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MALARIA - INDIA: (17): GUJARAT STATE)
**************************************
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 26 Sep 2011
Source: Times of India [edited]
<http://timesofindia.indiatimes.com/city ... 120085.cms>


There has been a rise in the number of malaria cases, including _P.
falciparum_ cases, in the state. In just 2 weeks, various district
health centres in the state recorded as many as 8228 confirmed malaria
cases, while the number of _P. falciparum_ cases stood at 2625.

Surat and Ahmedabad topped the chart. The high mosquito density in
these cities is proving to be a problem for officials. In just 2
weeks, both these cities recorded the highest number of malaria cases
with Surat recording as many as 1274 cases closely followed by
Ahmedabad with 1020 cases. The tribal district of Dahod has now
emerged as another troubled zone with 829 malaria cases recorded in
the past 2 weeks.

The overall fever cases in the state rose from 33 460 to 38 828,
indicating the changing weather pattern in the state. "Fever cases are
not being given a go by. In cities and in district hospitals we have
been maintaining a constant vigil over these cases," says a senior
health official.

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

[Gujarat State is endemic for malaria including _P. falciparum_. A
report from the WHO Regional Office for South-East Asia (SEA-MAL-256;
<http://203.90.70.117/catalogue/2006-201 ... al-256.pdf>)
state that "Retrospective analysis of reported cases and deaths in
Ahmedabad, Gujarat State revealed a mean incidence of 12.2 cases per
1000 [population] which was 9 times greater than that officially
reported (1.3 cases per 1000 annually). In the same study, annual
malaria-attributable mortality detected was 22 deaths per million
which was far greater than the far greater than the officially
reported (0.3 deaths per million) (Yadav et al. The burden of malaria
in Ahmedabad city, India: a retrospective analysis of reported cases
and deaths. Ann Trop Med Parasitol. 2003 Dec;97(8):793-802;
<http://www.ncbi.nlm.nih.gov/pubmed/14754491>). This analysis indicate
that the number of cases are about 10 times higher than the number of
reported cases. Thus the number of cases reported by Times of India
does not necessarily means a surge but may just indicate a interest in
reporting the cases.

HealthMap Location: <http://healthmap.org/r/1hSc> - Mod.EP]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (22): (UTTAR PRADESH,
JHARKHAND)
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A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
[1] Uttar Pradesh (Purvanchal)
[2] Uttar Pradesh
[3] Jharkhand (Ranchi)

******
[1] Uttar Pradesh (Purvanchal)
Date: Sun 25 Sep 2011
Source: Hindustan Times, Press Trust of India report [edited]
<http://www.hindustantimes.com/Encephali ... 49967.aspx>


With 3 more reported deaths in the last 24 hours at the Baba Raghav
Das (BRD) Medical College, the cumulative death toll of encephalitis
in Purvanchal and adjoining regions of Uttar Pradesh has reached 332
this year [2011]. According to additional director health, Gorakhpur
Mandal, Diwakar Prasad, the 3 deaths in the last 24 hours include a
child each from Gorakhpur, Kushinagar, and Deoria districts. "Out of
2246 encephalitis patients since January this year, 332 have succumbed
to the disease," he said.

At present 312 encephalitis patients are undergoing treatment at BRD
Medical College and in the nearby district hospitals. 28 new patients
suffering from the disease have been admitted in BRD Medical College
in the last 24 hours, the official added.

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

[There is no mention of the etiologic agent responsible for these
cases. Given recent previous reports from this area, some are probably
due to Japanese encephalitis virus infections.

There is no mention of vaccination history in this population. -
Mod.TY]

******
[2] Uttar Pradesh
Date: Sun 25 Sep 2011
Source: Yahoo News, Indo Asian News Service (IANS) report [edited]
<http://in.news.yahoo.com/japanese-encep ... 26682.html>


Japanese encephalitis is back in eastern Uttar Pradesh and has claimed
the lives of over 300 children in the past 2 months alone, health
officials say. The killer disease, an annual hazard for lakhs [100
000s] of people living across the poverty-ridden part of Uttar
Pradesh, is taking 3-4 lives every day. More than 3000 children have
died of the virus since 2006.

"Despite several preventive measures, the virus strikes back every
year during the monsoon season, taking an annual toll of 400-500,"
said KP Kushwaha, head of paediatrics at the BR Medical College in
Gorakhpur, which has become the nodal centre for treatment of the
afflicted. "Since a majority of the cases converge to this medical
college from all disease-prone districts in the neighbourhood, we face
the brunt of the pressure," he said. "Even right now, against a bed
strength of 200, we are treating 470 patients in our wards."

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

[Uttar Pradesh can be located on the HealthMap/ProMED-mail interactive
map of India at <http://healthmap.org/r/1i16>. A district map of Uttar
Pradesh can be seen at
<http://upload.wikimedia.org/wikipedia/c ... on_map.gif>.

This report, perhaps covering a broader geographic area, indicates
that Japanese encephalitis virus is the only etiological agent
involved. Previous reports speak of an "acute encephalitis syndrome"
with not specified etiology, but with an association with water
suggesting enterovirus infections. No mention is made in this report
of the coverage of JE virus vaccination in the population of the
affected areas of Uttar Pradesh. - Mod.TY]

******
[3] Jharkhand (Ranchi)
Date: Tue 27 Sep 2011
Source: The Telegraph [summ., edited]
<http://www.telegraphindia.com/1110927/j ... 558697.jsp>


The outbreak of Japanese encephalitis in and around Ranchi has assumed
pandemic proportions, with authorities at Ranchi Institute of Medical
Sciences (RIMS) reporting 12 child deaths since 16 Aug [2011] till
date. Moreover, 36 among the 81 children admitted to the state-run
hospital have been confirmed to be suffering from the mosquito-borne
viral disease. All 36 are children, between the age group of 5-11
years.

Confirming the broad figures of patients under treatment, RIMS
director Tulsi Mahto said, "A total of 81 patients suffering from high
fever came to our hospital. We sent blood samples of 51 suspected
cases to the department of microbiology. Tests confirmed 36 were
Japanese encephalitis [virus or antibody?]-positive. 11 tested
negative and the results of the 4 are awaited."

He added they had adequate medicine stocks, but the severity of the
disease was such that some children succumbed. "We are getting
patients from across the state and are trying to accommodate them. At
the paediatrics and neonatology department, there are 90 beds but
patients inflow is high," Mahto added. AK Sharma, head of department
of paediatrics and neonatology at RIMS, said they had been successful
in saving the lives of most children. "We are doing our best. Till
now, we have been able to save 90 per cent of the patients. In many
cases, people have admitted their children here after visiting private
hospitals," Sharma claimed. "The death toll stood at 12 till Tuesday
[27 Sep 2011]," he added.

Experts say that Japanese encephalitis [virus], caused [transmitted]
by _Culex_ mosquitoes, which breeds in rice fields, marshes,
waterlogged drains, and pig farming regions, is a poor man's disease.

Meanwhile, confirmatory tests will start in the less affected East
Singhbhum district from Tuesday [27 Sep 2011] at Mahatma Gandhi
Memorial Medical College and Hospital. Across the district, 58
suspected cases have been reported at MGM and the premier Tata Main
Hospital. But the district was waiting for Elisa test kits to arrive
from the renowned National Institute of Virology (NIV), Pune.

One kit, able to test 90 cases, arrived on Saturday [24 Sep 2011],
delayed by a few days. Authorities, seeing the situation was under
control, had continued with symptomatic treatment.

