers per se is not
responsible for dengue and chikungunya virus infections. However, if
the unavailability of safe household water is leading to a water
storage in and immediately around houses, this practice is probably
leading to abundant breeding sites for _Aedes aegypti_, the mosquito
vector of both viruses. - Mod.TY]

Panic gripped the village and its nearby areas after a plumber of the
village returned from Kolkota and other states suffering from an
unknown disease. Within a short span, hundreds of villagers including
children suffered from the same disease suspected to be chikungunya
[virus infection]. Many villagers were suffering from fever and joint
pains, which are symptoms of chikungunya. However, a team of doctors,
after visiting the areas, opines that few persons could be classified
as suffering from chikungunya disease, and other patients were
suffering from malaria and water-borne diseases.

[In] the [15] blood samples [from patients], which have been sent to
SCB medical college and hospital, Cuttack, chikungunya virus has been
detected. Similarly, a medical team has also collected blood samples
of another 6 persons of Chatua village to send to Cuttack for
examination today [18 Dec 2010].

Chief District Medical Officer Mr Rabindranath Das has said that
mosquitoes are the main cause of the spread of chikungunya [virus] in
these villages. Medical teams have been pressed into service to give
these villages awareness about these diseases and preventive
measures. All the collected blood samples will be sent to the Indian
Council of Medical Research (ICMR), Bhubaneswer for further
examination and diagnosis of the disease," added Dr Das.

[Byline: Amarnath Parida]

--
Communicated by:
T J Allen <tjallen@pipeline.com>

[This year (2010), there have been chikungunya virus infections in
Delhi, Tamil Nadu, and Maharashtra states, and now Orissa state. It
will be of interest to find out how many of these presumptive
chikungunya virus infection cases in Orissa are actually caused by
this virus, and if dengue viruses are circulating in these areas as
well. There are no vaccines or anti-viral drugs available to prevent
or treat chikungunya virus infections, so only palliative treatment
is available. The most effective measure to reduce this outbreak is
elimination or larvicidal treatment of water catchments where the
vector mosquitoes are breeding.

[A HealthMap/ProMED-mail interactive map of India showing the
location of Orissa state can be accessed at
<http://healthmap.org/promed/index.php?v=22.9,79.6,5>. - Mod.TY]

RABIES, HUMAN - GEORGIA, AND ex AZERBAIJAN
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Date: Sat 18 Dec 2010
Source: AZE.az News Service [in Russian, trans. Corr.ATS, edited]
<http://aze.az/news_v_gruzii_ot_47793.html>


An 11-year-old boy has died in Tbilisi [capital city of Georgia] as a
result of rabies virus infection on Fri 17 Dec 2010. He had been
transferred to the Tbilisi Infectious Diseases Hospital from Telavi
Hospital on the previous day. It is believed that he had been bitten
by a dog several days previously while visiting his relatives in
Azerbaijan. The child received post-exposure vaccination prophylaxis,
but the precise interval between exposure and vaccination has not
been revealed.

Another case of rabies was registered in Tbilisi in November [2010].
On that occasion, a 17-year-old youth bitten by a dog died from
rabies after failing to seek medical treatment until 3 months after the event.

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

[Dogs are the source of 99 percent of human rabies deaths, and canine
rabies is common in Georgia and the South Caucasus region of Eurasia.
The incubation period for rabies is typically 1-3 months but may vary
from less than one week to more than one year. The initial symptoms
of rabies are fever and often pain or an unusual or unexplained
tingling, pricking or burning sensation (paraesthesia) at the wound
site. As the virus spreads through the central nervous system,
progressive, fatal inflammation of the brain and spinal cord
develops. Therefore, it is imperative to seek immediate treatment by
the only option available: Post-exposure vaccination.

A map of Georgia showing the proximity of the city of Tbilisi to
Azerbaijan can be accessed at: <http://eurodialogue.org/Georgia-Map>. - Mod.CP]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (27): (UTTAR PRADESH)
*************************************************************
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Date: Tue 28 Dec 2010
Source: Yahoo News, Press Trust of India (PTI) report [edited]
<http://in.news.yahoo.com/encephalitis-c ... 0-882.html>


In Gorakhpur 2 people succumbed to encephalitis at a hospital, taking
the toll due to the deadly brain fever in eastern Uttar Pradesh to
541 this year [2010]. Health officials said today [28 Dec 2010] that
as many as 6 fresh cases of acute encephalitis syndrome (AES) have
been reported at the Baba Raghav Das Medical College Hospital in the
last 2 days. Additional director (Health) UK Srivastava said the dead
belonged to Kushinagar and Gorakhpur districts.

As many as 67 patients are presently undergoing treatment at various
government hospitals of Gorakhpur, Mahrajganj, Deoria, Kushinagar,
Basti, Sant Kabir Nagar, and Siddharthanagar, he said.

This year [2010], a total of 3754 people suffering from encephalitis
have been admitted to various government hospitals, of whom 541 died.

Meanwhile, the Japanese encephalitis vaccination drive has been
successfully completed in 7 districts of eastern Uttar Pradesh.

