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CHOLERA, DIARRHEA AND DYSENTERY UPDATE 2011 (08 ): INDIA
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Cholera - India (Haryana)
Date: Wed 6 Apr 2011
Source: Tribune of India [edited]
<http://www.tribuneindia.com/2011/20110406/haryana.htm#7>


Cholera has broken out in pockets of Yamunanagar district. Sources in
private hospitals say the number of cholera patients could well be 100
or more.

Dr Vijay Mohan Atreja, deputy civil surgeon and malaria officer,
Yamunanagar, said yesterday, 5 Apr 2011, that 26 cases had been
detected in 3 villages of the Khijrabad belt, namely Pipli Majra,
Bahadurpur and Bambepur.

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MALARIA - INDIA (08 ): (LUNGLEI DISTRICT, MIZORAM STATE) NOT
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Date: Mon 11 Apr 2011
Source: newKerala.com [edited]
<http://www.newkerala.com/news/world/ful ... 87835.html>


The cause of the mysterious death of 5 people in a remote
Thanzamasora hamlet in southern Mizoram last month [March 2011] was
not malaria, as had been reported earlier, the state health department
said today.

Health officials, during a meeting of Anti-Malaria Month Advocacy
here, clarified that the cause of the mysterious death was 'Indian
tick typhus,' a very rare disease, and not cerebral malaria as stated
earlier. The officials said that malaria, considered to be the biggest
killer disease in Mizoram, has claimed "only" 2 lives during this
year.

Dr C Lalthanmawia, director of health services, in his power point
presentation on the scenario of malaria in Mizoram, highlighted that
of the 17 002 blood samples collected during this year, 805 were found
to be malaria positive. Of these, 768 were malaria due to _Plasmodium
falciparum_. He said Mizoram has witnessed a fall in the number of
malaria-related deaths in 2010 with only 31 people succumbing to the
killer disease, as compared to 199 in 2009 and 99 in 2008.

According to the record of State Vector-Borne Diseases Control
Programme (SVBDCP), of the 322 929 blood samples tested during last
year [2010], 15 130 were found to be positive with malaria, of which
14 189 were malaria due to _Plasmodium falciparum_, more deadly than
malaria due to _Plasmodium vivax_. As many as 15 099 malaria patients
were cured. As many as 9399 people were tested positive for malaria,
of which 7387 were malaria _Plasmodium falciparum_, during the year
2009. Of these 119 people died, the record said.

Among the 8 districts of Mizoram, Lunglei district in southern
Mizoram topped with 11 malarial deaths in 2010 and Champhai district,
bordering Myanmar, did not have any death due to malaria, the record
said.

According to the death investigation report of the health department,
most of the malarial deaths happened due to negligence on the parts of
the patients that led to delayed treatment. "In 2009, malaria patients
were on an average 4 days late when they took treatment. In 2010, they
were on an average 2 days late. There was a sign of improvement due to
extensive health awareness campaign through the media," officials
said. The health department has set up FTD/ASHA in all towns and
villages to help malaria patients get treatment on time.

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

[This outbreak, in which 6 people died in the Indian village of
Thanzamasora, was initially reported as malaria (Malaria - India (07):
(LU) 20110401.1009); ProMED-mail thanks Ronan Kelly for informing us
that the outbreak was actually due to Indian tick typhus caused by
_Rickettsia conorii_. A detailed discussion of this disease can be
found at ProMED-mail post: Indian tick typhus - India (Himachal
Pradesh) 20070806.2554.

Thanzamasora is a small village in the Lunglei district of the Indian
state of Mizoram (<http://mcdf.wordpress.com/2011/03/>). All 66
families in Thanzamasora belong to the Chakma people, the largest
ethnic group in the Chittagong Hill Tracts, where they make up more
than half the tribal population
(<http://en.wikipedia.org/wiki/Chakma_people>). Lunglei district is
one of the 8 districts of Mizoram state in India. The district is
bounded on the west by Bangladesh, and on the east by Myanmar. For a
map of this district, see
<http://en.wikipedia.org/wiki/Lunglei_district>. The interactive
HealthMap/ProMED-mail map of the Indian state of Mizoram is available
at <http://healthmap.org/r/0DRY>. - Mod.ML]

RABIES - INDIA (03): (TAMIL NADU), DOG CONTROL, HUMAN
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Date: Thu 21 Apr 2011
Source: The Times of India [edited]
<http://timesofindia.indiatimes.com/city ... 042206.cms>


Rabies kills 15 in Chennai, corporation in denial
-------------------------------------------------
The Chennai Corporation has hidden information on a serial killer.
Rabies, which has no effective treatment, has killed 15 people in the
city in the last 4 months.

The corporation has contributed to the problem by withholding
information about rabies deaths to agencies involved in fighting the
disease. The civic body has also not reported the 12 deaths in 2010
and 13 deaths in 2009.

Experts say that if the corporation had reported the deaths, animal
birth control and vaccination programmes could have been strengthened
for stray dogs in the suburbs. "We would have strengthened awareness
campaigns that would encourage people to take the vaccines after they
are bitten by an animal. These vaccines are available free at all
government and corporation hospitals," said the director of public
health Dr RT Porkai Pandian.

The rabies deaths occurred in the government hospitals in the city
and the death certificates were issued by the corporation. But the
civic body did not report the deaths to the state health department.
As a result, Chennai city's data on rabies death showed zero for the
last few years at the national level. In 2009, Tamil Nadu recorded 3
deaths against 263 across the country and in 2010 they recorded 2
deaths against 162 nationally (source: National Health Profile 2010).

The 25 rabies deaths in the city in the last 2 years went unreported.
Chennai Corporation says that they did not inform the state health
department as the victims weren't residents of Chennai. "People who
died in 2009 and 2010 lived in the suburban areas, where there is no
good vaccination programme for stray dogs. In effect, we have had only
2 cases this year," said Deputy commissioner of health Ashish Kumar.

But health care professionals find the corporation's defense "lame
and irresponsible." They say that the corporation's action is wrong in
terms of procedure and medical practice.

"It's alarming that Chennai has so many cases," said Porkai Pandian.
"If they register a rabies death in the city, no matter where the
victim belongs to, it's a death the civic body should own up," he
said. Rabies, a viral disease that is transmitted to humans from
animals, leads to death in all cases. It spreads when the infected
saliva enters the body through a bite.

Stray dogs affected with rabies in one area can quickly spread the
virus to other animals, experts say. "The virus has no borders," they
say, and add that a dog with rabies in Alandur can spread the
infection to those in neighbouring Guindy.

Non-governmental agencies (NGOs) involved in the animal birth control
programme say that though Chennai started its rabies prevention
programme much ahead of many other cities, it has a long way to go.
The city has outsourced the stray dog animal birth control and
vaccination programme to 3 NGOs. The dogs are sterilised and the
anti-rabies injection is given. But this vaccine is valid only for a
year and there is no guarantee of follow-up vaccinations. The last
stray dog census was done in 2003.