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

[A HealthMap/ProMED-mail map showing the location of Ranchi in
Jharkhand state can be accessed at <http://healthmap.org/r/1hT6>. -
Mod.TY]

DENGUE/DHF UPDATE 2011 (39)
***************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
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<http://www.isid.org>

*****

- Pakistan (national). 30 Sep 2011. The WHO this Friday [30 Sep 2011]
warned of a possible dengue epidemic in Pakistan, where so far this
year 12 466 cases have been registered with 125 related deaths. Punjab
province has registered 93 per cent of the cases, according to the
statement made in Geneva by WHO spokesperson Tarik Jaserevic. In
addition to Punjab, the most affected provinces are Lahore and Sindh,
which are the areas hardest hit by floods at the beginning of the
rainy season.
<http://www.cooperativa.cl/oms-advirtio- ... 32348.html>
[in Spanish, trans. Mod.TY]

[A HealthMap/ProMED-mail interactive map of Pakistan can be accessed
at <http://healthmap.org/r/1iGJ>. - Mod.TY]

- Pakistan (Hoshiarpur, Punjab province). 30 Sep 2011. 3 persons,
including 2 minors, have tested positive for dengue in the Civil
Hospital in Hoshiarpur, a senior health official said today [30 Sep
2011]. A dozen suspected dengue cases have come in the hospital and
medical reports of these patients are awaited. Due to prevailing
weather conditions more than a dozen viral fever cases are being
reported in the hospital daily.
<http://news.in.msn.com/national/article ... id=5478915>

[A HealthMap/ProMED-mail interactive map showing the location of
Hoshiarpur, Punjab province can be accessed at
<http://healthmap.org/r/1iSY>. - Mod.TY]

- Pakistan (Khyber Pakhtunkhwa province). 29 Sep 2011. The Health
Department of Khyber Pakhtunkhwa (KP) on Thursday [29 Sep 2011]
confirmed 173 dengue patients out of 377 suspected cases with 6 deaths
in the province. The Directorate General Health Services said in a
report 8 suspected cases were reported on Wednesday [28 Sep 2011] with
3 confirmed [dengue] positive. One patient was admitted to a hospital
while 7 were patients discharged after necessary treatment.
<http://www.thenews.com.pk/NewsDetail.as ... -173-in-KP>

[A HealthMap/ProMED-mail interactive map showing the location of
Khyber Pakhtunkhwa, Punjab province can be accessed at
<http://healthmap.org/r/1iSS>. - Mod.TY]

- Pakistan (Bahawalpur, Multan, Punjab province). 28 Sep 2011. Dengue
virus has begun its journey across Punjab. The Multan Health
Department teams have confirmed 68 more patients tested positive for
dengue, of which 33 were from Multan. According to reports, one
patient succumbed to dengue in Bahawalpur.
<http://www.dailytimes.com.pk/default.as ... 011_pg7_17>

[A HealthMap/ProMED-mail interactive map showing the location of
Punjab province can be accessed at <http://healthmap.org/r/1iST>. -
Mod.TY]

- India (Ahmedabad, Gujarat state). 30 Sep 2011. In the last 2 weeks,
there have been 256 dengue cases and majority of these cases, 142 in
number, are being reported from private hospitals. On Wednesday [28
Sep 2011] a one-year-old girl from Ramol area died.
<http://articles.timesofindia.indiatimes ... -infection>

[A HealthMap/ProMED-mail interactive map showing the location of
Ahmedabad, Gujarat state, can be accessed at
<http://healthmap.org/r/1iSU>. - Mod.TY]

- India (Delhi). 30 Sep 2011. Delhi reported 14 new dengue cases on
Thursday [29 Sep 2011] taking the total number of cases of the disease
to 230 for this season. According to the Municipal Corporation of
Delhi, there has been sharp increase in dengue cases across the city
in the last few days and Central Zone -- Lajpat Nagar, Defence Colony,
GKI, South Extension -- and South Zone -- Saket, Vasant Kunj, and
Mehrauli -- remain worst affected.
<http://articles.timesofindia.indiatimes ... s-mosquito>

[A HealthMap/ProMED-mail interactive map showing the location of Delhi
can be accessed at <http://healthmap.org/r/1gpL>. - Mod.TY]

- India (Ludhiana, Punjab state). 27 Sep 2011. The total number of
confirmed dengue patients is 670 in last 2.5 months," said Dr Ashwini
Chaudhary. He also said that out of total 670 cases, more than half of
them were from Ludhiana, 147 were from Bhatinda, and 100 were from
Jalandhar. Around 4400 cases of other mosquito-borne diseases have
been reported in the Punjab province over the past 2 months, forcing
the state government to close down schools for 10 days.
<http://www.newstrackindia.com/newsdetails/242925>

A HealthMap/ProMED-mail interactive map showing the location of
Ludhiana, Punjab state, can be accessed at
<http://healthmap.org/r/1iSV>. - Mod.TY]

- India (Thiruvananthapuram, Kerala state). 25 Sep 2011. According to
the recent reports, the number of patients being hospitalized with
dengue fever and other contagious diseases in Thiruvananthapuram is
increasing. As many as 814 persons have been confirmed with fever
[dengue virus infections and probably other causes] in the district
and are under treatment in various hospitals. In the district
Kaliyoor, Aryanadu, and Vattiyoorkkavu are the areas reported with
dengue fever cases. 10 persons have been confirmed with dengue fever
so far.
<http://www.asianetindia.com/news/dengue ... 94058.html>

[A HealthMap/ProMED-mail interactive map showing the location of
Thiruvananthapuram, Kerala state, can be accessed at
<http://healthmap.org/r/1iGM>. - Mod.TY]

- India (Bhubaneswar, Orissa state). 19 Sep 2011. A 27-year-old man
from Chittalapur village in Talcher block died of dengue, raising
death toll in the disease to 25 in the district. He was shifted to
Bhubaneswar for treatment, where he tested positive for dengue.
<http://articles.timesofindia.indiatimes ... ngue-fever>

[A map showing the location of this area in Orissa state can be
accessed at <http://en.wikipedia.org/wiki/Bhubaneswar>. Bhubaneswar
can be located on the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/1iSW>. - Mod.TY]

FOODBORNE ILLNESS - INDIA (02): (MUMBAI) KLEBSIELLA SUSPECTED
*************************************************************
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 4 Oct 2011
Source: Food and Beverage News [edited]
<http://www.fnbnews.com/article/detnews. ... ectionid=1>


The recent food poisoning incident at the Indian Institute of
Technology (IIT), Bombay, is being linked to _Klebsiella_.

The caterers who were serving in the IIT [Indian Institute of
Technology] canteen, were completely clueless about which food content
could have possibly triggered food poisoning and so were the FDA (Food
and Drug Administration, Maharashtra) officials. It was learned that 4
samples of the stools and water were taken, out of which 3 indicated
_Klebsiella_ and the last one _E. coli_. However, the same could not
be confirmed, as the FDA was still investigating its origin, informed
Mahesh Zagade, food safety commissioner, FDA, Maharashtra.

A source informed Food and Beverage News that _Klebsiella_ was linked
to pneumonia and known to reside in the colon. "Something in the food
must have triggered its multiplicity. The samples needed to be
cultured for validation of the claim," the source said.

"The predominant [gastrointestinal] symptoms of _Klebsiella_ are
watery diarrhea and cramps. However, vomiting does not occur.
Organisms other than commonly identified pathogens should not be
ignored if present in high concentrations in both food and feces of
infected persons," states Dr Sardesai, technical director, Equinox
Labs.

Meanwhile the IIT said that the caterers who were given the contract
of the canteen were associated with the institute for the last 4 years
and that this was the 1st incident of its kind. "We are equally
concerned and have given strict instructions to the cooks to wear
caps, wash their hands thoroughly, and follow precautions," said a
source.

[Byline: Irum Khan]

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

[There is not enough information in this posting to assess the
significance of the _Klebsiella_ isolate but isolation of coliforms
certainly points to some sort of fecal contamination of the water.

_Klebsiella_ species are thought of as etiological agents of pneumonia
(hence the species named _K. pneumoniae_) or urinary tract infections
and have been newsworthy lately because of strains that are multiply
resistant. Diarrhea related to this genus, however, is not unheard
of.

Although the most commonly thought of cause of
antimicrobial-associated diarrhea is _Clostridium difficile_, some
cases of hemorrhagic colitis following antimicrobial use have been
linked to _Klebsiella_, particularly _K. oxytoca_. Although reported
previously, an Austrian study by Hogenauer, et al (1) reported 22 _C.
difficile_ negative adults with antimicrobial-associated colitis, 5 of
whom grew _K. oxytoca_ from the diarrhea without other pathogens found
and were found to produce a cytotoxin. Endoscopy revealed mucosal
edema and hemorrhage and not pseudomembranes. The hemorrhagic colitis
could be reproduced in a rat model following antimicrobial
administration. The same group furthermore was unable to find this
organism in non-hemorrhagic colitis cases after antimicrobials (2) but
also described the entity in an adolescent (3).

A similar illness associated with _K. pneumoniae_ was noted in a woman
returning from Egypt to France (4). This isolate adhered to HeLa cells
(similar to enteroaggregative _E. coli_) and produced changes in the
actin cytoskeletal proteins in the affected cells (similar to
enteropathogenic _E. coli_) but genes similar to the _E. coli_
pathotype virulence factors were not found.