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

[This outbreak smolders on relentlessly. The etiologies of the
apparent majority these cases identified as acute encephalitis
syndrome are still not defined. Both JE virus and an unnamed
water-borne virus (enterovirus?) are reportedly involved. There is no
explanation offered in any reports thus far of why the non-JE
virus(es) have not been identified after several months. The campaign
with fresh JE virus vaccine has been initiated. One hopes that this
vaccination campaign will end cases of JE virus infection.

A map showing the location of Uttar Pradesh state can be accessed at
<http://www.indianorphanages.net/images/ ... al-map.gif>. A
HealthMap/ProMED-mail interactive map of India is available at
<http://healthmap.org/r/02lp>. - Mod.TY]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (28 ): (UTTAR PRADESH)
*************************************************************
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Date: Thu 30 Dec 2010
From: TJ John <tjacobjohn@yahoo.co.in> [edited]


The Gorakhpur region in eastern Uttar Pradesh (UP) is a paddy (rice)
cultivating area. That means the combination of Culicine mosquitoes
that breed in rice fields and water birds that develop Japanese
encephalitis (JE) viremia. Thus, it is a JE affected eco-type area; in
2006 and since then some JE vaccination (Chinese live SA14-14-2) has
been going on. In 2006, when a mass campaign was conducted, the
prevalence plummeted. Since then the EPI [Expanded Program on
Immunization] mode of vaccine delivery is beset with many problems, so
JE continues relentlessly. The National Institute of Virology [NIV]
(of Pune, Maharashtra, an ICMR [Indian Council of Medical Research]
Centre) has established a field station in Gorakhpur for
investigations. That is how we know that there are JE cases and non-JE
cases.

The non-JE "acute encephalitis syndrome" could be one or more
conditions. Enterovirus(es) have been proposed since both the field
station and the Lucknow Medical College virologist have isolated many
enteroviruses including a rare isolate from CSF. The NIV people
discount the enterovirus theory but the Lucknow people insist it is an
enterovirus disease.

It cannot be an enterovirus syndrome since it is annually recurrent
and geographically confined. Enteroviruses spread widely. My guess is
that it may not even be a viral syndrome -- virologists look only for
viruses. It could even be a non-infectious problem (such as the
'hepatomyoencephalopathy' we have described in western UP -- it was
called Saharanpur encephalitis for over 2 decades and investigated by
NIV repeatedly. Our systematic studies showed it to be _Cassia
occidentalis_ poisoning of children who ate lots of the beans. A
Google search on Saharanpur encephalitis is a way to search or look
for hepatomyoencephalopathy, or else I can send a series of
publications.

--
Dr T Jacob John
Department of Clinical Virology
Christian Medical College
Vellore, Tamil Nadu
India
<tjacobjohn@yahoo.co.in>

[ProMED-mail is grateful to Dr John for his comments.

As Dr John indicated, clearly a health landscape view ("healthscape")
is essential to determine the etiology and epidemiology of the cases
of encephalitis that have been going on in this area of Gorakhpur.
Until that information is in hand, prevention and control will not be
possible. Vaccination to prevent Japanese encephalitis virus
infections will be helpful, but for less than half the reported cases.
Another (other) etiological agents that are endemic in the area must
be involved in the cases termed acute encephalitis syndrome. Dr John
mentions possible involvement of the plant _Cassia occidentalis_ (or
_Senna occidentalis_) with the common name of coffee senna or
coffeeweed. It contains toxins in all parts (seeds, roots, leaves,
fruits). The symptoms of intoxication include diarrhea, tremors and
dark brown urine if plant parts are consumed in large quantities. The
toxic compounds in it include anthraquinones, emodin glycosides,
toxalbumins, and alkaloids.

A map showing the location of Uttar Pradesh state can be accessed at
<http://www.indianorphanages.net/images/ ... al-map.gif>.
A HealthMap/ProMED-mail interactive map of India is available at
<http://healthmap.org/r/02lp>. - Mod.TY]

MALARIA ­ INDIA, (MUMBAI): URBAN MALARIA COMMENT
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Date: Tue 4 Jan 2011
From: Michael J. Bangs, PhD, MSPH
<Michael_Bangs@fmi.com>


It comes as no surprise that Mumbai would be
experiencing urban malaria; probably has for a
long time but is now being more widely recognized
(and reported). As urbanization increases in
India one can presume 'urban' malaria will become
more of an issue in the future.

Regard subject posting below (Malaria, Fever -
India: (Mumbai), RFI) [14 Jul 2010] I would like
to comment on the last remark provided in the
communication : [Malaria mosquitoes (Anopheles
spp.) do not breed in the water sources mentioned
here, but dengue vector mosquitoes (Aedes spp.)
do. It is likely that the fever cases referred to
are cases of dengue. - Mod.JW] [ProMED-mail
regrets that due to technical difficulties the
following discussion was not posted when
originally sent in July 2010. - Mod.MPP]

Comment: On the contrary, the potential larval
habitats mentioned in the article (i.e., "Water
stagnation -- be it in puddles on the road, in
discarded rubber tyres, in water tanks, or even
in buckets used to store water inside homes -- is
what makes Mumbaikars vulnerable to mosquitoes,
said doctors.") can, in fact, all be acceptable
aquatic sources for _Anopheles stephensi_ in
urban areas. Moreover, this species serves a
primary malaria vector along the northwestern
coastal zone and western interior of India.