"In almost every city, there is a participatory approach to animal
birth control. Every local body outside Tamil Nadu funds 50 per cent
of the cost but that does not happen in Chennai," said Chinny Krishna,
vice-president of the Animal Welfare Board.

[byline: Pushpa Narayan]

--
communicated by:
Merritt Clifton
Editor, Animal People
PO Box 960, Clinton, WA 98236
USA
<anmlpepl@whidbey.com>

[The following are extracts from a commentary forwarded by Merritt
Clifton.

In the report in the Times of India on 10 Jun 2009, referred to
above, the Chennai Corporation stated that Chennai was rabies-free. In
that article, Dr B Kuganatham, health officer, Chennai Corporation was
quoted as saying: "There has been no rabies cases in the last one
year," whereas the above report quotes the corporation deputy
commissioner (health) as saying: "People who died in 2009 and 2010
lived in the suburban areas, where there is no good vaccination
programme for stray dogs. In effect, we have had only 2 cases this
year."

According to this article: "In 2009, Tamil Nadu recorded 3 deaths
against 263 across the country and in 2010, the State recorded 2
deaths as against 162 nationally" quoting from the National Health
Profile 2010.

Dr S Chinny Krishna, of the Animal Welfare Board of India (Government
of India) has written that: "Rabies is almost totally preventable by
the most cost effective method of vaccination of the dog. The majority
of human rabies cases are from owned animals. The Government of India
must make rabies a notifiable disease. Stating that rabies deaths per
year are so much less than those from malaria, TB and AIDS is no
answer. The Deccan Chronicle today also carried a remark by the Union
Home Secretary, Mr G K Pillay, that "over 100 000 people die from road
accidents per year; 20 times as many as deaths from terrorist attacks,
left wing extremism and insurgencies put together." While we have to
prioritise our expenditure based on deaths, declaring rabies as a
notifiable disease would involve no major expense and the Government
must do so without any further delay."

Both Chinny Krishna and Major General (retired) Rammehar Kharb
(current chairman of the AWBI) have been pushing for years for rabies
to be made a notifiable disease in India, so that accurate data can be
collected about where it exists, enabling the AWBI, the Blue Cross,
and other animal welfare organizations to target and eradicate the
reservoirs for the disease.

Chennai, formerly known as Madras, is the capital city of the Indian
state of Tamil Nadu, located on the Coromandel Coast of the Bay of
Bengal. Chennai being the 4th most populous metropolitan area and the
5th most populous city in India, is also the world's 36th largest
metropolitan area. A map of Tamil Nadu, showing the location of Chenai
can be accessed at
<http://www.mapsofindia.com/maps/tamilna ... strict.htm>. -
Mod.CP]

INDIAN TICK TYPHUS - INDIA: (MIZORAM)
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Date: Wed 20 Apr 2011
Source: IBN Live [edited]
<http://ibnlive.in.com/generalnewsfeed/n ... 54950.html>


The Mizoram Health Department will send dog ticks known
as_Rhipicephalus sanguineus_, collected from Mizoram's Thanzamasora
hamlet, to the laboratories of the National Centre for Disease Control
in New Delhi for tests, in view of the deaths of 6 villagers due to
Indian tick typhus.

According to an official statement here, the cause of death of the 6
people at Thanzamasora in Lunglei district during March 2011 was
declared as cerebral malaria, but it was found to be due to a rare
disease known as Indian tick typhus.

The statement said that the blood samples of some patients in
Tnazamasora, showing the same symptoms, were sent to the National
Centre for Disease Control, and the laboratory tests confirmed that
the disease was Indian tick typhus, transmitted by a particular tick
found in rodents and domestic dogs, caused by a bacterium known as
_Rickettsia conorii_.

The disease was detected in 1999 from a French tourist and also among
tea garden workers in Kerala in 2004, the statement added.

--
Communicated by:
Merritt Clifton
Editor, Animal People
Clinton, WA
<anmlpepl@whidbey.com>

[The manifestations of illness in the cases and how many non-fatal
cases occurred are not stated.

The following is part of the case report of the French tourist
mentioned above with a discussion of the Indian tick typhus (ITT)
variant with the citations removed
(<http://www.cdc.gov/ncidod/eid/vol7no5/parola_letter.htm>):

Although ITT was clinically described at the beginning of the
century, the etiologic agent has never been isolated from patients in
India, nor has a case been diagnosed by strain-specific serologic
testing. A spotted fever group rickettsia was isolated in 1950 from a
brown dog tick, _Rhipicephalus sanguineus_, collected in India and
assumed to be the agent causing ITT. It was designated as _Rickettsia
conorii_, the agent of Mediterranean spotted fever , which occurs all
around the Mediterranean and is transmitted by the same tick species.
However, the disease as it appears in India differs from the common
description of Mediterranean spotted fever. The rash is frequently
purpuric, and an inoculation eschar at the bite site is rarely found,
as in this case. The disease as known in India is mild to moderately
severe, although our case may be considered severe.

Strain differences within the species _R. conorii_ may account for
differences in clinical presentation. Although different isolates of
_R. conorii_ can be distinguished antigenically, molecular taxonomic
methods demonstrated recently that these rickettsiae are closely
related and cluster together. Thus, the species is considered by many
as _R. conorii_, including 4 serovars: _R. conorii_ with 3 type
strains, Seven being the one most commonly identified in our
laboratory in isolates from France, Portugal, North Africa (D. Raoult,
unpub. data), Kenya, and Morocco (apparently a unique isolate); _R.
conorii_ Indian tick typhus; _R. conorii_ Astrakhan, and _R. conorii_
Israel.

The brown dog tick, _Rhipicephalus sanguineus_ Latreille, is unusual
among ticks in that it can complete its entire life cycle indoors
(<http://entomology.ifas.ufl.edu/creature ... g_tick.htm>).
Because of this, it can establish populations in colder climates, and
has been found in much of the world. Many tick species can be carried
indoors on animals, but cannot complete their entire life cycle
inside. Although _R. sanguineus_ will feed on a wide variety of
mammals, dogs are the preferred host in the U.S. and appear to be
required to develop large infestations.

Infestations in houses can explode to very high levels quickly.
Typically, a few ticks are brought into the house or kennel, often on
a dog which has been away from home. The early stages of the
infestation, when only a few individuals are present, are often missed
completely. The 1st indication that the dog owner has that there is a
problem is when they start noticing ticks crawling up the walls or
curtains! - Mod.LL]

TULAREMIA, IMPORTED - GERMANY: (BERLIN) ex TURKEY, ALERT
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Date: Thu 5 May 2011
Source: Eurosurveillance 2011; 16(18 ) [edited]
<http://www.eurosurveillance.org/ViewArt ... leId=19860>


Tularemia in Berlin -- 2 independent cases in travelers returning
from Central Anatolia, Turkey, February 2011
----------------------------------------------------------------------
[authors: Schubert A, Splettstoesser W, Batzing-Feigenbaum J, et al]

Tularemia, though rare, has recently been increasingly reported in
Germany. Most cases are indigenous infections. This report describes 2
epidemiologically independent infections with _Francisella tularensis_
subspecies _holarctica_ detected in Berlin in February 2011 that were
acquired in central Anatolia, Turkey. In Turkey, there have been
repeated tularemia outbreaks since 2000 and the disease should
therefore be considered as a differential diagnosis in travellers
returning from that country.