References
----------
1. Hoegenauer C, Langner C, Beubler E, et al: _Klebsiella oxytoca_ as
a causative organism of antibiotic-associated hemorrhagic colitis. N
Engl J Med 2006; 355(23): 2418-26 (available at
<http://www.nejm.org/doi/pdf/10.1056/NEJMoa054765>).
2. Zollner-Schwetz I, Hogenauer C, Joaining M, et al: Role of
_Klebsiella oxytoca_ in antibiotic-associated diarrhea. Clin Infect
Dis 2008; 47(9): e74-8 (available at
<http://cid.oxfordjournals.org/content/47/9/e74.long>).
3. Hoffman KM, Deutschmann A, Weitzer C, et al: Antibiotic-associated
hemorrhagic colitis caused by cytotoxin-producing _Klebsiella
oxytoca_. Pediatrics 2010; 125(4): e960-3 (available at
<http://pediatrics.aappublications.org/c ... /e960.long>).
4. Guerin F, Le Bouguenec C, Gilquin J, Haddad F, Goldstein FW: Bloody
diarrhea caused by _Klebsiella pneumoniae_: a new mechanism of
bacterial virulence? Clin Infect Dis 1998; 27(3): 648-9 (available at
<http://cid.oxfordjournals.org/content/27/3/648.full.pdf>). - Mod.LL]

[Mumbai can be located on the HealthMap/ProMED-mail interactive map of
India at <http://healthmap.org/r/1iZ2>. - Sr.Tech.Ed.MJ]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (24): (UTTAR PRADESH)
*************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Tue 4 Oct 2011
Source: News 24, Press Trust of India (PTI) report [edited]
<http://news24online.com/8-more-dead-in- ... 34617.aspx>


With 8 more deaths reported in the past 36 hours, the cumulative death
toll due to encephalitis in eastern Uttar Pradesh has risen to 376
this year [2011]. Of the persons who have succumbed to the disease, 4
are from Kushinagar and one each from Mahrajganj, Deoria, Basti, and
Gorakhpur districts, said Diwakar Prasad, additional director health,
Gorakhpur division. They were undergoing treatment at BRD Medical
College Hospital [MCH] in Gorakhpur and other government hospitals in
adjacent districts, he said.

According to data available, as many as 44 patients have succumbed to
various kinds of encephalitis in the region in the past 10 days.
Prasad said that out of 2480 encephalitis patients admitted in the
government hospitals in the region this year, 376 have succumbed to
the disease. At present, 321 encephalitis patients are undergoing
treatment at BRD Medical College and hospitals in adjacent districts.
43 fresh patients of encephalitis have been admitted in BRD MCH and
district hospitals of the region during the past 36 hours, Prasad
said. Experts say 2 mainly kinds of encephalitis [viruses] are
prevailing in the region -- Japanese encephalitis, which is caused by
mosquito bite, while the other type of encephalitis occurs due to
consumption of unsafe drinking water. Both are vector borne diseases,
they said.

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

[The encephalitis cases continue to appear in Uttar Pradesh, and the
etiologies of all of them remain unclear. There is no indication in
the report above of the proportion of the 2480 encephalitis cases that
are due to Japanese encephalitis virus infections, or the specific
viruses responsible for the remaining cases. The report indicates that
some of these cases are due to consumption of contaminated drinking
water, suggesting enterovirus infection, but adds further confusion by
stating that these are vector-borne. ProMED-mail would be interested
in learning about which specific viruses are involved in those cases
not due to Japanese encephalitis virus.

A district map of Uttar Pradesh can be seen at
<http://upload.wikimedia.org/wikipedia/c ... on_map.gif>.
A HealthMap/ProMED-mail interactive map showing the location of Uttar
Pradesh state can be accessed at <http://healthmap.org/r/1iZ5>. -
Mod.TY]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (25): (UTTAR PRADESH, BIHAR)
********************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Wed 5 Oct 2011
Source: Thomson Reuters Foundation AlertNet [edited]
<http://www.trust.org/alertnet/news/ence ... hern-india>


More than 400 people in northern India have died in the past month
from encephalitis, a rare condition that causes inflammation of the
brain, government officials said on Wednesday [5 Oct 2011].
Encephalitis is most often caused by a viral infection from eating or
drinking contaminated food or water, from mosquito or other insect
bites, or through breathing in respiratory droplets from an infected
person. Around 347 people have died in the Indian state of Uttar
Pradesh, while 54 children have died in the neighbouring state of
Bihar. Over 2000 cases have been reported in the last 3 months.

"Acute encephalitis syndrome has 2 types of infections -- Japanese
encephalitis [virus], which occurs due to mosquitoes, and enteroviral
encephalitis, which is caused due to unsafe drinking water," said
Dinesh Kumar Srivastava from the Community Medicine Department in
Uttar Pradesh's Gorakhpur district, where patients are receiving
treatment.

Officials said the main areas where the outbreak of the virus has been
noticed have been poor, flood-hit areas of the region, where this
year's [2011] monsoons have left pools of stagnant water that have
allowed mosquitoes to breed and infect villagers. The floods have also
led to the contamination of clean water sources such as wells, leaving
many people with no option but to use the same dirty water for both
drinking and sanitation. The infection spreads every year in
impoverished parts of Uttar Pradesh during the monsoon season,
resulting in hundreds of deaths.

According to the World Health Organisation, viral encephalitis causes
high fever, headache, stiff neck and back, vomiting, confusion and, in
severe cases, seizures, paralysis, and coma. Infants and elderly
people are particularly at risk of severe illness.

Officials say the government has earmarked 22 million rupees (USD 450
000) to tackle problems like the unavailability of clean drinking
water, lack of sanitation, and water logging, to prevent the virus
from spreading. But local aid workers say efforts need to be stepped
up. "The infection started in the early 1970s and since then it has
become an annual feature. The government is adopting short term
measures to deal with the infection instead of making any long term
plan to get rid of the virus," said Sanjay Kumar Srivastava from
Action for Peace, Prosperity and Liberty (APPL), a charity doing
research on the disease. "Besides, no preventive measures are taken to
stop the outbreak," he added, suggesting that vaccinations be more
readily available to adults as well as to children.

[Byline: Alka Pande, Nita Bhalla]

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

[Previous reports of unspecified acute encephalitis syndrome
implicated contaminated water as a source of the infectious agent,
suggesting, without stating, that enteroviruses might be involved. The
report above states that enteroviruses are involved, but does not
indicate which ones are responsible for the encephalitis cases that
are occurring. At least, this points to the source of the problem and
suggests preventive measures that might be taken. There is no
indication that a vaccination campaign for Japanese encephalitis is
being planned.

A HealthMap/ProMED-mail interactive map showing the location of Uttar
Pradesh and Bihar states can be accessed at
<http://healthmap.org/r/1iZ5>. - Mod.TY]

LEISHMANIASIS, VISCERAL - INDIA
*******************************
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: Thu 6 Oct 2011
Source: India National Vector Borne Disease (NVBDCP) Control Program
[edited]
<http://nvbdcp.gov.in/ka-cd.html>


The NVBDCP updated numbers on visceral leishmaniasis, kala azar
---------------------------------------------------------------
24 231 cases and 60 fatalities have been reported.

State / Cases / Fatalities
Assam / 5 / 0
Bihar / 18 519 / 56
Himachal Pradesh / 1 / 0
Jharkhand / 4264 / 3
Sikkim / 3 / 0
Uttar Pradesh / 8 / 1
West Bengal / 1431 / 0

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

[The data clearly show that visceral leishmaniasis is prevalent in at
least 3 states: Bihar, Jharkhand, and West Bengal despite government
attempts to control the infection.

A recent paper by John TJ et al (Continuing challenge of infectious
diseases in India. Lancet. 2011; 377(9761): 252-69; abstract available
at
<http://www.thelancet.com/journals/lance ... 2/abstract>)
discusses why a series of infectious diseases continues to be a
problem in India and points to the need for changes in the structure
of the public health care system.

A HealthMap/ProMED-mail interactive map of India can be seen at
<http://healthmap.org/r/1jDZ>. - Mod.EP]

MALARIA - PAKISTAN (02): (SINDH)
********************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Date: Fri 7 Oct 2011
Source: The Express Tribune [edited]
http://tribune.com.pk/story/268433/tran ... -outbreak/


For a sickness [malaria] in which 6 cases raise alarm, 130 patients
are enough to declare an emergency. This has been the spread of
malaria so far in Tharparkar district after the rains. Across Sindh
[province], the total is even worse: 11 985.