As far back as 1908 a severe epidemic was
reported "in the densely crowed city of Bombay,
the epidemic being due to the establishment of
_A. stephensi_ in the wells and cisterns
throughout the city, an unexpected adaptation
which only this species has displayed." (Boyd,
1949. Malariology). [Actually a few other
species, notably, _An. claviger_ show this
tendency of 'urbanization' under ideal
conditions]. _Anopheles stephensi_ is the only
anopheline in India (and Pakistan) which can
readily adapt to the conditions available in many towns and cities.

This species has also been implicated as the
primary vector responsible for past outbreaks in
Kolkata, Bangalore and other cities in India and
Pakistan (Karachi) -- often exhibiting very
localized but intense transmission. "In such
situations it breeds in wells, cisterns, roof
gutters, fountain basins, garden tanks, tubs,
discarded tins, and receptacles of all
descriptions" (Covell, 1928. Malaria in Bombay,
Bombay Govt Press; In: Boyd, 1949.). _An.
stephensi_ is atypical for an anopheline (also,
interestingly tolerant of relatively high
pollution); therefore mistaking such container
habitats as Aedes 'only' is understandable except
when dealing with this species.

Not discounting the possibilities of dengue
contributing to these reported illnesses (or
concurrent with malaria infections), it seems
unlikely that many local health care
practitioners would mistake dengue for malaria
infection. For Mumbai, one would assume (hope)
that many of cases of "malaria" (versus those
reported as "fever") would have been reliably
confirmed by the majority of private and public hospitals.

During a decade or more of intense malaria
eradication efforts in India (late 1950's thru
the 1960's), _An. stephensi_ was effectively
brought under control and urban malaria became an
extremely uncommon occurrence. However, from 1970
onwards that all began to change with the shift
in national control priorities. As a result,
malaria transmission rapidly resurged, both in
rural and urban areas. The fact that Mumbai would
now experience outbreaks of malaria should come as no surprise.

More troubling for India and Pakistan is that
with the explosive urban expansion in both
countries the subsequent increase in suitable
ecological conditions for this mosquito will
likewise place a larger proportion of the human population at risk.

--
Michael J. Bangs, PhD, MSPH
Technical Advisor
Public Health and Malaria Control
Kuala Kencana
<Michael_Bangs@fmi.com>

[ProMED thanks Michael Bangs for his comments and
detailed information on the habitats for
different malaria vectors on the Indian
subcontinent. The point that increasing
urbanization is driving increased transmission is
well taken. ProMED will be happy to post a
comment from health authorities in India and Pakistan. - Mod.EP]

UNDIAGNOSED HEMORRHAGIC DEATHS - INDIA: (MANDYA)
************************************************
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Date: 3 Jan 2011
Source: The Times of India [edited]
<http://timesofindia.indiatimes.com/city ... z1A6gUkz3U>


Children died of slow blood clotting: Docs
------------------------------------------
Mystery deepened over the death of 2 children at Ragimuddenahalli of
Mandya district on Monday [3 Jan 2011] with doctors not confirming
the cause of deaths. The children died after vomiting blood on
Sunday. Meanwhile, the 3 children admitted to Cheluvamba Hospital
here on Sunday [2 Jan 2011] with similar symptoms are said to be out of danger.

Ruling out viral infection or encephalitis as suspected earlier, Dr
Krishnamurthy, hospital superintendent, attributed the deaths to
delay in blood clotting. "Their blood clotting time was 90-120
seconds against the normal 15-20 seconds," he said. He said blood
clotting is normally delayed in cases of people consuming rat poison
or in haemorrhages.

"The 3 children who are being treated now are below 3 years. They
could have eaten bondas mixed with rat poison. But this is a distant
possibility as the 5 children might not have chanced upon the same
bondas," Krishnamurthy felt. According to the parents, they all had
dinner at their respective homes.

"This makes the things more complicated for us to arrive at a
conclusion and identify the reason," he said. He has directed the
doctors to send blood samples to the forensic laboratory in Bangalore
where experts can trace the chemical that slows down blood clotting.
"Only after receiving the report from Bangalore we can arrive at a
conclusion," he added.

Meanwhile, health officials from Mandya Dr Arvindappa said he visited
Cheluvamba Hospital and felt that children might have died of acute gastritis.

--
Communicated by:
Ronan Kelly
<ronankelly@comcast.net>

[Bondas are either a spicy or sweet treat generally made with potato
or other vegetable filling. If the flour used were contaminated it
would difficult to understand why the phenomenon is not occurring in
other locations.

A number rodenticides or anticoagulants can affect the clotting time
and could be accidentally incorporated into food, but all at the same
time in the same location is very odd.