Case description and clinical diagnosis
---------------------------------------
In March 2011, 2 travelers returning from Turkey, both in their 20s,
were diagnosed with tularemia in Berlin, Germany. Both had stayed
independently in Turkey between the end of 2010 and early 2011 to
visit their respective families in Yozgat, central Anatolia, 218 km
[136 mi] east of Ankara in the Ak mountains. The population of Yozgat
in 2008 was 71 768, the province counted 492 127 inhabitants (1).

Both patients had similar general symptoms including fever,
pharyngitis, otitis and cervical lymphadenopathy, but showed different
locations of the ulcerations characteristic of tularemia. Both
infections were characterized by slow and subacute clinical
progression.

Patient 1 stayed in Turkey between 25 Jul 2010 and 29 Jan 2011. Onset
of symptoms was on 15 Dec 2010. Patient 2 had been in Turkey from 24
Dec 2010 to 8 Jan 2011 and fell ill on 10 Jan 2011. The patients were
diagnosed in mid-February 2011, after their return to Berlin. Patient
1 was diagnosed with oropharyngeal tularemia, patient 2 with the
ulceroglandular form. The latter form is the most common expression of
tularemia. Typical symptoms are ulcerations at the inoculation site
linked with regional, often purulent inflammation of the [draining]
lymph nodes. The exact description of primary clinical symptoms is
very important to elucidate the transmission routes and further
epidemiological links (2,3). Further interviews with patient 2
revealed additional epidemiological information: the patient and one
of his siblings both fell ill on 10 Jan 2011, and a further sibling 2
days later. However, these patients remained in Turkey.

Laboratory confirmation
-----------------------
The detection of the pathogen by bacterial culture is difficult,
special media are needed and growth is generally slow. More sensitive
laboratory methods like PCR are only available in a small number of
specialized laboratories (2,3). Laboratory confirmation for the cases
was available on 4 Mar 2011. The German national reference laboratory
for tularemia in Munich could detect _F. tularensis_ subspecies
_holarctica_ (Jellison type B) via PCR in both cases. Specific DNA
sequences were detected in the purulent puncture material of affected
lymph nodes.

A serological diagnosis done previously in the hospital in Berlin for
patient 2 had shown IgG and IgM antibodies against _F. tularensis_
lipopolysacharides. The infection in patient 1 was not proved
serologically in the hospital, but was confirmed through specific
antibodies in the national reference laboratory.

Public health implications
--------------------------
After the diagnoses were confirmed, information was immediately
reported according to the WHO International Health Regulations (IHR)
to the Robert Koch-Institute (RKI). At that time, no recent data were
accessible about the tularemia situation in Turkey. Data about
tularemia infections related to recent travel to Turkey or to
neighboring countries were not found.

Turkish citizens are one of the larger populations with migration
background in Germany. At the end of 2010 nearly 2 per cent of the
German population were Turkish (1 629 480 inhabitants) (4). In Berlin
at the end of 2009, 3 per cent of the population were Turkish citizens
(108 000 inhabitants) (5). In addition, an unknown number of German
citizens of Turkish origin still have intensive contacts with their
families in Turkey and frequently travel there. Therefore, the health
authorities in all 16 German federal states were informed on 8 Mar
2011 during the weekly epidemiological telephone conference (EpiLag),
since more imported infections in international travellers could not
be excluded.

To get further data about the situation in Turkey, but also to alert
other countries, the RKI informed the Turkish IHR focal point and the
WHO Regional Office for Europe about the infections. Furthermore,
information was sent to the Early Warning and Response System (EWRS)
of the European Union. On the national level the decision was made to
involve the German National Centre for Biological Security at the RKI
because the pathogen _F. tularensis_ is classified as a potential
biological risk agent [category A. - Mod.LL]. Overall, the risk of
further transmission and the threat to public health in Germany was
estimated as low.

Epidemiological considerations
------------------------------
In the past years tularaemia outbreaks in Europe were documented in
Norway (6,7), Sweden (8 ), Spain (9), and the UN Administered Province
of Kosovo in accordance with Security Council Resolution 1244 of 1999
(10). Parts of Turkey have been strongly affected by the re-emergence
of tularemia and a number of outbreaks have been published since 2000
(11-16). In Germany, tularemia cases are rare, however, increasing
numbers have been reported since 2007. Some travel-associated
tularemia cases have been reported in Germany (10 of 74 cases between
2001 and 2009), but only 1 case dating back to 2003 originated from
Turkey (17,18 ).

Through information exchange via the national German and Turkish IHR
Focal Points with the General Directorate of Primary Health Care in
the Turkish Ministry of Health, further details were provided about
the current situation in Turkey and possible sources of infection
(personal communication: Dr Tamer Sami Pelitli, 18 Mar 2011). More
than 100 tularemia cases were reported to the national reference
laboratories from central parts of Turkey, especially in the Yozgat
province in 2010. The cases had been confirmed serologically and
through PCR in 2 reference laboratories in Ankara and Bursa, Turkey.
Based on this information the Ministry of Health of Turkey has
implemented an action plan to fight the spread of tularaemia in 2010.
This action plan is focused on the rehabilitation of water systems. As
a promising result the number of reported tularaemia cases decreased
in 2011 compared with the previous years. After being informed by the
German IHR Focal Point about the 2 cases in Berlin, the Turkish
Ministry of Health started active surveillance work in the Yozgat
province, but has not yet detected new transmission risks for
tularemia.

In both cases from Berlin the source of infection could not be
identified conclusively. However, based on the available
epidemiological information, the most probable cause of the 2
infections is consumption of contaminated water during the stay in a
region of Turkey endemic for tularemia. Transmission has often been
associated with decentralized drinking water supply like cisterns and
insufficiently treated surface water (15). The clinical presentation
at least in one of the patients diagnosed in Berlin supports this
suggestion. Oropharyngeal tularemia is presumably related to oral
ingestion of the pathogen.

Clinical considerations
-----------------------
Due to the relatively unspecific general symptoms of tularemia and
the variety of the primary disease patterns (depending on the route of
infection) clinical diagnosis is not easy. Therefore, early suspicion
of tularemia depends on a precise medical history and epidemiological
data regarding in particular travel history, animal contacts,
occupation, and insect bites. The diagnosis should subsequently be
confirmed through sensitive biomolecular methods like PCR with direct
identification in blood, lymph node punctuates or wound swabs, and
specific serological tests, both of which are available in specified
laboratories.