According to the Sindh Malaria Control Programme, they are worried
enough to dispatch teams immediately. However, strangely enough, when
asked what it was doing in Tharparkar, Sindh health department
officials claimed that although there was an outbreak, there was no
need to panic.

One official explained that after the floods a lot of water had
accumulated in different areas, forcing people to constantly be on the
move. Tharparkar, however, is considered a 'high-risk transmission
zone' as the district has several man-made wells used to store
drinking water. These wells usually become a breeding ground for
mosquitoes.

Sindh Malaria Control Programme director Dr Nahid Jamali told The
Express Tribune that there was no doubt that malaria cases were on the
rise in the province. She added that aggressive fumigation had helped
kill mosquitoes and control the spread of the disease.

On the other hand, the chairperson of the Infection Control Committee
at the Aga Khan University Hospital (AKUH), Dr Bushra Jamil, said that
the situation in the cities was quite bad. She added that in order to
stop the spread of the disease it was very important to create
awareness and educate people. "Resurgence of the virus [sic]
constitutes at least 15 to 20 per cent cases as it [the virus] [sic]
remains untraced in the liver," she said. "Certain agents used to
treat the disease, in order to eradicate it from the liver are often
not used in endemic cases, which may lead to a reoccurrence."

A doctor from a private hospital said that they were unable to control
the malaria problem every year because they did not have qualified
professionals who could assess the situation or take preventive
measures.

The lack of available funds has also caused hiccups in delivering
medical aid. According to the spokesperson for the Office Coordination
Humanitarian Affairs (OCHA) Stacey Winston, of the USD 357 million
requested so far only USD 43 million were collected. "This is very
inadequate for the needs of 5.4 million people across Sindh and
Balochistan," she said. The money collected by OCHA is primarily used
for water, food, healthcare, and sanitation.

--
Communicated by:
ProMED-mail


[Please refer to our comment in ProMED-mail post 20110828.2639
concerning the state of the Pakistani malaria control programme:
"According to WHO's Regional Office for the Eastern Mediterranean
[EMRO], Pakistan had 1.5 million malaria cases in 2008 (latest
reported year) of which 24 per cent were _Plasmodium falciparum_
(http://www.emro.who.int/rbm/CountryProfiles-pak.htm).

"The malaria control programme in Pakistan has struggled to contain
the infection, and a recent estimate from Integrated Regional
Information Networks [IRIN -- a service of the UN Office for the
Coordination of Humanitarian Affairs] found that only about 25 per
cent of cases receive qualified medical care and treatment
()."

The malaria control program in Pakistan has recently been reviewed
(Kakar Q et al: Malaria control in Pakistan: new tools at hand but
challenging epidemiological realities. East Mediterr Health J. 2010;
16(Suppl.): S54-60; available at
http://www.emro.who.int/publications/em ... ticle7.htm).

A HealthMap/ProMED-mail interactive map of Pakistan can be seen at
http://healthmap.org/r/1jD-. - Mod.EP]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (26): (UTTAR PRADESH)
*************************************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Date: Sun 9 Oct 2011
Source: Investors, United Press International (UPI) via COMTEX report
[edited]
http://www.investors.com/NewsAndAnalysi ... dreds.aspx


Encephalitis, a deadly viral disease, has killed hundreds of people,
many of them children, in the past 2 months in India, health
authorities said. Gorakhpur in the northern state of Uttar Pradesh has
been the worst hit so far with more than 370 reported dead, NDTV
television channel reported Sunday [9 Oct 2011]. The broadcaster said
the disease appeared to be spreading outside the state with Delhi and
Chandigarh areas reporting similar cases.

CNN-IBN, quoting public health experts, reported that although the
water or mosquito-borne viral disease has been concentrated in the
eastern parts of Uttar Pradesh for years, claiming hundreds of lives
each year, the epidemic has been badly mismanaged as the state is one
of the poorest in the country.

The network said pediatric hospitals in the Gorakhpur area are unable
to handle the rush of encephalitis patients. "Every day we have to
cope with this situation and this has been going on for the last 2
months. The number of patients is so large we cannot cope with the
resources we have," said one pediatrician at the BRD Medical College
and Hospital. The network said the hundreds of patients admitted to
various hospitals are suffering either from the mosquito-borne
Japanese encephalitis or its water-borne strain [enteroviruses].

The situation is repeated year after year in the state during the
monsoon season and the epidemic has still not been contained, CNN-IBN
reported. The report said the state government has allocated more than
USD 5 million to handle the current crisis, but Dr RN Singh, who has
been fighting to eradicate the disease, says it is too little too
late. He says he is fed up as the issue has not yet been taken up as
an emergency on a national scale.

--
Communicated by:
ProMED-mail from HealthMap alerts


[Reports of undetermined acute encephalitis syndrome (AES) cases in
northeastern India this year (2011) have suggested a relationship to
contaminated water perhaps due to enteroviruses. ProMED-mail
subscriber Ronan Kelly of FluTrackers ,
provided some helpful references that indicate the enterovirus and
other virus infections diagnosed in the recent past. It is unfortunate
that the viruses responsible for the many recent AES cases apparently
have not been identified in the recent reports that have come to
ProMED-mail.

References
----------
1. Sapkal GN, Bondre VP, Fulmali PV, et al: Enteroviruses in Patients
with Acute Encephalitis, Uttar Pradesh, India. 2009. Emerg Infect Dis.
2009; 15(2): 295-8;

Abstract
--------
An outbreak of viral encephalitis occurred in northern India in 2006.
Attempts to identify an etiologic agent in cerebrospinal fluid by
using reverse transcription-PCR showed positivity to enterovirus (EV)
in 66 (22 per cent) of 306 patients. Sequencing and phylogenetic
analyses of PCR products from 59 (89 per cent) of 66 specimens showed
similarity with EV-89 and EV-76 sequences.

2. Beig FK, Malik A, Rizvi M, et al: Etiology and
clinico-epidemiological profile of acute viral encephalitis in
children of western Uttar Pradesh, India. Int J Infect Dis 2010;
14(2): 141-6;
http://www.sciencedirect.com/science/ar ... 1209001945
Summary
-------
87 patients were enrolled in the study. The most common etiology of VE
was enterovirus 71 (42 per cent), followed by measles (21 per cent),
varicella zoster virus (16 per cent), herpes simplex virus (11 per
cent), and mumps (11 per cent). Japanese encephalitis virus was not
found in any case. Enterovirus 71 infection caused significant
morbidity in children; mortality occurred in 50 per cent. A
preponderance of cases occurred in December. In our study generalized
convulsions along with altered sensorium were the significant findings
in patients with VE. Enterovirus 71, the major etiology of VE in our
study, was associated with significant mortality and morbidity. Such
studies should be conducted frequently to assess the role of emerging
VE in different regions.

3. Kumar A, Shukla D, Kumar R, et al: An epidemic of encephalitis
associated with human enterovirus B in Uttar Pradesh, India, 2008. J
Clin Virol 2011; 51(2): 142-5;
http://www.sciencedirect.com/science/ar ... 3211000989
Abstract
--------
Enterovirus RNA was detected in 37 (41 per cent) of 90 CSF samples by
real-time polymerase chain reaction (PCR). Seroneutralisation,
amplification, and sequencing of the 3'-end of the VP1 region of EV
isolates revealed coxsackievirus B5 (CBV) and echovirus 19 (ECV) as
the main serotypes causing this epidemic. Phylogenetic analysis showed
that sequence divergence among the same serotypes was 0-4 per cent at
the nucleotide level. This is the 1st report suggesting that CBV 5 and
ECV 19 may be responsible for an epidemic of encephalitis in India.
These serotypes were variant and evolved within the studied area.

An interactive HealthMap/ProMED-mail interactive map showing the
location of Uttar Pradesh state can be accessed at
http://healthmap.org/r/1iZ5. - Mod.TY]

DENGUE/DHF UPDATE 2011 (40)
***************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

*****
Asia
---
- India (national). On 5 Oct 2011 Ronan Kelly
of Flu Trackers submitted the following report. Official figures
released 4 Oct 2011 covering the period 1 Jan to Sep 2011.