There is likely something more to this story: For example, we are not
told if any of these children have any other health conditions that
may have made them susceptible to something that normally healthy
children would not be susceptible to. We look forward to results from
the laboratory. - Mod.TG]

[The interactive HealthMap/ProMED map for Mandya in India is
available at: <http://healthmap.org/r/0lxb> - CopyEd.EJP]
....................tg/ejp/mpp

CHIKUNGUNYA (01): INDIA (GOA)
********************************************************
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Date: 11 Jan 2011
Source: The Times of India (TOI), Times News Network (TNN) [edited]
<http://timesofindia.indiatimes.com/city ... 238726.cms>

13 persons have tested positive for chikungunya [virus infection] in the very 1st week of the new year [2011]. According to official statistics provided by directorate of health services, 42 samples were collected and sent for examination to the GMC's [Goa Medical College] microbiology department of which 13 have tested positive for chikungunya [virus? antibody?].

Of the positive cases, 3 are from Vasco, 2 each are from Aldona primary heath centre, Canacona, and Panaji urban health centre. The others are from Valpoi, Colvale, Mapusa, and Casarvarnem.

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

[This is the 1st time that ProMED has reported chikungunya virus infections in Goa. However, occurrence of Goa cases is not surprising because the mosquito vector of both dengue and chikungunya viruses is present there. Dengue cases in Goa were reported in 2009 (see ProMED-mail archive no 20090921.3322). In 2010, chikungunya virus infections were widely reported in India, in Delhi, Tamil Nadu, Maharashtra, and Orissa states.

A map of Goa, on India's west coast, can be accessed at <http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
A HealthMap/ProMED-mail interactive map of India showing the location of Goa can be accessed at
<http://healthmap.org/r/018C>. - Mod.TY]

Georgien - Tollwut
11.01.2011

Ein 11-jähriger Junge, der vermutlich in Aserbaidschan von einem Hund gebissen wurde, ist in Tbilisi (Hauptstadt) an der Tollwut gestorben. Eine nachträgliche Impfung (Postexpositionsprophylaxe) wurde durchgeführt, der Abstand zum Biss wurde aber nicht berichtet. Bereits im November starb ein 17-Jähriger in Tbilisi, der erst drei Monate nach dem Hundebiss medizinische Behandlung erhielt. Risikoreisende sollten geimpft bzw. auf die Notwendigkeit der sofortigen Postexpostionsprophylaxe hingewiesen werden. / Quelle: crm

MALARIA - INDIA (02): (MUMBAI)
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Date: Mon, 10 Jan 2011
Source: Times of India [edited]
<http://timesofindia.indiatimes.com/city ... 251072.cms>


Malaria still a threat in Mumbai
--------------------------------
The city, which reeled under the spell of malaria during the last monsoon,
hasn't been able to bounce back completely till now. Doctors claim that
they are still seeing several cases of the disease, which is unusual during
winter.

BMC [Bombay (now Mumbai) Municipal Corporation] statistics show that, with
a total of 4391 people testing positive, there was a positivity rate of
3.07 per cent for malaria in December 2010. The current rate is 2.6 per
cent. Not only are Mumbaikars suffering from a spate of malaria, but a
severe one at that, say doctors.

Dr Khusrav Bajan, physician and intensivist at Hinduja Hospital in Mahim,
said a number of malaria patients had to be admitted. "We admitted 4 cases
of a severe nature in just 2 days. It is really surprising as we generally
don't see many cases of severe malaria in December and January," he said.

A 49 year old patient has been admitted to KEM Hospital for the past 2
weeks. He has been suffering from intermittent fever accompanied by chills
and flu. His family, though, was not surprised to find out that he was
diagnosed with malaria. "Someone or the other from our locality keeps
getting fever. This has been happening for quite a few months. The doctors
have given medication, so my father should be fine soon," said the
patient's son. "There is a construction site nearby, because of which there
has been a mosquito menace," added the resident of a Wadala chawl [a group
of one or 2 room housing units].

Apart from the general symptoms of fever and chills, city doctors currently
claim that malaria is accompanied by other symptoms as well. "We recently
discharged a 72 year old man who had been shuffled from hospital to
hospital, which kept treating him for anaemia for 2 months. When he came to
us, the tests revealed that he was also suffering from falciparum malaria,"
said Dr Hemant Thacker, senior physician at Bombay Hospital. He added,
"Apart from anaemia, people are also suffering from chronicity and
unspecific fevers for a long period of time."

But Dr A R Pazare, head of medicine at KEM, said it was "not so out of the
ordinary" to see malaria cases even after the monsoon. "We do see malaria
cases in the months of October and November. Even in December and January,
there are a few cases," he added.

The BMC, too, said it was not an unusual phenomenon. Dr G T Ambe, executive
health officer, said: "Of the total number of slides taken in December,
4390 people tested positive. The positivity rate in December 2010 was less
than what we saw in 2009. Whatever cases we are getting are mainly due to
construction work."

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

[Reports of malaria in Mumbai continue to appear. It is difficult to
explain from construction sites alone and it appears that the infection is
actually widespread in the community. The last posting (Malaria - India,
(Mumbai): urban malaria comment 20110104.0040) linked the emergence of
malaria in urban Mumbai to increasing urbanization, and it is difficult to
continue to maintain that the situation is caused primarily by poorly
managed construction sites. - Mod.EP

The interactive HealthMap/ProMED map for Mumbai is available at
<http://healthmap.org/r/00BT> - CopyEd.EJP]

MALARIA - INDIA (03): (MUMBAI) COMMENT
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Date: Thu 13 Jan 2011
From: Yuvaraj Jayaraman <j_yuvan@yahoo.com> [edited]


Malaria in Mumbai: comment
--------------------------
Malaria in cities need not only be endemic but can also be introduced by
migrants from endemic areas to cities in search of jobs. These migrants can
be low level of parasitemia [and asymptomatic].

