Wüstenschiff

MALARIA - INDIA (18): (RAJASTHAN)
*********************************

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


Date: Sat 15 Oct 2011
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city ... 361338.cms


The number of malaria cases in Bikaner's Sardar Patel Medical College
hit record levels with around 1400 patients being admitted to the
hospital in the last fortnight with 6 deaths.

In September 2011, the average weekly number of patients detected with
the disease was around 400 cases. "So far, the number of deaths in the
district has touched 22 since January 2011, while 60 per cent of them
were reported in the last 3 months alone," said a health department
official.

Reacting to the alarming rise of cases, department officials said the
surge is mainly because of cases coming from other districts.
"Patients from Nagaur, Churu, Sriganganagar, Hanumangarh and even from
some parts of Jaisalmer and Jodhpur are coming to Bikaner for
treatment, and this has increased the number," deputy chief medical
and health officer (Bikaner) Dr Devendra Choudhary said.

Moreover, the officials said that each year after the rainfall, the
number of malaria patients increases. "This is the period when the
cases increase," the official said.

The cases of malaria _Plasmodium falciparum_ (Pf), which is fatal, are
also on the rise. So far, 6 patients have died due to this form the
disease in the district, while 16 patients have died when they were
admitted to the hospital in a complicated situation with _Plasmodium
vivax_ (Pv) malaria, a health department official said.

Also, in Jaipur, the official death toll due to dengue is one person,
who died some 10 days ago. Also, the officials claimed that the number
of dengue cases have declined this year [2011] in comparison to last
year. "This year, the number of dengue cases so far is 52, while in
the corresponding period last year, the figure was 103. But to the
contrary, the malaria patients increased. Malaria Pf cases are 56, and
Pv cases are 1103, while last year [2010], it was 53 and 638
respectively," he said.

--
communicated by:
ProMED-mail from HealthMap alerts


[The latest map of malaria in India is provided in the World Malaria
Report 2009
(http://www.who.int/malaria/publications ... ind_en.pdf).
Here, Rajasthan has a malaria annual incidence rate of between 1 and
100 cases per 1000 population.

An article in the New Scientist (2010) estimates that the number of
malaria cases officially reported by the Indian authorities is 10
times lower than the real number. The article also provides a map of
malaria in India
(http://www.newscientist.com/data/images ... 1_1070.jpg)
in which the risk of death due to malaria increases towards the border
with Pakistan.

ProMED-mail has previously commented on the malaria situation in
Pakistan, where malaria seems to be increasing, and this could also
spread over the border into India.

For the ProMED-mail HealthMap of the location of this outbreak, see
http://healthmap.org/r/1lfN. - Mod.EP]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (28): (BIHAR, 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


In this update:
[1] Bihar
[2] Uttar Pradesh

******
[1] Bihar
Date: Mon 17 Oct 2011
Source: The Telegraph [edited]
http://www.telegraphindia.com/1111018/j ... 633942.jsp


Japanese encephalitis -- a form of brain fever -- has hit the state
capital and its neighbouring areas. At least 10-12 cases of the
disease are being reported at Patna Medical College and Hospital
(PMCH) daily over the past few days. Dr Nigam Prakash Narayan, a
senior doctor at the paediatrics ward of the hospital, said: "About
250 patients of encephalitis have been admitted to the hospital so
far. Of them, around 100 are down with Japanese encephalitis [virus
infection]. This is apart from high number of cases registered at the
government medical college in Gaya. The mortality rate of Japanese
encephalitis patients is about 20-25 per cent. Thus, the disease has
taken an epidemic form in the state."

Dr Narayan said: "Most of the patients coming to the hospital are from
Patna, Hajipur, Muzaffarpur, and Chhapra districts. Several of them
are in critical condition."

With the number of suspected Japanese encephalitis cases on the rise,
the PMCH authorities are finding it tough to cope with the pressure of
patients. The health hub is running short of beds as well as
medicines. "Many Japanese encephalitis patients are lying on the floor
as beds are not available. We are also running short of required
medicines. Worse, there is no special arrangements for such patients
though new cases are pouring in every day," a senior officer of the
hospital said.

Experts said Japanese encephalitis [JE] is caused [by JE virus
transmitted] by the bites of _Culex tritaeniorhynchus_ mosquitoes. The
symptoms of Japanese encephalitis include high fever, headache and
nausea, bouts of unconsciousness or convulsions, altered sensorium or
impact on sensory part of the brain, chills, confusion and agitation,
rigidity of neck, lethargy, and inability to talk or feel anything.

Doctors suggested people to use medicated mosquito nets and repellents
to avoid getting infected. They also asked to keep rooms of children,
especially infants and toddlers, spick and span.