Early diagnosis allows immediate therapy with effective antibiotics
like doxycycline or fluoroquinolones, which can be combined with
aminoglycosides in severe cases. Drugs used empirically in many cases
of lymphadenitis of uncertain origin are cephalosporins,
amoxicillin/clavulanate, and macrolides which, however, are not
effective against tularemia. Sometimes even surgical interventions to
eliminate a suspected tumour are performed during infection with _F.
tularensis_. In these cases, tularaemia is frequently diagnosed only
retrospectively by histopathological examination and/or by detection
of _F. tularensis_-specific antibodies.

Clinical physicians should currently be aware of possible infections
with _F. tularensis_ in travelers from some regions of Turkey. In case
of clinical signs suggestive of tularemia, effective diagnostic
methods should not be delayed, since diagnostic delay can easily
result in extended suffering of the patient. Besides addressing the
public health aspects of the disease, epidemiology plays a major role
in supporting the early and effective clinical diagnosis and treatment
of tularemia.

[For the citations, please refer to the source URL above. - Mod.LL]

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communicated by:
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[_F. tularensis_ can be divided into 2 clinically significant
subspecies, _F. tularensis tularensis_ (also known as type A or
subspecies nearctica) and _F. tularensis holarctica_ (also known as
type B or subspecies _palaearctica_). Other much less clinically
relevant subspecies are also described.

Type A appears to be the most prominent type in North America,
primarily endemic in rabbits, and was involved in the Martha's
Vineyard (Massachusetts) pneumonic tularemia outbreaks. The infectious
dose to produce infection in humans to cause moderately severe disease
is as few as 50 bacilli and it is lethal to guinea pigs and rabbits.

Type B is found in Europe and Asia but also in North America. The
reservoirs include rodents, voles, muskrats, and beavers. An
infectious dose of 12 000 bacilli is much more likely to produce only
mild, self-limited disease in humans. It is not lethal in rabbits and
guinea pigs.

Regarding water-related outbreaks of tularemia, outbreaks include 64
cases in Dagestan, Russia associated with a flood-plain swamp (1), 49
cases in Tuscany, Italy linked to an unchlorinated water system (2),
and an outbreak in the Smolensk province of Russia also attributed to
contamination of a water supply (3).

References
----------
1. Tikhenko NI, Efremenko VI, Omarieva E, et al. Outbreak of
tularemia in the Republic of Dagestan. Zh Mikrobiol Epidemiol
Immunobiol. 2001; (6 Suppl): 68-72 (in Russian, abstract in English
available from <http://www.ncbi.nlm.nih.gov/pubmed/12718181>).
2. Greco D, Allegrini G, Tizzi T, et al. A waterborne tularemia
outbreak. Eur J Epidemiol. 1987; 3(1): 35-8 (abstract available from
<http://www.ncbi.nlm.nih.gov/pubmed/3582597>).
3. Rogutskii SV, Khramtsov MM, Avchinikov AV, et al. An
epidemiological investigation of a tularemia outbreak in Smolensk
Province. Zh Mikrobiol Epidemiol Immunobiol 1997; (2): 33-7 (in
Russian, abstract in English available from
<http://www.ncbi.nlm.nih.gov/pubmed/9245138>). - Mod.LL]

CHICKENPOX, CHILDREN - INDIA: (ASSAM)
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Date: Mon 9 May 2011
Source: The Assam Tribune [edited]
<http://www.assamtribune.com/scripts/det ... 011/city07>


State witnessing spurt in chickenpox cases
------------------------------------------
Guwahati and many other areas of the State are witnessing a spurt in
cases of chickenpox [varicella]. Among those who have been affected
are a large number of children. Concerns about the disease stem from
the fact that the infection is highly contagious and can spread
without direct contact with a carrier. An airborne disease, it can
spread through sneezing or coughing of an infected person apart from
direct contact.

According to doctors' a child or adult with chickenpox may develop
itchy, fluid-filled blisters which burst and form crusts. The virus
that causes chickenpox is varicella-zoster virus [now human herpes
virus 3], the same virus that also causes herpes zoster in adults.

There has been an increase in the number of people who have been
diagnosed with chickenpox in clinics and doctors' chambers in the past
few weeks, and those infected have come in from varied backgrounds,
which imply that the infection has not been restricted to any
particular strata.

Anyone infected by the virus should ideally stay in quarantine to
minimize contact with others. Proper hygiene should be maintained, and
the diet should ensure that dehydration does not take place.
Scratching should be avoided as it may lead to scars.

This season, a large number of young children have been infected by
the virus. Dr Ranjan Saikia, a city based pediatrician mentioned that
the number of cases is quite high in and around Guwahati. He said in
case of a child showing the symptoms of chickenpox, a doctor's advice
should be sought immediately. He stated that children between the age
of 15 months and 10 years can also be vaccinated to resist the
infection.

Keeping the child in quarantine is recommended, and those in contact
with the child must take necessary protection so that the infection
does not spread, he added. In case of a lactating mother being
infected, the infant may be breast fed, but otherwise contact with the
mother should be minimized.

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

[Chickenpox is prevalent worldwide and outbreaks have occurred
throughout India in the recent past. Chickenpox is highly infectious
and spreads from person to person by direct contact or through the air
from an infected person's coughing or sneezing or from aerosolization
of virus from skin lesions. A person with chickenpox is contagious 1-2
days before the rash appears and until all blisters have formed scabs.
It takes from 10-21 days after exposure for someone to develop
chickenpox.

In children, chickenpox most commonly causes an illness that lasts
about 5-10 days. Children usually have symptoms such as high fever,
severe itching, an uncomfortable rash, and dehydration or headache. In
addition, about 1 in 10 unvaccinated children who get the disease will
have a complication from chickenpox. These complications include
infected skin lesions, dehydration from vomiting or diarrhea, or more
serious complications such as pneumonia and encephalitis.

Certain groups of people are more likely to have more severe illness
with serious complications. These include adults, infants,
adolescents, and people whose immune systems have been weakened
because of illness or medications such as long-term use of steroids.
Serious complications from chickenpox include bacterial infections
which can involve many sites of the body including the skin, tissues
under the skin, bone, lungs (pneumonia), joints, and blood. Other
serious complications are due directly to infection with the
varicella-zoster virus and include viral pneumonia, bleeding problems,
and encephalitis.

In some countries a chickenpox vaccine is available (but not yet in
India) and is usually administered in 2 doses in combination with MMR
(mumps, measles and rubella) vaccine which provides a high degree of
protection in children.