State / Cases (change since last month) / Fatalities (change since
last month)
Andhra Pradesh / 235 (+125) / 3 (-)
Assam / 1 (-) / 0 (-)
Bihar / 2 (+2) / 0 (-)
Goa / 7 (-) / 0 (-)
Gujarat / 493 (+205) / 0 (-)
Haryana / 39 (+25) / 1 (-)
Jammu & Kashmir / 1 (+1) / 0 (-)
Jharkhand / 12 (+8) / 0 (-)
Karnataka / 263 (+57 / 3 (-)
Kerala / 857 (+124) / 8 (+4)
Madhya Pradesh / 14 (+11) / 0 (-)
Maharashtra / 223 (-) / 2 (-)
Orissa / 1697 (+821) / 25 (+2)
Punjab / 609 (+335) / 0 (-)
Rajasthan / 81 (+29) / 0 (-)
Tamil Nadu / 1091 (+223) / 4 (+2)
Uttar Pradesh / 50 (+49) / 1 (+1)
Uttarakhand / 4 (+2) / 0 (-)
West Bengal / 149 (+55) / 0 (-)
Chandigarh / 1 (-) / 0 (-)
Delhi / 245 (+179) / 3 (+2)
Puducherry / 34 (+4) / 0 (-)
Total / 6098 (+2,245) / 50 (+11)
http://nvbdcp.gov.in/den-cd.html

[A map showing the states in India can be accessed at
http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg.
- Mod.TY]

- India (Punjab state). 10 Oct 2011. The count of dengue cases has
crossed the 2000 mark. The health department is sticking to its
official count of 448 patients, including 226 from Ludhiana city.
Giving a count of the number of patients, medical superintendent of
Dayanand Medical College and Hospital said 1090 patients have been
admitted till date. Christian Medical College and Hospital authorities
said they have 280 dengue patients. In SPS Apollo Hospital there are
250 patients, in Oswal Cancer hospital there are 120, and Guru Tegh
Bhadaur Hospital and Ludhiana Mediciti have admitted 110 patients each
this season.
http://timesofindia.indiatimes.com/city ... 296457.cms

[A HealthMap/ProMED-mail interactive map showing the location of
Punjab state can be accessed at http://healthmap.org/r/1iSV. -
Mod.TY]

- India (Hyderabad, Andhra Pradesh state). 9 Oct 2011. There is a
massive dengue outbreak in Hyderabad city with private hospitals
recording a collective average of 20-30 cases a day over the last two
weeks. However, doctors allege that the government is downplaying the
outbreak and is sticking to its official figure of 56 cases so far
when the actual numbers are much more. 3 people, 2 from Hyderabad and
one from Visakhapatnam have succumbed to the vector-borne disease till
date this year [2011].
http://articles.timesofindia.indiatimes ... sion-fever

[A HealthMap/ProMED-mail interactive map showing the location of
Hyderabad, Andhra Pradesh state can be accessed at
http://healthmap.org/r/1j_d. - Mod.TY]

- Pakistan (Islamabad). 9 Oct 2011. Within the last 5 days, the allied
hospitals in town have registered 240 more dengue fever suspects while
84 more patients have been confirmed positive here for the infection
by National Institute of Health, Islamabad, taking the total number of
confirmed cases so far reported at the allied hospitals to 233. To
date, a total of 1208 suspects have been received by the allied
hospitals of which 233 have been tested positive while 337 negative by
the NIH. The NIH has, however, yet to confirm status of 638 suspects
whose blood samples have been sent to the NIH by the allied hospitals.
The data reveals that 41 percent of the suspects of the allied
hospitals so far tested by the NIH have come out to be positive.
http://www.thenews.com.pk/TodaysPrintDe ... 1672&Cat=6

[A HealthMap/ProMED-mail interactive map showing the location of
Islamabad can be accessed at http://healthmap.org/r/1kcY. - Mod.TY]

- Pakistan (Punjab province). 8 Oct 2011. The number of dengue
patients in Punjab has reached 14 760 and 12 761 of these coming from
Lahore. 14 448 patients have now recovered and discharged from various
hospitals of Punjab, from which 12 503 come from Lahore. Currently,
1592 dengue patients are under treatment at various hospitals in the
province, of which 1297 are in Lahore.
http://www.allvoices.com//contributed-n ... 07-not-out

[A HealthMap/ProMED-mail interactive map showing the location of
Punjab province can be accessed at http://healthmap.org/r/1kdg. -
Mod.TY]

- Pakistan (Lahore, Punjab province). 5 Oct 2011. Dengue claimed 9
more lives in Lahore today [5 Oct 2011], taking the death toll to 168
in the Punjab province, out of which 154 deaths have been in the
city.
http://tribune.com.pk/story/267331/deng ... es-to-160/

[A HealthMap/ProMED-mail interactive map showing the location of
Lahore in Punjab province can be accessed at
http://healthmap.org/r/1kdh. - Mod.TY]

- Pakistan (Faisalabad, Punjab province). 5 Oct 2011. The number of
dengue patients in Faisalabad has reached 855 with 45 new cases
reported in the 2 leading hospitals of the city here on Tuesday [4 Oct
2011]. According to executive district officer (EDO) health Dr Abdur
Rauf, 45 new dengue patients were reported today [5 Oct 2011]. Out of
them, 21 patients belong to Faisalabad district while remaining from
other districts including 14 from Lahore, 5 from Toba Tek Singh, 2
each from Jhang and Chiniot and one from Rawalpindi.
http://www.thenews.com.pk/TodaysPrintDe ... 0945&Cat=2

[A HealthMap/ProMED-mail interactive map showing the location of
Faisalabad, Punjab province can be accessed at
http://healthmap.org/r/1kc_. - Mod.TY]

- Pakistan (Khyber Pakhtunkhwa province). 7 Oct 2011. As many as 220
dengue cases have been confirmed among the 538 reported cases in
Khyber Pakhtunkhwa, said an official of Health Department.
http://www.brecorder.com/pakistan/gener ... cial-.html

[A HealthMap/ProMED-mail interactive map showing the location of
Khyber Pakhtunkhwa province can be accessed at
http://healthmap.org/r/1iSS. - Mod.TY]

- Pakistan (Karachi, Sindh province). 7 Oct 2011. A sudden surge in
dengue viral fever cases was seen on Thursday [6 Oct 2011] when
another 43 people, including 36 in Karachi, tested positive for the
disease, the Provincial Dengue Surveillance Cell said. So far, 7
people, including 6 in Karachi (5 in September and one in October),
have died of the fever. Some 75 patients, including 57 in Karachi, are
undergoing treatment at various hospitals in the province. The data
compiled by the cell shows that 529 people, including 432 in Karachi,
have tested positive for dengue in the province this year [2011] so
far.
http://www.thenews.com.pk/TodaysPrintDe ... 1329&Cat=4

[A HealthMap/ProMED-mail interactive map showing the location of
Karachi, Sindh province, can be accessed at
http://healthmap.org/r/1kc-. - Mod.TY]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (27)
********************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


In this update:
[1] Bihar
[2] Delhi
[3] Uttar Pradesh
[4] National

******
[1] Bihar
Date: Mon 10 Oct 2011
Source: Rediff News [edited]
http://www.rediff.com/news/report/encep ... 111010.htm


Encephalitis, a mosquito-borne disease [virus], has killed 61
children, mostly Mahadalits [a usually landless and often homeless
class of people], while more than 50 are still fighting for their
lives in Bihar's Gaya district, health officials said on Monday [10
Oct 2011].

All the children died at Anugrah Narain Medical College and Hospital
(ANMCH) in Gaya. The disease has killed a dozen children in the last
one week. "With the deaths of 2 children in the last 24 hours and 10
children in the past 5 days, the death toll has risen to 6," Ajay
Kishor Ravi, who heads the hospital's children's department, said.

According to health officials, the disease started claiming lives of
children from 23 Aug [2011]. Since then, children continue to die of
it. Superintendent of ANMCH, Sitaram Prasad, said that government had
employed several medical teams to control the disease. He said that
more than 270 children with suspected encephalitis were admitted for
treatment at hospital. "Some children are still battling for life as
their condition remains critical. However, some are showing signs of
improvement," he said. Prasad said those children who died mostly
belonged to poorest of the poor families in Gaya and its neighbouring
districts.

Bihar Health Minister Ashwini Kumar Choubey said measures were being
taken to check the spread of the disease. "The government decided to
identify the villages affected and carry out intensive spraying of DDT
to kill mosquitoes," he said.

A district administration official said that encephalitis hit Gaya in
2009, 2007 and 2005 and killed dozens of children.

With 45 samples of brain fever cases having tested positive [for what
pathogen?] in the last the one-and-half-months, the disease has been
the reason for a lot of worry at the Patna Medical College and
Hospital. Three people reportedly died due to the disease, and 2
months ago 51 children died in Muzaffarpur district but the state
government is yet to confirm these as encephalitis deaths.