Dr Narayan said: "It is high time the state government took up some
extensive programmes like sprinkling of insecticides in affected areas
to stop the menace immediately."

Today in Gaya, 6 persons reportedly died of Japanese encephalitis
[virus infection]. With this, the toll touched 68.

State health department officials said measures were being taken to
curb the spread of the disease. "We have identified 420 villages in
Gaya where malathion is sprayed to kill mosquitoes. Also, people are
being advised to keep pigs away from human habitation as they act as
vectors of the disease [pigs are amplifying hosts of JE virus. Wild
birds are the reservoirs and mosquitoes are the vectors. - Mod.TY]
Some stray cases are being reported from other districts as well and
we are trying our best to stop the spread of the disease. It is also
important that people keep their house and surroundings clean and
maintain personal hygiene," said Sanjay Kumar, the secretary of the
health department.

The deputy chief malaria officer SK Aman, has asked the Gaya civil
surgeon to seek help of the welfare and education departments and the
municipal corporations to contain the disease.

Around 308 Japanese encephalitis patients have got admitted to Anugrah
Narayan Magadh Medical College and Hospital till today. The 1st case
was reported on 23 Aug [2011].

[byline: Sumi Sukanya]

--
communicated by:
Ronan Kelly
for FluTrackers.com


[The cases of Japanese encephalitis virus infections and deaths
continue to mount in Bihar state. Mention is made of vector control
efforts, but not of a vaccination campaign in the areas where cases
are occurring.

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

******
[2] Uttar Pradesh state
Date: Tue 18 Oct 2011
Source: Jagran Yahoo [in Hindi, machine trans., & summ., edited]
http://in.jagran.yahoo.com/news/local/u ... 73750.html


In the last 24 hours, 10 of 18 patients [with Japanese encephalitis
virus infections] died. Overall, from January 2011 until the last
patient arrived for treatment, 449 have died.

--
communicated by:
Ronan Kelly
for FluTrackers.com


[More details on the occurrence of encephalitis cases in eastern Uttar
Pradesh state are provided in the 12 Oct 2011 report on ProMED-mail
post archive no 20111012.3054). Deaths are continuing in Uttar Pradesh
state.

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

TRICHINELLOSIS - INDIA (UTTARAKHAND)
************************************

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 17 Oct 2011
Source: The Pioneer [edited]
http://www.dailypioneer.com/nation/1382 ... pauri.html


A total of 10 people died and a larger number of people from 4
villages were hospitalized after they consumed wild boar meat.

Paubo block of Pauri district, including the village of former
Uttarakhand chief minister and BJP [Bhartiya Janta Party] national
vice-president Ramesh Pokhriyal Nishank, has been affected.

The villagers died from trichinosis, caused by eating raw or
undercooked pork or bush meat infected with the larvae of
trichinella.

On Sunday [16 Oct 2011], Nishank visited Pauri District Hospital and
directed the chief medical superintendent and doctors to ensure proper
treatment and provide all necessary medical facilities to the
_Trichinella_ infected patients. Nishank also visited his native
village Pinani and Shival, Gadigaon, and Charghad to enquire about
those who had fallen sick.

Deputy chief medical officer Dr KD Sharma told The Pioneer that so
far, 10 people had died after eating the infected meat, while the
condition of 18 admitted to hospital remains serious. Sharma added
that the villagers consumed the wild boar meat on 9 Sep 2011,
following which some of the infected persons went for treatment to the
All India Institute of Medical Sciences (AIIMS) and other hospitals in
Delhi and returned to the district after that.

The 1st death occurred about 10 days ago while the latest deaths
occurred during this weekend [15-16 Oct 2011]. Dr Mukesh Sundriyal of
Pauri District Hospital identified trichinosis as the cause. The
larvae can be detected by conducting a muscular biopsy.

The 1st symptoms of the illness are evident after 4 to 10 days but the
parasite migrates in the human body within 4 to 10 weeks and can
become active at any time during this period.

Death is caused by the effect of the parasite on the brain,
respiratory system, and cardiac system. Sundriyal emphasised that
everyone who had eaten the infected pork should undergo a
haemagglutination blood test and take the prescribed medicines in
order to avert serious or even fatal consequences.