Guwahati is the largest city in the Indian state of Assam. It can be
located in the HealthMap/ProMED-mail interactive map of Assam at:
<http://healthmap.org/r/00J->. - Mod.CP]

RABIES - INDIA (05): (ANDHRA PRADESH) CANINE, HUMAN
***************************************************
A ProMED-mail post
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ProMED-mail is a program of the
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<http://www.isid.org>

Date: Wed 18 May 2011
From: Merritt Clifton <anmlpepl@whidbey.com> [edited]


Re: ProMED-mail Rabies - India (04): (AP) canine, human
20110517.1500, the following is a response to the moderator's comment
that "In the longer term, control of rabies in the canine population
may be the best solution."

To date, unfortunately, high-volume prophylactic canines rabies
vaccination has never really been attempted (or at least never
sustained), except as a component of the national Animal Birth Control
(ABC) program which has been promoted by the Animal Welfare Board of
India since December 1997, and was implemented as official national
policy in 2003.

The ABC programs have markedly increased the pace of dog vaccination
in India, but have 2 inherent weaknesses as a vehicle for achieving
high-volume vaccination:
1. Capturing and holding street dogs for long enough to perform
sterilization surgery takes a great deal more effort than just
catching dogs for long enough to perform vaccination. A really good
surgical team might sterilize 40-50 dogs in a day; a really good
vaccination team can do 10 times that many.
2. The ABC programs have yet to be successfully extended to all parts
of India. Many excellent ABC programs are now up and running, but it
would be optimistic to presume that more than about 25 percent of
India is currently served by any ABC program at all.

Two further problems are logistic:
One of them is that quality 3-year vaccines (which in effect protect
street dogs for their usual life expectancy) are not always easily
available in all parts India. Many dogs, if vaccinated at all, are
vaccinated with vaccines of low potency.

The other logistic problem is that keeping vaccines adequately cold
in a hot climate is problematic, especially given the weaknesses of
the Indian electricity grid. Urban areas often suffer rolling
blackouts; rural areas sometimes barely have any grid at all.

These are surmountable obstacles. Oscar Larghi MD, confronted and
overcame them in Brazil, Uruguay, and Argentina many years ago. But
they do have to be taken into account.

A 3rd problem, which I mentioned previously on ProMED quite a few
years ago, is vaccination resistance among the Indian public. This has
several components, and is visible in all strata of Indian society,
including among the members of the Federation of Indian Animal
Protection Organizations.

Among less educated people, there is often the same basic fear and
misunderstanding of vaccination that probably most ProMED members
working in the developing world have encountered. Sometimes this fear
and misunderstanding have been made worse by the activities of quacks,
selling ineffective home-brewed vaccines for livestock and human
diseases.

Among well-educated people, is resistance from several influential
religious communities.

Some Jains, for example, reject vaccination because cultivating a
vaccine even in an egg yolk offends their interpretation of ahimsa,
the concept of doing no harm. This can become a very sensitive matter.
Jains may be disproportionately represented in medicine, veterinary
work, and animal advocacy, and are most certainly not all in agreement
with each other about vaccination. Debate among the factions can be
intense, as I can testify from experience on several occasions as the
facilitator and moderator.

There are many other Indian religious communities with objections or
reservations about vaccination. I have encountered this among some
Hindus, some Muslims, and some Theosophists. As among my Jain friends,
there is no unanimity, but there is considerable depth of religious
conviction involved, on both sides of the issue.

At present, most Indian animal advocacy organizations endorse canine
rabies vaccinations, but up to 10 percent have reservations, and
perhaps 5 percent are still opposed.

Also of note, by the way, about 60 percent of the Indian dog
population are pets, more or less under the control of particular
people. About 35 percent are "community pets," not under anyone's
control, but relatively well socialized to people. About 5 percent are
completely feral.

The current national dogs-to-humans ratio is about 1/28, a
substantial change from as high as 1/10 circa 1997, through the
combination of the accomplishments of the ABC programs and the rapid
increase of motorized transportation. The old 1/10 ratio may still be
observed in dog-friendly villages, while in the interiors of some very
large cities with effective ABC programs the ratio is up to 1/140.

Rabies has been eradicated from the cities with ratios in the
vicinity of 1/140 -- interior Visakhapatnam, Chennai, Jaipur, and
Bangalore, for example. But rabies does still occur at the rapidly
expanding outer margins of these cities. In 2007, after the Bangalore
ABC programs were suspended for several months, canine rabies returned
to the inner city, but I understand it was again eradicated. Earlier
this year [2011] a scandal erupted in Chennai when the ABC programs
learned that rabies cases were occurring in outlying districts, of
which they were not advised, and were therefore left unable to respond
with the necessary saturation dog vaccination.

--
Merritt Clifton
Editor, Animal People
PO Box 960
Clinton, WA 98236
USA
<anmlpepl@whidbey.com>
<http://www.animalpeoplenews.org>

[ProMED-mail welcomes this perceptive and instructive comment from
Merritt Clifton regarding the rabies situation In India.

His comment concerning the logistic problems hampering canine
vaccination programs in India, specifically the maintenance of vaccine
quality in a hot climate, may have similar relevance in the
post-exposure treatment of human victims of dog bites. It is
disturbing that the 60-year-old woman, who is the principal subject of
the original press report, died 2 months after receiving treatment. -
Mod.CP]

UNDIAGNOSED DISEASE - INDIA (ORISSA): REQUEST FOR INFORMATION
*************************************************************
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Date: Mon 16 May 2011
Source: Xinhua News Agency [edited]
<http://news.xinhuanet.com/english2010/h ... 877689.htm>


An unknown disease has struck some villages in eastern Indian state
Orissa's Malkangiri district killing at least 16 persons, including 14
children, over the last 10 days, reported the Press Trust of India on
Monday [16 May 2011].

The report quoted medical officers as saying a medical team has
rushed to the area to take stock of the situation. As the victims are
afflicted with lumps on mouth and other parts of the body, the
symptoms indicated that the disease could be anthrax or malnutrition,
according to the report.

The area is inaccessible and the only link to the place is
motor-launch across the Balimela reservoir. In the absence of medical
care in the area, people mostly depend upon 'quacks' and herbal
treatment of diseases, according to the report.

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

[Anthrax is infrequent in children, even rare, if for no other reason
than that they are rarely occupationally exposed as are adults; note
that 14/16 were children. And "mouth lumps" are not the usual
cutaneous lesion. Oropharyngeal anthrax is severe and usually lethal
for humans but that is not the same as lumps on the mouth. The disease
is regularly seen in humans and cattle in Orissa. Malnutrition would
add to the susceptibility and the probability of butchering a
sick/dead animal with anthrax. But in this instance I must doubt the
validity of the preliminary diagnosis.

Balimela and the Balimela Reservoir can be seen on the
HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/0Q*C>. - Mod.MHJ]

[There is certainly not sufficient clinical information provided in
the brief news description to diagnose the condition affecting this
largely pediatric group and Dr Hugh-Jones' comments above on anthrax
are appreciated.