Last month [September 2011], union Health and Family Welfare Minister
Ghulam Nabi Azad informed the Rajya Sabha that clinical and
epidemiological data suggested that it was an outbreak of acute
encephalitis syndrome, resulting in 150 cases and 55 deaths, mostly
among children. In a written reply, the minister said these cases were
reported from early June to mid-July 2011 from Muzaffarpur and its
bordering areas in Bihar.

[Byline: M I Khan]

--
Communicated by:
ProMED-mail from HealthMap Alerts


[This report initially reports only JE virus as the pathogen
responsible for the encephalitis cases but later quotes an official
who mentions the unspecified acute encephalitis syndrome, which likely
involves enteroviruses as well. Because the breeding sites of _Culex_
mosquito vectors of JE virus are likely to be widespread, vector
control with insecticides is difficult. DDT use is particularly
problematic environmentally. It is not mosquito-specific, affecting
populations of useful insects as well, is a stable compound that is
bioaccumulative, and moves up food chains in the field. Vaccination is
a feasible way to prevent JE virus infections in people living in
areas where JE virus transmission is likely to occur. This and the
following reports below do not give any indication of the proportion
of the at-risk populations that have been vaccinated.

A HealthMap/ProMED-mail interactive map showing the location of Bihar
state can be accessed at http://healthmap.org/r/18Od. - Mod.TY]

******
[2] Delhi
Date: Tue 11 Oct 2011
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... od-samples


A 5th patient has tested positive for Japanese encephalitis [virus
infection; JE], a deadly mosquito-borne disease [virus] that affects
the brain. The blood sample of a 30-year-old resident of Inderpuri in
southwest Delhi was examined at National Centre for Disease Control
(NCDC). He has been undergoing treatment at Ram Manohar Lohia Hospital
since 1 Oct [2011].

Japanese encephalitis cases have been reported in the city the 1st
time this year [2011]. "The man tested positive for the disease
[virus] on Monday [3 Oct 2011?], but his condition improved, and he
was discharged from the hospital on 8 Oct [2011]. It seems to be a
mild case," said Dr R P Vashishtha, state surveillance officer. He
said all 5 cases reported to date are mild and not life-threatening.
Four other cases -- which included 2 children -- were reported from
Gole Market, Jehangirpuri and Bawana, said Vashishtha.

He said the source of the infection is yet to be traced. "We tested
the blood samples of pigs in the affected areas because they are the
reservoirs of the disease, but all of them tested negative. Now, we
are expanding the investigation, and blood samples of the animals
slaughtered in Ghazipur are being investigated for the infection," he
said. [Pigs are amplifying hosts. Wild birds are reservoirs, and may
well have been the source of virus in these cases. - Mod.TY]

Diagnostic facilities for the disease will soon be set up at Babu
Jagjiwan Ram Hospital at Jehangirpuri, Mahrishi Balmiki Hospital at
Pooth Khurd, and Baba Saheb Ambedkar Hospital at Rohini.

Dr V K Monga, chairman of the MCD health committee, said the disease
is fatal and transmitted by mosquitoes and cripples the brain. "It
spreads through germs [virus] carried by mosquitoes, which breed in
ponds and paddy fields. The germs are transferred to the pigs through
mosquito-bite. When a mosquito bites an infected pig and then a human
being, the germs [virus] are transferred to that person. The initial
symptoms of the disease are fever and vomiting. Later, it assumes
dangerous proportions and renders the brain ineffective. Presently,
there is no cure available. People should use protection against
mosquitoes," he said. "We are taking all possible steps to stop
mosquito breeding by removing weeds from water bodies and undertaking
fogging in areas along railway tracks and in stagnant water," said
Monga.

--
Communicated by:
ProMED-mail from HealthMap Alerts


[Cases of JE virus infection within Delhi city are of concern, given
the large human population there.

A HealthMap/ProMED-mail interactive map showing the location of Delhi
can be accessed at http://healthmap.org/r/01Jf. - Mod.TY]

******
[3] Uttar Pradesh
Date: Wed 12 Oct 2011
Source: BBC News [edited]
http://www.bbc.co.uk/news/world-south-asia-15269441


More than 400 people, mainly children, have died in an outbreak of
viral encephalitis in northern India, health officials say. So far,
2300 patients have been admitted to a hospital in the affected
Gorakhpur area of Uttar Pradesh state. A doctor told the BBC that it
was a "tragedy beyond imagination," with children dying every day.
Nearly 6000 children have died of encephalitis in the hospital since
the 1st case was detected in 1978. Most of the deaths this year [2011]
have happened since July 2011, doctors say.

The disease occurs regularly during the monsoon in the Gorakhpur
region bordering Nepal in the foothills of the Himalayas. The
low-lying areas are prone to floods, providing a breeding ground for
mosquitoes which commonly transmit the virus. Doctors say affected
patients come from 10-12 districts in the region and are mostly poor.

Until 2005, the majority of deaths were caused by Japanese
encephalitis, caused by a mosquito-borne virus, doctors say. But in
the past 6 years, children have been dying of other forms of viral
encephalitis, caused by a mosquito-borne virus, doctors say. Both the
diseases cause headaches and vomiting and can lead to comas, brain
dysfunctions, seizures and inflammations of the heart and kidneys.
Doctors say children between the age of 6 months-15 years are worst
affected, and most of the victims are poor people from rural areas.

"It is an unbelievable tragedy. There are 5-10 children dying
everyday," Dr KP Kushwaha, head of paediatrics at the BRD Medical
College, the only hospital treating patients, told the BBC. Most of
the 370 beds in the paediatrics and medicine departments at the
hospital are overflowing with more than one patient to a bed, he said.
A 5th of the children who survive have to live with neurological
weaknesses, doctors say. "Children are most affected because they have
lower immunity, and they end up consuming a lot of contaminated water
at home," Dr Kushwaha said.

Though the incubation period of viral encephalitis is between 3-30
days, patients are brought to the hospital from far-flung areas
because of the lack of adequate healthcare in their villages. "The
public health care system is in a shambles. And the tragedy repeats
itself every year," said Kumar Harsh, a local journalist.

The government says it has tried to check the regular outbreak of the
encephalitis in the region. In 2006 and 2010, 2 massive vaccination
drives against Japanese encephalitis were carried out in Gorakhpur,
leading to a drastic decline of the disease in the area.

The disease is caused by contaminated water. Also, people took
precautions by using mosquito nets and repellents. But tackling other
forms of viral encephalitis has proved to be a tougher challenge, and
controlling it will require a vast improvement in sanitation and
drinking water supplies in rural areas, health officials say.

The state government disbursed over millions of rupees from a federal
health programme for treatment of patients at the state-run BRD
Medical College in 2009. Part of this money was spent in hiring 135
researchers, doctors and paramedical staff to beef up treatment. Most
of the money ran out by August 2009, leaving only 36 of them receiving
regular salaries, say authorities.

The encephalitis outbreak in Gorakhpur has attracted national and
international attention; scientists from the US-based Centers for
Disease Control visited the area in 2009 and took away medical samples
to examine the virus.

In 2005, a virulent outbreak of Japanese encephalitis in Gorakhpur
killed 1000 people, mostly children. This was the worst outbreak since
1978.

[Byline: Soutik Biswas]

--
Communicated by:
ProMED-mail from HealthMap Alerts


[This report does not indicate what the other mosquito-borne virus
might be in addition to JE virus. It does mention that contaminated
water is involved in the encephalitis cases. Previous studies have
shown that several viruses, mainly enteroviruses, have been involved
in encephalitis cases in this area of Uttar Pradesh state (cited in
ProMED-mail archive no. 20111010.3035). Improving sanitation to
eliminate contaminated water in areas of extreme poverty is a
significant and costly challenge.

A HealthMap/ProMED-mail interactive map showing the location of Uttar
Pradesh state can be accessed at http://healthmap.org/r/01r4. -
Mod.TY]

******
[4] National
Date: 4 Oct 2011
>From Ronan Kelly


[On 5 Oct 2011, Ronan Kelly of Flu Trackers submitted the following
report, official figures released 4 Oct 2011 covering the period from
1 Jan to September 2011.]