--
communicated by:
ProMED-mail from HealthMap alerts


[A recent review (Gottstein B, et al. Epidemiology, diagnosis,
treatment and control of trichinellosis. Clin Microbiol Rev 2009;
22(1): 127-45;
http://cmr.asm.org/cgi/content/full/22/ ... d=19136437)
indicates that _Trichinella pseudospiralis_ has been reported from
Mumbai, but information from the rest of India is lacking. A map from
the same paper of the worldwide distribution of _Trichinella_ spp. can
be found at http://cmr.asm.org/cgi/content/full/22/1/127/F3?ck=nck

Wild boar is a well known source of infection with trichinella. The
reported mortality is very high and this suggests that there are many
undiagnosed cases. The report does not contain detailed information on
how the boar meat was consumed, especially whether it was used in
sausages for wider distribution which would result in more cases.

We assume that the diagnosis was made by a test for specific
antibodies against trichinella as muscle biopsy will have a low
sensitivity and it is an invasive procedure.

The state of Uttarakhand can be seen on the HealthMap/ProMED-mail
interactive map at http://healthmap.org/r/1lEi. - Mod.EP]

HANTAVIRUS - INDIA: (ANDHRA PRADESH), REQUEST FOR INFORMATION
*************************************************************

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


Date: Tue 18 Oct 2011
Source: Deccan Chronicle [edited]
http://www.deccanchronicle.com/channels ... ellore-440


Detection of the dreaded hantavirus in 2 people from SPSR Nellore
district led a team headed by Dr Ramesh from the Integrated Disease
Surveillance Project of the National Institute of Epidemiology,
Chennai to visit the habitations of the patients on Friday and
Saturday [14-15 Oct 2011].

Hantavirus [infection can cause] a life-threatening disease, spreading
to humans through the droppings and urine of rodents, especially deer
mice [deer mice, _Peromyscus maniculatus_, do not occur in India. -
Mod.TY]. The symptoms of the disease are chills, fever and muscle
aches, in addition to dry cough, malaise, headache, nausea, vomiting,
and shortness of breath.

The indications are similar to leptospirosis, dengue, Japanese
encephalitis, and chikungunya, and the only way of prevention is to
avoid exposure to rodent urine and droppings, according to district
malaria officer, Dr M Kanakadri.

A 66 year old woman from the Nawabpeta area of Nellore town succumbed
to the disease after 3 weeks treatment in a corporate hospital at
Chennai few days ago.

However, an agriculture labourer of Nellipudi village in Vakadu mandal
survived with treatment at the same hospital, although he too was
tested positive for [a] hantavirus [infection].

In-charge epidemiologist Dr Veera Pratap has denied a report in a
vernacular daily about the death of a 50 year old woman due to the
virus at Chinnapadug-upadu village near Nellore. Dr Pratap, who
assisted Dr Ramesh and his team during their visit to the district,
said that the woman tested negative for [a] hantavirus [infection].
However, she was also treated at the same hospital in Chennai where
the other 2 cases were under treatment.

The team came to study all the cases that were treated during the same
period in the hospital, since the symptoms were similar, though the
tests proved negative for some. They visited the homes of the patients
and elicited information about the symptoms from the relatives.

"They want to send a detailed report to the virology wing in New Delhi
to seek their advice to deal with the hantavirus before it spreads,
since the virus is new to our region," Dr Pratap said.

Meanwhile, the medical and health wing officials have started
collecting blood samples from the family members of the patients and
people living in the locality as a precautionary measure. The district
medical and health officer, Dr N Dasaradha-ramaiah, told this
newspaper that they will send the samples for testing.

[byline: Pathri Rajasekhar]

--
communicated by:
ProMED-mail from HealthMap Alerts


[ProMED-mail would appreciate receiving information indicating the
tests used to make the diagnosis of a hantavirus infection and,
especially, the identity of the hantavirus involved in these cases. It
would also be of interest to have a clinical description of these 2
cases as well.

It would not be surprising if Seoul hantavirus is found in this area,
as it is widely distributed around the world in _Rattus norveigicus_.
Thottapalayam virus is a hantavirus harbored by the Asian house shrew
(_Suncus murinus_) in the Indian subcontinent and China. However, it
has not been associated with human disease. A newly identified but not
yet named genetically distinct hantavirus was found in the Chinese
mole shrew (_Anourosorex squamipes_) captured in Cao Bang Province,
Viet Nam. This shrew species occurs in South East Asia, extending
westward to Bhutan and Assam in northern India. It has not yet been
associated with human disease either. A 4 Feb 2010 ProMED-mail post
(archive no. 20100205.0385) mentioned serological evidence of
hantavirus infections and 2 fatal and other cases in India with
serologic evidence in 2 different test formats for a Puumala virus, a
hantavirus commonly found in Europe.