Using GIDEON (Global Infectious Disease & Epidemiology Network
<http://web.gideononline.com>), and entering the following criteria:
India / severe (hospitalized, hemorrhagic fever, fatal, etc) / ears,
nose, throat, and oral cavity / oropharyngeal mass/ subcutaneous or
soft tissue lesion(s) or abscess -- melioidosis (infection with
_Burkholderia pseudomallei_) emerges as the leading diagnosis. This
would certainly not be a typical presentation or geographic location,
though it is occasionally seen in India. Lumps in the oropharyngeal
area could be compatible with actinomycosis, but this is not usually
lethal.

Other information regarding these cases, including postmortem
cultures and histopathology would be welcomed. - Mod.LM]

RABIES - INDIA (06): (ANDHRA PRADESH), CANINE, HUMAN
****************************************************
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[1]
Date: Wed 18 May 2011
Source: News One [edited]
<http://www.inewsone.com/2011/05/18/anot ... dhra/51482>


A man died of rabies in Andhra Pradesh on Wednesday [18 May 2011],
taking the toll due to dog bites to 5 in 10 days, officials said.

The daily-wage laborer died of rabies at a government hospital in
Kakinada in East Godavari district of coastal Andhra Pradesh, doctors
said. The 45-year-old bit his wife before his death, and she too has
been admitted to the hospital. The victim had been bitten by a stray
dog 4 months ago, but he did not receive anti-rabies vaccine.

All 5 deaths have occurred in East Godavari district, leaving the
people scared. The government has constituted a technical committee to
inquire into the deaths.

While 3 people, including an 8-year-old girl, died in Rajahmundry, 2
deaths have been reported from Kakinada.

Activists of various political parties staged a protest on Wednesday
[18 May 2011] outside Rajahmundry municipal corporation office. They
blamed the municipal authorities for the deaths. They also alleged
that government-run hospitals have not stocked adequate doses of
anti-rabies vaccines; 3 of the victims had approached the hospitals
after dog bites but were reportedly sent away, as the vaccine was not
available.

Meanwhile on Wednesday [18 May 2011], the state government submitted
a report to the state Human Rights Commission concerning the death of
the 8-year-old girl as a result of lack of anti-rabies vaccines at
Rajahmundry hospital. The state government, as well as the district
administration, admitted in their reports that there had been a
shortage of the vaccine during the period 4-26 Apr 2011. The
commission, which issued the notice to the government, has adjourned
the hearing to 28 Jun 2011.

According to the health authorities, there are close to 67 000 stray
dogs in the urban areas of East Godavari district alone, while their
number is over 20 lakh [2 million] across the state.

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

******
[2]
Date: Sat 21 May 2011
Source: IBN Live, AP/PTI report [edited]
<http://ibnlive.in.com/generalnewsfeed/n ... 96883.html>


A 10-year-old boy, who was admitted in a government hospital near
here following a dog bite, has died, family sources said. The boy was
moved to Kakinada Government General Hospital on Thu 19 May 2011 and
died late last night [20 May 2011] due to rabies virus infection. He
had been bitten by a dog on 26 Apr 2011 and was admitted to a primary
health centre before being moved to the hospital in Kakinada, East
Godavari district. The victim is the 3rd person to have succumbed to
rabies in the district in the last few weeks.

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

[Unlike previous reports from the region, these deaths can be
attributed unequivocally to shortage of vaccine for post-exposure
prophylaxis of victims bitten by rabid dogs. This is a deficiency
which should be remedied without delay.

The reader of the report is left wondering whether the woman who
received a bite from her rabid husband is similarly not receiving
acceptable post-exposure vaccine therapy.

Rajahmundry is a city and municipal corporation of the Indian state
of Andhra Pradesh. It is the 4th largest city in the state and is
located 400 km east of the state capital, Hyderabad, on the banks of
the River Godavari (see the map at:
<http://en.wikipedia.org/wiki/Rajahmundry>).

Andhra Pradesh state can be located in the map of the States of India
at: <http://www.indianorphanages.net/home/in ... iamap.html>. -
Mod.CP]

[Kakinada is located on the ProMED/HealthMap interactive map at:
<http://healthmap.org/r/0SdC> - Mod.JW>]

RABIES - INDIA (07): (ANDHRA PRADESH) CANINE, HUMAN
***************************************************
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 23 May 2011
From: Merritt Clifton <anmlpepl@whidbey.com> [edited]


A comment on some political issues affecting rabies control in Andhra
Pradesh
----------------------------------------------------------------------
There are some political issues involved in this situation, which in
themselves have little directly to do with rabies, but are
contributing to the difficulty of controlling the Andhra Pradesh
rabies outbreak.

The big issue in the background, again having nothing to do with
rabies but everything to do with who funds whom to do what, is the
movement toward splitting Andhra Pradesh into 2 different states. One
state would still have Hyderabad as capital. The other would have
Visakhapatnam as capital. The folks in Hyderabad are, however, not
eager to cede administrative authority, jobs, and economic influence
to the upstarts in Visakhapatnam, which has quadrupled in size in only
20 years.

The major dog vaccination programs in India are adjuncts of the
national Animal Birth Control [ABC] program, begun in 2003. The
primary participants are local humane societies and for-profit
veterinary clinics who contract with their communities to do ABC
according to a protocol set forth by the Animal Welfare Board of India
[AWBI]. Federal subsidies for ABC are distributed by the AWBI, which
is headquartered in Chennai, not in New Delhi with the rest of the
government.

The original ABC service providers in the part of Andhra Pradesh
where the present rabies outbreak is occurring were the Kakinada SPCA
(Society for the Prevention of Cruelty to Animals), the Visakha SPCA,
and the Blue Cross of Hyderabad, founded by actress Amala Akkineni.

I am not sure the Kakinada SPCA program ever advanced beyond
paperwork. Founded in 1896, the organization had become moribund by
2008, when according to The Hindu [newspaper] of 3 Dec 2008 it "had
its working committee abolished by the district collector...owing to
detection of irregularities in its functioning." It has been
reconstituted, I understand, but meanwhile Kakinada has to this day
apparently never had any functional ABC and canine rabies vaccination
program.

The Blue Cross of Hyderabad withdrew from doing ABC, including
high-volume vaccination of other than its own dogs, after becoming
caught between political factions who each sought to control the
allocation of the federal ABC money. There was some violence toward
Blue Cross of Hyderabad employees, and Amala Akkineni said, in effect,
"If you can't conduct yourselves in a civilized manner, we don't want
to be involved. We will not allow ourselves to be used in a partisan
dispute."

An outside contractor, Animal Help of Ahmedabad, was brought to
Hyderabad to take up ABC and vaccination after the Blue Cross of
Hyderabad withdrew, but also discontinued work in Hyderabad as result
of personnel being injured in factional violence. (Animal Help
continues to provide ABC service to many other cities in India and
Bhutan.)

Some ABC work is being done in Hyderabad by private contractors, but
there is a great deal of skepticism within the Indian animal welfare
community about the efficacy of the programs.