When vector population is high, especially around construction sites,
mosquitoes easily pick up infection from these infected migrants. Since
sexual reproduction of these parasites occurs in mosquitoes, transmission
is rampant and on a wide scale.

One has to remember those cases that come to hospitals are the tip of the
iceberg, there might be many more cases treated elsewhere. What Mumbai
requires now is investigation of these outbreaks (from where the patients
come) to stamp out the local foci of transmission.

Unless this is taking place, cases of malaria will troop into hospitals.
Hence the physicians reporting cases here should also make an official
report to the Brihan Mumbai Corporation to enable them to initiate
appropriate action.

Malaria may be usually low in December and January, but the climate now is
warmer facilitating the longer lifespan of mosquitoes and an increase in
number of cases. Also, with the above coupled with poor/inadequate control
measures, the situation will get out of control.

--
Yuvaraj Jayaraman MD (Pub Health)
National Inst of Epidemiology (ICMR)
Chennai 600077
India
<j_yuvan@yahoo.com>

[ProMED-mail thanks Dr Yuvaraj for his comment. We agree that malaria
transmission can be initiated by migrants being gametocyte carriers in
areas where there is a suitable _Anopheles_ vector and the climatic
conditions permits malaria transmission. However, the number of reports in
Mumbai clearly indicate that the point where a few local outbreaks could be
explained from breeding at construction and immigrant labor, has been passed.

It seems that local transmission from a human reservoir is now happening in
Mumbai. There is probably a reservoir of malaria in the poorer areas of
Mumbai. A survey of slum, squatter, and pavement dweller communities of
Mumbai City published in 2002, found that annual diarrhoea, typhoid, and
malaria cases were estimated to be 614, 68, and 126 per 1000 population
respectively (Kumar Karn S, Harada H: Field survey on water supply,
sanitation and associated health impacts in urban poor communities -- a
case from Mumbai City, India. Water Sci Technol. 2002; 46(11-12): 269-75;
available at
<http://scripts.mit.edu/~varun_ag/readin ... Mumbai.pdf>).

If indeed there is a malaria incidence of 126 per 1000 population per year
in the poorer areas of Mumbai, it is clear that small changes in vector
distribution and density can easily explain the spread of malaria to more
affluent parts of the city. - Mod.EP]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE 2011 (02)
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*****

Cholera - India (Maharashtra)
Date: Wed 12 Jan 2011
Source: The Times of India (TOI), Times News Network (TNN) [edited]
<http://timesofindia.indiatimes.com/city ... 263822.cms>


If the initial test results are anything to go by, cholera seems to
be rearing its ugly head in Mumbai. Doctors of Bandra's Bhabha
Hospital told TOI that stool samples of 12 children sent for the
Hanging Drop (HD) test have confirmed the presence of cholera bacteria.

There has been a spurt in diarrhoea cases in the city in the past 2
weeks with nearly 200 patients seeking treatment. Doctors of Bhabha
Hospital said that they had treated more than 100 diarrhoea patients
in the last 10 days. "All had come with complaints of severe loose
motions, fever, dehydration, and weakness," said a doctor adding that
both adults as well as kids were equally affected by the disease.

The situation was similar at Parel's KEM [King Edward Memorial]
Hospital. Here too the doctors claimed to have treated close to 100
cases in the last 2 weeks.

[Byline: Sumitra Deb Roy]

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

[The interactive HealthMap/ProMED map of India is available at
<http://healthmap.org/r/00BT>. - Sr.Tech.Ed.MJ]

UNDIAGNOSED HEMORRHAGIC FEVER, FATAL - INDIA: (GUJARAT) REQUEST FOR INFORMATION
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Date: Tue 18 Jan 2011
Source: The Times of India (TOI), Times News Network (TNN), Ahmedabad [edited]
<http://timesofindia.indiatimes.com/city ... 308549.cms>


Mystery fever claims a life
---------------------------
[Gujarat] State health authorities have called a team from the
National Institute of Virology (NIV) to investigate the mystery fever
that has claimed one life and left 2 people critical in different
city hospitals. Doctors have not been able to pin-point the origin or
the spread of the fever which is reported to begin with fever,
stomach pain and vomiting, and rapidly deteriorate later.

The 1st case of the mystery fever was reported with the death of a
30-year-old woman from Sanand, who was admitted to Shalby Hospital
[in Ahmedabad] on 29 Dec 2010 with high fever, abdominal pain, and
severe vomiting. Despite all the medication administered, her
condition continued to worsen, her blood count crashed with platelets
dipping to alarming levels. She eventually suffered internal
hemorrhaging and succumbed to systemic organ failure. The woman did
not test positive for dengue fever, the severe form of which [dengue
haemorrhagic fever] has similar symptoms.