Reference:
Clement J, Maes P, Muthusethupathi M, Nainan G, Van Ranst M. First
evidence of fatal hantavirus nephropathy in India, mimicking
leptospirosis. Nephrol Dial Transplant. 2006; 21(3): 826-7;
http://ndt.oxfordjournals.org/cgi/content/full/21/3/826

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

RABIES - INDIA (16): (TAMIL NADU), CANINE, HUMAN, LIBIDO
********************************************************

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 22 Oct 2011
Source: The Daily Mail [edited]
http://www.dailymail.co.uk/news/article ... abies.html


A woman who told her doctor she had a sudden, unbelievable increase in
her sex drive (hypersexuality) died 4 days later of rabies. The 28
year old, who lived in India, complained that she felt constantly
aroused, sometimes with no stimulation at all. Her confounded
physician referred her to the Sri Gokulam Hospital and Research
Institute in Salem, Tamil Nadu. They discovered that a small bite from
a puppy 2 months earlier [had] caused the disease.

Fear of water caused by paralysis of the swallowing muscles
[hydrophobia] is widely known as a symptom of rabies. But it can also
cause hypersexuality, a result of inflammation of the brain. Peter
Costa, the communications director for the Global Alliance for Rabies
Control, said that by the time the disease reaches that stage, it is
incurable. He said: "If you've been bitten or suspect you've been
licked or scratched by an infected animal, you should seek treatment
within 24 hours."

Pet vaccination programmes have been largely successful in staving off
the disease in the United States, but around the world, between 55 000
and 70 000 people die of rabies each year, Mr Costa told LiveScience.
Most of the deaths are in children under age 15 in areas where
vaccinations are lacking. Mr Costa said: "Dogs are responsible for
more than 99 per cent of human rabies cases." He said education is the
key to halting the spread of the disease,.

The Indian woman did not seek medical attention after she was bitten
by the dog, because the bite was small, and the animal was just a
puppy. Early treatment, however, could have saved her life. Mr Costa
said: "If you've been bitten, wash the wound with soap and water for
about 10 minutes, and then seek appropriate medical treatment." If
doctors think a bite will put someone at risk of rabies, they'll
inject antibodies that fight rabies right around the wound. Then
patients get 4 vaccinations in the arm over 2 weeks.

Mr Coasta said the case of the Indian woman highlights the need for
pet vaccinations. "The public health system in the United States and
Europe has done just a tremendous job, to the point where I think
people forget why we vaccinate our animals," he said. "Rabies is just
outside the front door."

--
communicated by:
ProMED-mail

[In most cases of rabies, symptoms 1st appear one to 3 months after
infection with the virus. Early symptoms are often similar to those
seen with influenza and may include fever, headache, and general
tiredness. In addition, the infected person may experience discomfort,
numbness, or pain at the site of the bite. Progressive symptoms may
include insomnia, anxiety, confusion, slight or partial paralysis,
excitability, bizarre behaviour, hallucinations, agitation,
hypersalivation, and difficulty in swallowing.

This patient's hypersexuality can be considered an example of bizarre
behaviour. However, it has been observed that in the prodromal phase
of the disease, there may be both incontinence and abnormal
stimulation of the sex organs.

The Indian state of Tamil Nadu can be located in the
HealthMap/ProMED-mail interactive map at
http://healthmap.org/r/1mm2. - Mod.CP]

DENGUE/DHF UPDATE 2011 (42)
***************************

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 province). 24 Oct 2011. According to official
figures, so far 18 235 dengue patients have recovered and been
discharged from various hospitals in Punjab province, out of which, 16
270 belonged to Lahore alone. The record shows that from 1 Jan - 18
Sep [2011], only 50 people died of DHF, but in next 36 days, 281
people died, which showed the severity of the epidemic. Independent
figures show that more than 35 000 people have been diagnosed with
dengue virus, but the government's health department rejected these
figures and said only around 20 000 people were affected, and 273 died
[It is not clear whether these figures are national or for just Punjab
province. Mod.TY].
http://www.shanghaidaily.com/article/ar ... p?id=25437

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

- Pakistan (Rawalpindi, Punjab province). 18 Oct 2011. The number of
dengue fever cases is increasing, as on an average 3 teaching
hospitals of the city are receiving over 50 suspect patients daily,
while so far over 1732 suspect cases have been registered with allied
hospitals. The allied hospitals of the town have received 437
confirmed positive cases of dengue fever.
http://ftpapp.app.com.pk/en_/index.php? ... 1&Itemid=2

[A HealthMap/ProMED-mail interactive map showing the location of
Rawalpindi in Punjab province can be accessed at
http://healthmap.org/r/1b2L. - Mod.TY]