The Visakha SPCA persevered, despite encountering probably more
trouble from various directions than the other original Andhra Pradesh
service contractors combined. The Visakha SPCA sterilized and
vaccinated more than 70 000 dogs between 1998 and 2008, eradicating
rabies from inner Visakhapatnam (the original city) and pushing
outward into the Visahka Circle (the surrounding villages, which have
now been absorbed as suburbs.) This was among the major successes in
the history of Indian humane work. In 2010, however, a different
political faction won control of the Visakhapatnam municipal
government, and immediately severed the ABC contract with the Visakha
SPCA. A projected city-run program is still not up and running, almost
a year later, meaning that high-volume dog sterilization and
vaccination has been neglected all this while.

I was advised just last night [22 May 2011] that the Visakha SPCA
stands ready to take up where they left off, and feels capable of
again eradicating rabies from their service area, given municipal
cooperation.

Meanwhile, though, the Visakha SPCA is being prominently blamed in
local media by some politicians for not continuing the work that they
were ordered by the municipal government to stand down from doing.

--
Communicated by:
Merritt Clifton
Editor, Animal People
PO Box 960
Clinton, WA 98236
USA
<anmlpepl@whidbey.com>
<http://www.animalpeoplenews.org>

[ProMED-mail thanks Merritt Clifton for providing this background
information that reveals the complexity of the political and
administrative situation in Andhra Pradesh and how it impinges on
efforts to control canine rabies within the state.

A map of the state of Andhra Pradesh, showing the locations of
Hyderabad and Visakhapatnam, can be accessed at
<http://pics.34000.org/andhra-map/show/3.html>. - Mod.CP]

DENGUE/DHF UPDATE 2011 (22)
***************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

- India (Mangalore, Karnataka state). 26 May 2011. A team of district
health officials visited the migrant workers' colony at
Lingappayyakadu near [Mulki], following reports in the media about
possible outbreak of dengue. District health and family welfare
officer Dr O R Srirangappa said that 5 persons in [one house] and 2
[in another] in Lingappayyakadu were suspected of being dengue. They
are receiving treatment in hospitals in Mangalore and Mulki.
<http://mangalorean.com/news.php?newstyp ... sid=240835>

[A HealthMap/ProMED-mail interactive map showing the location of
Mangalore in Karnataka state can be accessed at
<http://healthmap.org/r/0Uyj>. - Mod.TY]

MALARIA - INDIA (10): (MUMBAI)
******************************
A ProMED-mail post
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ProMED-mail is a program of the
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Date: Thu 9 Jun 2011
Source: news24online.com [edited]
<http://www.news24online.com/ViewDetails ... wsID=28076>


Malaria strikes Mumbai
----------------------
The financial capital of the country [India] is under attack from
malaria as several residents are gripped with the infection. The worst
areas are Andheri and nearby places.

The Brihanmumbai Municipal Corporation (BMC) announced a new 6-point
agenda to fight malaria and other diseases. It has also warned
citizens to take precautions against swine flu, after a 2nd wave of
H1N1 cases.

BMC officials said they would continue its battle against the disease
[malaria]. On the battle agenda are construction site corrections,
hygiene corrections at these sites, making doctors available for
workers, notices to 810 construction sites, medical check-ups every 15
days for labourers, and regular site inspections.

Sources say that BMC is targeting 2500 construction sites in Mumbai
and have drawn up other precautions to curb the rise in malaria
cases.

Meanwhile, tankers of mosquito larvaecidal oil (ML) that curbs
mosquito breeding had already arrived in 4 civic wards, but experts
say they are late.

[Byline: Ankur Tyagi]

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

[The article has no numbers of cases, but there are a constant flow
of reports of malaria in Mumbai, including a fatal case in a sailor
infected at Mumbai harbor. The Brihanmumbai Municipal Corporation
(BMC) again focus on malaria risk at construction sites, but a more
important reservoir is most probably slum areas (see comment by
Michael Bangs in ProMED-mail Malaria - India, (Mumbai): urban malaria
comment 20110104.0040).

In ProMED-mail posting 20100717.2397 we mentioned a study from 2002
of malaria in the slum areas of Mumbai (Karn and Harada. Water Sci
Technol. 2002; 46: 269-75), which reported an annual incidence of 126
per 1000 population. These data urgently need to be updated.

ProMED-mail will be happy to post further data or comments and
reports of malaria in returned travelers infected in Mumbai.

Mumbai, the capital of the Indian state of Maharashtra, can be
located on the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/00BT>. - Mod.EP]

MALARIA - INDIA (11): (MUMBAI) COMMENT
**************************************
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Date: Sat 11 Jun 2011
From: Ronan Kelly <ronankelly@comcast.net> [edited]


[re: ProMED-mail Malaria - India (10): (Mumbai) 20110610.1762]
--------------------------------------------------------------
In the referenced posting, your moderator [EP] asks for any data on
malaria in Mumbai.

Below is a 1 Jun 2011 report from the Times of India for the months
of January to April 2011:

The Times of India (TOI), Times News Network (TNN)
<http://articles.timesofindia.indiatimes ... tive-cases>

Rise in pre-monsoon malaria cases
---------------------------------
Even before the onset of the monsoon, Maharashtra has recorded over
28 000 cases of malaria. From January to April this year [2011], 28
400 people were found positive for malarial infection -- an increase
of over 8000 cases as compared to the corresponding period last year
[2010] when 20 091 cases were reported.

With 16 833 positive cases and 11 deaths due to malaria in the last 4
months, Mumbai continues to bear the highest burden of the disease in
the state followed by Thane (709 cases) and Kalyan (182 cases).

"Climactic conditions with temperature up to 30 deg C [86 deg F] and
a humidity level above 70 percent are favourable for
mosquito-breeding. Such conditions prevailed on most days in the last
4 months in Mumbai.

That is one of the reasons why there was a higher number of malaria
cases during the pre-monsoon period," Ashok Bhosale, entomological
consultant to the state government on malaria told TOI [Times of
India] on Monday [30 May 2011].

[Byline: Umesh Isalkar]

--
Ronan Kelly
<ronankelly@comcast.net>
FluTrackers

[ProMED-mail thanks Ronan Kelly for the article in the Times of India
from 1 Jun 2011.

The data do show a clear increase in the number of cases with 40
percent. It would still be interesting to have a comment from the
authorities as to why construction sites are repeatedly singled out as
the source and the high transmission in slum areas is not discussed.

Mumbai can be located on the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/00BT>. - Mod.EP]

HEPATITIS C VIRUS, BLOOD BANK - INDIA: (PUNJAB)
***********************************************
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ProMED-mail is a program of the
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Date: Sun 12 Jun 2011
Source: Daily Bhaskar [edited]
<http://daily.bhaskar.com/article/PUN-LU ... 79845.html>


Ludhiana city is shocked by a startling revelation by the blood banks
of big hospitals. It has been found that hepatitis C is rapidly
spreading among the masses in the city. The most interesting part of
the story is that the people who donated blood on a voluntary basis to
various hospitals in the city were not aware of the fact that they
were suffering from hepatitis C. But when the blood was tested in the
laboratories, the hospital authorities were amazed. This startling
fact has also rung alarm bells in the corridors of the Punjab State
AIDS Control Society (PSACS).