While the death of a young woman to fever caused concern, what set
the alarm bells ringing was 2 people who had come in [contact] with
the deceased also falling ill with similar symptoms. A young nurse at
Shalby Hospital, who attended to the 1st patient in the Intensive
Care Unit (ICU) is currently critical with the same symptoms. The
deceased woman's husband has also been admitted to Sterling Hospital.

"The nurse is critical and may have to be put on a ventilator,"
doctors said. They said that 2 people who were in close contact with
the deceased woman getting the fever shows that it is contagious.
Since test reports have not been positive for bacterial infection,
dengue, or other known infections [?], it is important to know
exactly what we are dealing with and also its spread, whether it is
through air, by mosquito, or other means.

Taking note that fever rapidly deteriorates the health of the
patient, NIV teams will collect samples and conduct other inquiries
to ascertain the kind of fever, its spread, and precautions needed to
prevent its spread and protocol needed for better management.

--
Communicated by:
Ronan Kelly
<ronankelly@comcast.net>

[The signs and symptoms of the deceased patient's illness are
compatible with those of a haemorrhgic fever. The results of
diagnostic tests are not disclosed, other than that dengue fever has
been excluded. Of other haemorrhagic fevers, Crimean-Congo
haemorrhagic fever (CCHF) is a possibility (although there have been
no previous reports in ProMED-mail of CCHF in India). When patients
with CCHF are admitted to hospital, there is a risk of nosocomial
spread of infection (as has occurred in this case) and in the past,
serious outbreaks have occurred in this way. According to the WHO
fact sheet
(<http://www.who.int/mediacentre/factshee ... index.html>)
patients with fatal disease do not usually develop a measurable
antibody response and in these individuals, as well as in patients in
the 1st few days of illness, diagnosis is achieved by virus detection
in blood or tissue samples. This may explain the difficulty in making
a positive diagnosis in this case. However, although CCHF is a
contagious disease, it is primarily a zoonosis transmitted by
_Hyalomma_ species ticks . Humans who become infected with CCHF
usually acquire the virus from direct contact with blood or other
infected tissues from livestock during this time, or rarely they may
become infected from a tick bite. The majority of cases have occurred
in those involved with the livestock industry, such as agricultural
workers, slaughterhouse workers, and veterinarians. The circumstances
and occupation of the diseased woman would be a relevant factor in
the diagnosis.

The outcome of the investigation being undertaken by the Indian
National Institute of Virology is awaited with interest.

A map showing the location of Sanand in the state of Gujarat can be viewed at
<http://en.wikipedia.org/wiki/Sanand>.
The HealthMap/ProMED-mail interactive map of India can be accessed at
<http://healthmap.org/r/0mRM>. - Mod.CP]

UNDIAGNOSED HEMORRHAGIC FEVER, FATAL - INDIA (02): (GUJARAT)
CRIMEAN-CONGO HEMORRHAGIC FEVER CONFIRMED
***************************************************************************
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 18 Jan 2010
Source: Thaindian News, Indo Asian News Service (IANS) report [edited]
<http://www.thaindian.com/newsportal/hea ... 89848.html>


Mystery virus which killed 3 identified
---------------------------------------
The mystery virus that created a panic of sorts among the medical
fraternity in Ahmedabad [Gujarat] following the death of a patient,
her consulting doctor, and nurse, has been identified, state Health
Minister Jay Narayan Vyas [in Gandhinagar] Tuesday [18 Jan 2011].
According to the Minister, a sample sent to the National Institute of
Virology, Pune [Maharashtra], has been identified as Crimean-Congo
hemorrhagic fever (CCHF) [virus].

A woman from Kolat village of Sanand Taluka near Ahmedabad was
admitted to a private hospital in Ahmedabad in the 1st week of
January [2011] after she was reported suffering from a mysterious
fever. The patient subsequently died. There was consternation in
medical circles when her consulting doctor, who had examined her,
also passed away as did the nurse, who had attended to her.

Vyas said that the state government was not taking chances and a team
of experts headed by Kamlesh Upadhyaya has been constituted to take
charge of the matter. "Survey teams have fanned out in a 5 km [3 mi]
area of the village to which the patient belonged to carry out a door
to door check," he added.

Meanwhile, a team from Delhi is expected here in the next 2 days to
conduct a study. Municipal health authorities said that random
sampling was being done in the city hospitals to check if there was
any spread of the virus.

--
Communicated by:
Ronan Kelly
<ronankelly@comcast.net>

[The previous post in this thread predicted that the undiagnosed
fever might be caused by Crimean-Congo haemorrhagic fever virus. The
confirmation above becomes the 1st report in ProMED-mail of the
occurrence of Crimean-Congo haemorrhagic fever (CCHF) in India. It
is likely that CCHF virus is present ticks in the vicinity of Kolat
village and their eradication should be undertaken.