State / JE virus infection cases (change since 13 Sep 2011) /
Fatalities (change since 13 Sep 2011)

Andhra Pradesh / 59 (-) / 1 (-)
Assam / 1319 (+11) / 250 (+4)
Bihar / 288 (-) / 54 (-)
Goa / 53 (-) / 1 (+1)
Karnataka / 94 (-) / 0 (-)
Kerala / 88 (+9)/ 6 (+3)
Maharashtra / 4 (-) / 3 (-)
Manipur / 11 (+9) / 0 (-)
Nagaland / 44 (-) / 6 (-)
Tamil Nadu / 483 (+79) / 14 (+1)
Uttar Pradesh / 2322 (+540) / 339 (+91)
West Bengal / 407 (+66) / 20 (+10)
Total / 5172 (+714) / 694 (+110)
http://nvbdcp.gov.in/je-cd.html=20

--
Ronan Kelly
Flu Trackers

[ProMED thanks Ronan Kelly for sending in these data.

A map showing the states in India can be accessed at
http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg.
- Mod.TY]

HEPATITIS - PAKISTAN: SURVEILLANCE, 2009 TO 2011
************************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Date: Fri 14 Oct 2011
Source: MMWR Weekly, Volume 60, No. 40 ,40);1385-1390 [abridged &
edited]
http://www.cdc.gov/mmwr/preview/mmwrhtm ... ovdelivery


Hepatitis A is thought to infect almost all persons living in Pakistan
by age 15 years (1), and hepatitis E is responsible for sporadic
infections and outbreaks (2). The prevalence of hepatitis B virus
(HBV) infection is estimated at 2.5 percent and the prevalence of
hepatitis C virus (HCV) infection, estimated at 4.8 percent, is one of
the highest rates in the world (3). Hepatitis surveillance in Pakistan
has been syndromic, failing to confirm infection, distinguish among
viruses, or collect information on risk factors. To understand the
epidemiology of viral hepatitis in Pakistan more clearly, the Ministry
of Health (MOH) asked the Pakistan Field Epidemiology and Laboratory
Training Program (FELTP) to establish a hepatitis sentinel
surveillance system in 5 large public hospitals in 4 provinces and
Islamabad Capital Territory. This report describes the implementation
of the viral hepatitis surveillance system in Pakistan and summarizes
major findings from June 2010 through March 2011.

A total of 712 cases of viral hepatitis were reported; newly reported
HCV infection accounted for 53.2 percent of reported cases, followed
by acute hepatitis A (19.8 percent), acute hepatitis E (12.2 percent),
and newly reported HBV infection (10.8 percent). A history of
healthcare-related exposures, particularly receipt of therapeutic
injections and infusions, commonly were reported by persons infected
with HBV and HCV, and most patients reported drinking un-boiled water.
These findings point to the need for improved provider and community
education about risks associated with unsafe injections, strengthening
infection control practices in health facilities, increasing hepatitis
B vaccination coverage, and improving access to clean drinking water
in Pakistan.

In August 2009, to monitor the effectiveness of the National Program
for Hepatitis Prevention and Control (NPHPC)'s activities and guide
implementation of evidence-based prevention interventions, the
Pakistan FELTP launched a hepatitis sentinel site surveillance system
in collaboration with CDC's Division of Viral Hepatitis. Criteria for
site selection were based on geographic distribution, patient load,
capacity for laboratory testing, ability to conduct data entry, and
capacity for transmitting viral hepatitis data to the National
Institute of Health in Islamabad, where FELTP is housed. Five public
sector tertiary-care hospitals, located in 4 provincial headquarters
(Lahore, Peshawar, Karachi, and Quetta) and in Islamabad (the federal
capital), were selected as sentinel sites for viral hepatitis
surveillance. The hepatitis surveillance system was fully operational
by June 2010.

During June 2010-March 2011, a total of 712 cases of viral hepatitis
were reported by the 5 sentinel sites. Newly reported hepatitis C was
the most common cause of viral hepatitis, accounting for 53.2 percent
of cases, followed by acute hepatitis A (19.8 percent), acute
hepatitis E (12.2 percent), and newly reported hepatitis B (10.8
percent). In addition, among patients, 28 (3.9 percent) had evidence
of HBV and HCV co-infection, and 11 (14.3 percent) of those with HBV
infection had evidence of co-infection with hepatitis D virus
infection [which may have enhanced the HBV infection - Mod.CP].

Most persons reported with viral hepatitis resided near the reporting
hospital, all of which were in large cities. For all types of viral
hepatitis, nearly twice as many cases were reported among males than
females. Most reported cases occurred among persons aged 20-39 years
(365 cases; 53.3 percent), although some variation occurred by type of
hepatitis. Of 24 women with acute hepatitis E infection, 75 percent
were of childbearing age (15-49 years), but information regarding
pregnancy status was unavailable. Hospitalization rates ranged from
7.1 percent for acute hepatitis A infection to 10.4 percent for newly
reported HBV infection. No deaths were reported among persons with any
type of viral hepatitis. Of the 25 persons with any type of hepatitis
who reported being vaccinated against HBV, 2 (8 percent) were aged 5
years or under, 3 (12 percent) were aged 6-19 years, and 20 (80
percent) were aged 20 years or older. Of the 13 hepatitis cases
reported among children aged 5 years or under, only 2 of the children
previously were vaccinated against HBV, including one child with newly
reported HBV infection.

Drinking un-boiled water during the past 6 months was commonly
reported by persons with all types of viral hepatitis. HBV-infected
case patients reported having undergone surgery and dental procedures,
exposure to therapeutic injections, intravenous infusions, and skin
piercing more commonly than did those with other types of viral
hepatitis.

MMWR Editorial Note:

This report describes the establishment of the 1st sentinel
surveillance system for viral hepatitis in Pakistan. Findings indicate
that all types of viral hepatitis are highly prevalent in Pakistan,
with newly reported HCV infection being the most frequently reported
in this system. Continued transmission of enteric viral hepatitis A
and E in Pakistan, as revealed by sentinel surveillance, can be
attributed to lack of sanitation. Because most drinking water in
Pakistan is contaminated, persons are encouraged to boil their
drinking water. However, as revealed by sentinel surveillance, the
majority of persons infected with any type of viral hepatitis reported
drinking un-boiled water, likely because of practicality and cost.

Previous studies indicated that almost all persons living in Pakistan
have been infected with hepatitis A virus by age 15 years (1).
Although acute hepatitis A is usually a self-limited asymptomatic or
mild illness in children, it can cause severe symptoms in adults.
Reports of acute hepatitis A infections among persons aged over 30
years might demonstrate an epidemiologic shift in age of infection,
likely resulting from improved sanitation in some areas. Similar
findings have been reported in a recent systematic review, which
suggested a decrease in hepatitis A endemicity in the South Asia
region that includes Pakistan (5). Furthermore, high prevalence of
acute hepatitis E infection among women of childbearing age is an
indicator of frequent exposure in a population at high risk for
mortality from infection. These data underscore the need for improved
access to safe drinking water in Pakistan to decrease hepatitis A and
E transmission.

Surveillance data also revealed that despite initiation of childhood
hepatitis B vaccination in 2002, the majority of children with
hepatitis reported to the surveillance system were not vaccinated, and
cases of HBV infection were reported among persons aged under 10
years, including children aged 5 years or less. In Pakistan, the 1st
dose of hepatitis B vaccine is given at age 6 weeks as part of the
pentavalent vaccine, which provides immunization against diphtheria,
tetanus, pertussis, HBV, and _Haemophilus influenzae_ type b
infections. Three-dose vaccine coverage in 2009 was reported to be
over 85 percent among children aged 12-23 months, although the
demographic and health survey conducted in 2005 reported a coverage of
57 percent (6). Based on the findings in this report and the coverage
survey data, routine coverage needs to be improved, and implementation
of the hepatitis B birth dose to prevent infection among infants
should be considered.

Data obtained through this system point to several potential
opportunities to improve viral hepatitis control and prevention,
particularly in injection safety and infection control. Consistent
with previous studies, HBV and HCV infections were associated with a
history of medical injections and procedures, suggesting that unsafe
injection practices and health-care procedures contribute to
transmission of HBV and HCV in Pakistan (3,4,7), although these
practices also were commonly reported among hepatitis A and E
patients. Use of therapeutic injections is a common practice in
Pakistan, with an estimated 4-8 injections per person per year, one of
the highest rates in the world (4). These injections frequently are
unnecessary and are administered for common, minor complaints such as
fever and fatigue (4). The high demand for these injections is driven
by the popular but erroneous belief that medications administered by
injection are more effective than those given orally and by economic
incentives for health-care providers, who can charge patients more for
medicines administered by injection (8). In Pakistan, injections often
are given by unqualified practitioners using un-sterile syringes,
which increases the risk for transmission of blood-borne infections,
including viral hepatitis (4,7). Addressing unsafe injections is
essential to curb the ongoing epidemic of HCV infection in this
country.