The PSACS has advised all the blood banks in the city to spread
awareness among the masses about this disease [virus infection]. The
society has also ordered the blood banks to dispose of the infected
blood safely under the Biomedical Waste Management Act to prevent the
further spreading of infection.

The surprising part of the story is that the national average of
hepatitis C infected donated blood is only 0.44 percent, whereas it
ranges between 0.81 and 2.13 percent in case of Ludhiana.

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

[The USA CDC states that [edited]: "HCV is transmitted primarily
through large or repeated percutaneous (i.e., passage through the
skin) exposures to infectious blood, such as
- Injection drug use (currently the most common means of HCV
transmission in the United States)
- Receipt of donated blood, blood products, and organs (once a common
means of transmission but now rare in the United States since blood
screening became available in 1992)
- Needlestick injuries in health care settings
- Birth to an HCV-infected mother
HCV can also be spread infrequently through:
- Sex with an HCV-infected person (an inefficient means of
transmission)
- Sharing personal items contaminated with infectious blood, such as
razors or toothbrushes (also inefficient vectors of transmission)
- Other health care procedures that involve invasive procedures, such
as injections (usually recognized in the context of outbreaks)"
(<http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm#section2>).

It is not clear which route (routes) of infection are most likely in
the affected population mentioned above.

The location of Ludhiana city in Punjab state can be accessed at
<http://healthmap.org/r/0Y*N>. - Mod.TY]

UNDIAGNOSED VIRAL FEVER - INDIA: (BENGAL), REQUEST FOR INFORMATION
******************************************************************
A ProMED-mail post
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ProMED-mail is a program of the
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Date: Mon 13 Jun 2011
Source: Times of India [edited]
<http://timesofindia.indiatimes.com/city ... 831156.cms>


Kolkata city is in the grip of a viral fever that has affected
thousands, including many in Ballygunge, Alipore and parts of central
Kolkata. It has been leading to high fever accompanied by a severe
lung and chest infection, often causing severe respiratory problems.
Experts have been taken by surprise by the late outbreak of this viral
epidemic, which usually occurs during change of seasons.

The new virus is far more potent and different from the ones that
have struck in previous years, said doctors.

"This one has been attacking the respiratory system, which makes it
more risky. Patients have been suffering from severe breathlessness
along with an intense joint and muscle pain. Many are also falling
prey to secondary bacterial infections. There have been several cases
where malaria has been detected in these patients as well," said
Tomonash Bhattacharya, tropical medicine expert.

Typical symptoms of the viral attack have been a dry cough followed
by high fever and joint pain. From the 3rd day onwards, patients have
had a severe lung congestion with respiratory trouble. The fever has
not been subsiding before a week, leaving victims too frail to resume
normal activities.

"It is the reactive phenomenon that has been causing the joint and
muscle pain. Antibodies triggered to fight the virus are responsible
for this. But it still remains unclear how the respiratory tract is
being affected so severely. We encounter new strains [of what?] every
year, and this one seems to be an alteration of its previous avatars,"
said Debashish Basu, preventive medicine specialist.

Use of antibiotics has been ruled out by doctors. Paracetamols are
being recommended to check the fever along with blood tests. Care
should be taken to make sure that the viral attack does not conceal
viral infections like dengue and chikungunya. Secondary bacterial
infections like pneumonia could also accompany the viral attack,
doctors pointed out. "In many cases, blood tests have also revealed
malaria, which is a worry. This means the disease is back and could be
mistaken for this viral fever," said Bhattacharya.

Even though it is too early for a malaria outbreak, inconsistent rain
over the last one month could have hastened it, some feared. "Scanty
rainfall helps mosquito breeding. This year [2011], we have had
erratic rain followed by a spell of intense heat which has forced many
to reject the mosquito net. This has obviously led to a spurt in
malaria. But it's still not an outbreak," said Bhattacharya. 20-25 per
cent of blood tests have so far been positive in the malaria-prone
pockets of the city like Kolutola, College Street, Taltala, Beniapukur
and parts of Tollygunge. The onset of monsoon could help to curb the
viral outbreak, felt experts.

"A viral outbreak is unusual in peak summer, for the virus dies out
in heat. But this is a heat-resistant variety that has appeared in May
2011. Other than adults, it has been affecting children as well,
especially those aged between 3-5 years. Youngsters are more
vulnerable due to their low resistance. Many are suffering from
dehydration, while some have also had seizures induced by high fever,"
said pediatrician Shantanu Ray. Liberal fluid intake has been
recommended by doctors. "It's also advisable to avoid the mid-day
heat. In case you can't, drink water and wear a cap. Be careful about
the water you drink, and avoid street food like sliced fruits, which
are prone to infection," added Ray.

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

[No evidence is presented to confirm the virus etiology of these
cases or indicate which virus might be involved in this setting.
Additional information on this outbreak and its cause would be
welcome.

A HealthMap/ProMED-mail interactive map showing the location of
Kolkata in Bengal state can be accessed at
<http://healthmap.org/r/0Y*L>. - Mod.TY]

[The above newswire seems to mention definitively "viral fever" as a
diagnosis, yet at the same time mentions that 20-25 percent of blood
tests done in known "malaria-prone pockets" of the city are positive
for malaria parasites.

According to the GIDEON database (<http://www.gideononline.com>),
leading diagnostic contenders for febrile illness with arthralgias and
pneumonia include: _Mycoplasma pneumoniae_, influenza, enterovirus and
adenovirus infections. While _mycoplasma pneumoniae_ does occur in
outbreaks, the outbreaks tend to be in closed populations such as
schools (as reminded by Mod.ML). The human metapneumovirus might also
be a possible etiology (also suggested by Mod.ML), having been 1st
identified in the Netherlands in 2000/2001. It has been shown to be a
major cause of lower respiratory infection in children, and the above
newswire mentions that children aged 3-5 years have been affected by
this outbreak as well as adults. While influenza is also a leading
cause of febrile respiratory illness with pneumonia, the absence of
reported increases in mortality associated with the above mentioned
epidemic would be unusual. Hence, this moderator has difficulty
finding a definitive diagnosis that would explain the outbreak as
described in the newswire.

This moderator wonders whether the above newswire might well be
describing a mix of concurrent outbreaks in the city, one related to
the increase in malaria, one related to a respiratory virus, and
perhaps concurrent chikungunya, explaining those cases with severe
arthralgias as a predominant symptom. Or as Mod.DK suggests, we might
well be seeing a new disease here.

More information from knowledgeable sources in the region would be
greatly appreciated. - Mod.MPP]