This report records a 3rd death. The deceased are the patient, the
attending physician, and the ICU nurse. The condition of the victim's
husband who is being treated in hospital is not revealed. - Mod.CP]

UNDIAGNOSED HEMORRHAGIC FEVER - INDIA: (MAHARASHTRA)
****************************************************
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: Sat 22 Jan 2011
Source: DNA (Daily News Analysis) [edited]
<http://www.dnaindia.com/mumbai/report_f ... ai_1497552>


Viral haemorrhagic fever in Mumbai
----------------------------------
Days after 3 cases of Crimean-Congo hemorrhagic fever (CCHF) were
detected in Ahmedabad, a 48-year-old resident of Thane [a city to the
north of Mumbai] has shown clinical symptoms of [a] viral
haemorrhagic fever and is critical. Doctors at Jaslok Hospital where
the patient was referred to earlier transferred him to the BMC
[Brihanmumbai Municipal Corporation]-run Kasturba hospital on Friday
morning [21 Jan 2011].

The disease has so far claimed 3 lives in Ahmedabad in the last few
days and has resulted in health authorities screening thousands of
people. The mortality rate from CCHF is approximately 90 percent, say
doctors, with death occurring in the 2nd week of illness.

Consulting physician at Jaslok, Dr Pratik Samdhani told DNA, "Sampat
was referred to me last night. He had high fever and was disoriented.
He was not responding to the treatment given by the local physician
for 6-7 days. His MRI scan revealed that he was bleeding in the
brain. Besides, he has a low blood platelets count. His kidney and
liver were deranged." The patient, whose dengue, malaria and
leptospirosis tests were negative, is on ventilator.

"Since patients with CCHF have already been detected in Ahmedabad and
the disease is infectious, the patient needed to be kept under 4th
degree of isolation. Since Jaslok [hospital] does not have this
facility, we decided to shift him to Kasturba Hospital," explained
Samdhani. "There is no improvement in his condition."

The patient is a vegetarian and had no contact with livestock. His
last visit outside the city was to Shirdi some days ago. "We have
recommended Kasturba to give him Ribavirine," Samdhani said.

Jaslok Hospital also gave the medication to 47 of its employees,
including Dr Samdhani, as a precautionary measure.

"Jaslok has also instructed Kasturba Hospital to send secretion
samples to the National Institute of Virology (NIV). This includes
nasal swab and sputum," said Dr Samdhani. Samdhani said the the viral
infection could either be arboviral or adenoviral [i.e., presumably
insect or aerosol aerosol transmitted, as opposed to tick-transmitted?].

Dr GT Ambe, executive health officer, BMC, said he is not aware about
the development. Doctors say that the disease is fatal. Unless it is
detected at an early stage, and treated aggressively, the patient
dies immediately after.

CCHF was successfully identified by the NIV few days ago. The disease
is endemic in many countries in Africa, Europe and Asia. In 2001,
cases or outbreaks were recorded in Kosovo, Albania, Iran, Pakistan,
and South Africa, according to WHO.

Doctors said after the virus strikes the patient, there is a
breakdown of blood and blood products. The tissues get damaged.
Thereafter one gets fever and develops a rash that leads to bleeding.
It can rapidly deteriorate to headaches, seizures, convulsions and
eventually lead to coma. The patient may also experience
irritability, and photophobia (irritation to light).

[Byline: Menaka Rao]

--
Communicated by:
Ronan Kelly
<ronankelly@comcast.net>

[Crimean-Congo haemorrhagic fever (CCHF) is primarily a zoonosis.
Sporadic cases and outbreaks of CCHF affecting humans do occur.
Humans who become infected with CCHF acquire the virus from direct
contact with blood or other infected tissues from livestock during
this time, or they may become infected from a tick bite. The majority
of cases have occurred in those involved with the livestock industry,
such as agricultural workers, slaughterhouse workers and
veterinarians. A detailed account of CCHF can found at the WHO website:
<http://www.who.int/mediacentre/factshee ... index.html>).

In the case of the patient in a Mumbai hospital the diagnosis has
been made mainly by association with a confirmed outbreak of CCHF in
Ahmedabad (in the state of Gujarat), far to the north of Mumbai (in
the state of Maharashtra). The observation that the patient is a city
dweller and a vegetarian is not compatible with the diagnosis of
CCHF. No positive diagnosis of the etiologic agent is reported but
dengue, malaria and leptospirosis infections have been excluded.
Curiously arboviral or adenoviral infection are being considered as
alternative diagnoses.

The results of the tests at the National Institute of Virology in
Pune (Maharashtra) are awaited.

A map of the states of India can be accessed at:
<http://www.mapsofindia.com/maps/india/i ... al-map.htm>. The
HealthMap/ProMED-mail interactive map of India is available
at:
<http://healthmap.org/r/008o>. - Mod.CP]

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

[1]
Date: Sun 23 Jan 2011
Source: The Times of India [edited]
<http://timesofindia.indiatimes.com/city ... z1BoAcNDYU>


Around half a dozen family members of a Bhiwandi resident stood
outside ward no. 14 at Kasturba Hospital near Chinchpokli. "We don't
want to talk to anyone until we get the test report from the National
Institute of Virology," said the patient's son. He said he hadn't
seen his father in the last 24 hours and was unaware whether he was
on ventilator support. "He will come through this, and I am sure we
will be able to leave in a day or 2." All members of the family have
been given a preventive course of Ribavirin as a precautionary
measure, he added.