Since 2000, a significant increase in injection drug use also has been
reported in Pakistan (9), and high prevalence rates of HCV infection
have been reported among injection drug users (IDUs) (60-93 percent)
(4). However, only one case of hepatitis C reported through the
surveillance system involved a reported IDU. This finding might be
explained by the social stigma associated with admitting to such a
behavior.

This report is subject to at least 4 limitations. 1st, because
sentinel hospital sites are public hospitals located in large cities,
the catchment population for the surveillance sites mainly includes
the urban poor. Persons with acute hepatitis who seek care in the
private sector and sites run by nongovernmental organizations (NGOs),
which account for 70 percent of health-care services in Pakistan and
provide services for high-risk groups (e.g., IDUs, men who have sex
with men, and persons with human immunodeficiency virus) (10) might
not be captured in this surveillance system. 2nd, surveillance data
only represent persons who came to a health-care facility and received
viral hepatitis testing; infected persons with mild disease not
requiring medical attention or lacking access to or failing to receive
medical care were not included, leading to a likely underreporting of
the number of persons with hepatitis infection. 3rd, because of
resource constraints and lack of diagnostic capabilities,
immunoglobulin M antibody to hepatitis B core antigen (IgM anti-HBc)
testing was not available, which limited the ability to distinguish
acute from chronic HBV infection; identification of HBV infections was
therefore solely based on acute symptoms and elevation of liver
enzymes, along with positive hepatitis B surface antigen (HBsAg) and
total anti-HBc. Similarly, lack of confirmatory testing using high
signal-to-cut-off ratios, nucleic acid testing, or recombinant
immunoblot assay for cases of HCV infection reported to the
surveillance system, based on positive ELISA test results, might have
led to an overestimation of the number of newly reported HCV
infections. Finally, the associations between risk factors and
hepatitis infections might be confounded by differences in the age
distribution of persons with various types of hepatitis infection.

--
Communicated by:
ProMED-mail

[Among the significant observations obtained from this surveillance
exercise are the following. Almost all persons living in Pakistan have
been infected with hepatitis A virus by age 15 due mainly to the
universal habit of drinking un-boiled water. Hepatitis E remains
sporadic, however. During the period June 2010 to March 2011, HCV
infection became the most frequent newly reported infection. And
despite initiation of childhood hepatitis B vaccination in 2002, the
majority of children with hepatitis reported to the surveillance
system had not been vaccinated. In Pakistan, injections are given
often by unqualified practitioners using un-sterile syringes, which
increases the risk for transmission of blood-borne infections, such as
viral hepatitis B, C and D. Curbing this practice would help to stem
the ongoing epidemic of HCV infection in this country.

The original unabridged text includes a figure displaying the
geographic distribution of the reported viral hepatitis cases by virus
type. Interested readers should consult the original document at the
source URL to view the full text and references cited.

The HealthMap/ProMED-mail interactive map of Pakistan can be accessed
at: http://healthmap.org/r/1iGJ. - Mod.CP]

HEPATITIS - PAKISTAN (02): SURVEILLANCE, 2009 TO 2011, A COMMENT
****************************************************************

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: Thu 13 Oct 2011
From: F. Blaine Hollinger, M.D. [edited]



Comments
--------
Among the many intriguing aspects of the surveillance program in
Pakistan is the relatively high rate of acute hepatitis A that was
observed in persons over 20 years of age (82 percent of the cases) in
a country in which it was stated that "almost all persons living in
Pakistan have been infected with hepatitis A virus by age 15 years."

Obviously, there are a number who escaped being infected in their
early childhood and presented in adulthood with clinically overt acute
hepatitis A. Symptoms with or without jaundice occur in 75-90 percent
of adults (versus 5-20 oercent of children <5 years of age). Even
then it is noteworthy that only 18 percent of the surveillance cases
were <20 years of age. It would be interesting to know something more
about the adults with acute hepatitis A from an epidemiological
viewpoint. Any epidemiological shift in the age of infection should
have left the younger patients more at risk of acquiring disease, not
the older subjects (40 percent of the cases were over 30 years old).

Regarding IgM-specific anti-HBc, while it is can be a good marker for
acute hepatitis B, about 15-25 percent of patients with acute
reactivation of their chronic hepatitis B may present with a
relatively low level of IgM anti-HBc that can be confusing unless a
ratio is determined between the sample result and the cut-off value.
Among the chronically infected, this component is predominantly a 7S
IgM fraction as opposed to a 19S component in acute disease. These
surveillance programs can be useful, but only if they are
demographically designed.

--
F. Blaine Hollinger, M.D.
Professor of Medicine, Molecular Virology & Epidemiology
Director, Eugene B. Casey Hepatitis Research Center
Baylor College of Medicine
One Baylor Plaza, BCM-385
Houston, TX 77030
USA


[ProMED-mail thanks Professor Hollinger for his interesting comments
on the outcome and design of the hepatitis surveillance program in
Pakistan. - Mod.CP]

MALARIA - PAKISTAN (03): (SINDH), COMMENT
*****************************************

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: 10 Oct 2011
From: Warner Anderson [edited]


The post on 7 Oct 2011 on the remarkable outbreak of malaria in
multiple provinces of Pakistan suggests that the recent disbanding of
the Ministry of Health has led to the consequences the international
community had predicted and feared. The Ministry of Health was
abolished at the national level, and the provinces are left to conduct
health matters on their own. The website of the former Ministry of
Health also announced the closure: http://www.health.gov.pk/.

Polio has spread over Pakistan's borders into China; national
coordination of anti-malaria efforts seems lacking, and Pakistan's
ability to mobilize a national response against infectious threats is
threatened. This issue is of grave concern to WHO and also to other
national governments, including the USA and Afghanistan. It makes it
difficult, if not impossible, to fund public health projects, removes
professional national-level oversight, and allows provincial
ministries of health to fall under local political and fundamentalist
sway.

Note: This is my professional opinion and does not necessarily
represent the official position of the Department of Defense or the US
government.

--
Warner Anderson MD FACP
International Health Division, OASD (HA)


[ProMED thanks Warner Anderson for his comment. We agree that the
question of coordination of health efforts like the malaria and polio
control programs and supervision of provincial governments are
important issues. ProMED will be happy to post a comment from the
Pakistani authorities. - Mod.EP]

DENGUE/DHF UPDATE 2011 (41)
***************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

******
- Pakistan (Punjab). 16 Oct 2011. Dengue fever claimed 4 more lives on
Sunday [16 Oct 2011], with the death toll reaching 211 in the
provincial metropolis and 231 in the Punjab in Pakistan. According to
the data, the number of dengue victims is increasing, and the total
has now reached 14 470 in Lahore after 221 more tested positive.
Meanwhile, sources also confirmed 244 more cases in the province after
which the total number of patients has soared to 16 793.
http://www.qnaol.net/QNAEn/News_Bulleti ... _0037.aspx

[A HealthMap/ProMED-mail interactive map showing the location of
Punjab province can be accessed at http://healthmap.org/r/0cco. -
Mod.TY]

- India (Delhi). 15 Oct 2011. With 14 more cases reported on Friday
[14 Oct 2011], dengue cases in the capital this season have reached
368. Four people have succumbed to the disease so far this season.
http://www.hindustantimes.com/14-more-c ... 57386.aspx

[A HealthMap/ProMED-mail interactive map showing the location of Delhi
can be accessed at http://healthmap.org/r/01Jf. - Mod.TY]

- India (Chandigarh, Haryana and Punjab states). 13 Oct 2011. Three
fresh positive cases of dengue have come up in the city today [13 Oct
2011]. The patients are residents of Sector 51, Bapu Dham Colony and
Maloya. With this, the total number of dengue patients in the city
hospitals has risen to 21.
http://www.dayandnightnews.com/2011/10/ ... hospitals/

[A HealthMap/ProMED-mail interactive map showing the location of
Chandigarh, Haryana and Punjab states, can be accessed at
http://healthmap.org/r/1l5F. - Mod.TY]

- India (Ahmedabad, Gujarat state). 12 Oct 2011. The city reported 14
cases of dengue on Tuesday [11 Oct 2011]. Even on Monday [10 Oct
2011], the figures were 31 dengue cases.
http://www.dnaindia.com/india/report_ma ... ad_1597882

[A HealthMap/ProMED-mail interactive map showing the location of
Ahmedabad, Gujarat state can be accessed at
http://healthmap.org/r/1d5o. - Mod.TY]