As news about the 48-year-old father suffering from a haemorrhagic
fever spread, doctors from the Bhiwandi-Nijampur Municipal
Corporation's (BNHC) Health Department visited the Gokul Nagar area.
Health officials surveyed around 200 families, checking people for symptoms.

BNMC's health officer K R Kharat said: "We spent the entire day
carrying out a survey in the Gokul Nagar area and checked around a
thousand residents." The authorities found no one with symptoms
similar to Crimean-Congo haemorrhagic fever (CCHF). The only spot of
worry was the statement given by a neighbour. "The patient's
neighbour told us that the family visited Rajasthan 15 days ago and
had stopped at Ahmedabad [in Gujarat state] on the return journey,''
he said. Ahmedabad district has witnessed 3 deaths due to the CCHF in
the last 2 weeks. The Bhiwandi doctors also discovered that on his
return, the patient had taken ill and was receiving treatment at a
local hospital before he was moved to Bhatia Hospital in Mumbai. He
was then admitted to Jaslok Hospital before the doctors there
transferred him to Kasturba.

Dr Pratik Samdhani from Jaslok Hospital said: "The patient had a
brain haemorrhage along with renal failure. And because we could not
collect the blood samples in complete isolation as required when a
person is suffering from an infectious disease, we had to send him to
Kasturba."

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

******
[2]
Date: Sun 23 Jan 2011
Source: The Times of India [edited]
<http://timesofindia.indiatimes.com/city ... 344335.cms>


The city may not need to worry about a Crimean-Congo haemorrhagic
fever [CCHF] outbreak just yet. The Pune-based National Institute of
Virology [NIV] said on Saturday [22 Jan 2011] that one of 2 samples
sent from Mumbai had tested negative. The other sample had been sent
by BMC [Brihanmumbai Municipal Corporation] officials on Saturday
morning and results will be known on Sunday [23 Jan 2011], said NIV
director A C Mishra.

A senior doctor of Kasturba Hospital who examined the patient said
his brain scan had shown a mid-brain haemorrhage, but there could be
various causes. "It definitely did not look like a case of CCHF
fever. He doesn't have any fever or rash that is associated with
haemorrhagic fever. He has a brain haemorrhage and had bled through
the nose and mouth," the doctor said, adding that these didn't add up
to a classical haemorrhagic fever.

The patient, a resident of Bhiwandi, was shifted from 3 private
hospitals before being admitted in a serious condition to civic-run
Kasturba Hospital in Chinchpokli on Friday [21 Jan 2011] evening.

Public health minister Suresh Shetty told the Times of India that
there should be no reason to panic. Viral haemorrhagic fevers are
caused by viruses that live on animals and can spread from person to
person only after direct contact of blood or body fluids. "Let's wait
for the NIV results. If the result is positive, we will have to get
the animal husbandry department to check cattle, as they are carriers
of this disease," he added.

Additional municipal commissioner Manisha Mhaiskar said it would be
premature to label him as a patient with haemorrhagic fever. "We need
a positive report to say such things," she said, adding that there
was no suspected patient at present. Both BMC and NIV officials
refused to divulge the source of the 1st sample that tested negative
on Saturday [22 Jan 2011].

The man's sample will be tested along with hundreds rushed from
Ahmedabad, where 3 people have died because of the Crimean Congo
Hemorrhagic Fever in the last fortnight. The Mumbai patient is under
the care of infectious diseases specialist Dr Om Shrivastava who told
the Times of India that it had looked like a case of viral
haemorrhagic fever on clinical examination. "But, rather than
speculating, we should wait for the reports," said Dr Srivastava, who
also consults at Jaslok Hospital which transferred the man to
Kasturba Hospital.

Dr Abhay Chowdhary of Haffkine Institute in Parel said that CCHF
doesn't spread through droplets or air. "It spreads only through
contact with blood or fluids of an infected person. So it is a
healthcare worker who doesn't observe all safety precautions who is
at high risk,'' he said. The main task is to establish whether cattle
in the state are carrying ticks that are infected with the virus. "If
one tick is infected, it will spread the virus to other ticks all
over the state. Each tick produces 10 000 eggs, and they transmit the
virus to eggs as well. So, we need to take care of our livestock,"
said Dr Chowdhury.

The state government has called a meeting of all health and animal
husbandry department officials for Monday [24 Jan 2011] morning. "We
will have the NIV report by then and can decide the further course of
action,'' said minister Shetty.

--
Communicated by:
Ronan Kelly <ronankelly@comcast.net>

[These 2 reports justify the skepticism expressed previously
regarding the preliminary diagnosis of CCHF, which now appears to
have been proposed on the basis of the patient's travel through
Ahmedabad (Gujarat state) earlier, where 3 cases of CCHF have been
confirmed. It is likely that the Mumbai patient's condition is the
result of a brain haemorrhage and may not be a consequence of an
infection. Results from the analysis of a 2nd sample of unspecified
clinical material submitted to the NIV are awaited.

A map of the states of India can be accessed at:
<http://www.mapsofindia.com/maps/india/i ... al-map.htm>. The
HealthMap/ProMED-mail interactive map of India is available at:
<http://healthmap.org/r/008o>. - Mod.CP]