- India (Jaipur, Rajasthan state). 24 Oct 2011. So far, 52 dengue
cases have been detected in Jaipur this year [2011]. Out of them, 30
were detected in the last 2-and-half months, the [health] department
said on Sunday [23 Oct 2011]. Till 1 Jul [2011], the figure of dengue
patients was just 22.
http://timesofindia.indiatimes.com/city ... 469873.cms

[A HealthMap/ProMED-mail interactive map showing the location of
Jaipur, Rajasthan state can be accessed at
http://healthmap.org/r/1n1m. - Mod.TY]

- India (Delhi). 20 Oct 2011. The city recorded its highest number of
dengue cases in a day after 24 more people tested positive for the
disease [virus], taking the number of persons diagnosed with the fever
here to 503. An average of 8-10 cases are being reported daily. The
1st case of dengue fever was reported this year [2011] in the month of
March. This is less in comparison to 5000 dengue cases that were
reported during this period last year [2010].
http://zeenews.india.com/news/delhi/cit ... 37590.html

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

- India (Ahmedabad, Gujarat state). There have been more than 450
cases of dengue [in 2011]. So far this year [2011], 5 people in
Ahmedabad have died of dengue [virus infections].
http://ibnlive.in.com/news/dengue-and-m ... 02-17.html

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

- India (Chandigarh, Haryana and Punjab states). 19 Oct 2011. On
Tuesday [18 Oct 2011], 2 fresh cases of dengue have been reported in
the city, taking the tally to 27 cases this season.
http://www.indianexpress.com/news/Aroun ... ty/862009/

[A HealthMap/ProMED-mail interactive map showing the location of
Chandigarh, Haryana and Punjab states can be accessed at
http://healthmap.org/r/1n1n. - Mod.TY]

HANTAVIRUS - INDIA (02): (ANDHRA PRADESH), COMMENTARY
*****************************************************

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


Date: Mon 24 Oct 2011
From: Jan Clement [edited]


We agree with the ProMED moderator that details of the obtained titers
or O.D. and exact nature of the lab formats used for the hantavirus
screening of the current Nellore cases could be very helpful. As
indicated already in a previous 4 Feb 2010 ProMED-mail post (archive
no. 20100205.0385), we found in 2006 and in ELISA and immunoblot
formats not only evidence of the murine Seoul virus (SEOV) infection,
but also of the arvicoline Puumala virus (PUUV) infection, the latter
in 2 fatal cases (from the Cochin, respectively Chennai region) with
symptoms similar to those now described in the Nellore cases. In the
meantime, we found similar serologic evidence for PUUV-like infection
in non-fatal hantavirus cases in Sri Lanka, considered as
leptospirosis cases, some of which also presented with cough or
dyspnea.

Wild rat-transmitted SEOV can be found worldwide but is, with about 2
per cent case fatality rate, mostly mild, and affects in humans more
the liver than the lung. However, as recently showed again in Sweden,
PUUV can also involve the lungs as well as the kidneys, leading to a
fatal form of viral ARDS [acute respiratory disease syndrome]
(Rasmuson J, Andersson C, Norrman E, Haney M, Evander M, Ahlm C. Time
to revise the paradigm of hantavirus syndromes? Hantavirus pulmonary
syndrome caused by European hantavirus. Eur J. Clin Microbiol Infect
Dis 2011; 30:685-690).

In Europe and Russia, however, PUUV infections are spread by bank
voles (_Myodes glareolus_), but this rodent is absent from India, as
are all other related species of the Arvicolinae subfamily.
Consequently, PUUV cannot be expected to be endemic in India, and we
had to do with cross-reactions. Sri Lanka is a country neighbouring
India, with fauna very similar to it, including the total absence of
rodent species of the Arvicolinae subfamily.

As indicated already in our ProMED-mail post no. 20100205.0385, RT-PCR
on all these "PUUV-positive" sera, including the 2 fatal cases, was
negative for all hitherto known hanta-viral pathogens, including PUUV
and Thottapalayam virus (TPMV), with a positive control on live TPMV.
It should be noted, however, that, in comparison to SEOV and other
murine hantaviruses found in the Far or South East, PUUV is
genetically more closely related to the American hantaviruses, giving
in 35 per cent a lethal form of viral ARDS, called hantavirus
pulmonary syndrome (HPS), a picture reminiscent of the current Nellore
cases.

Given the fact that TPMV, the only indigenous hantavirus with a
documented presence in India, is genetically completely distinct from
all other known rodent-borne and even from most of the many (now over
21) recently discovered insectivore-borne hantaviruses, it seems
improbable that TPMV should give cross-reactions with PUUV in
serology. Moreover, no human pathogenicity is known for TPMV, as it is
for all other insectivore-borne hantaviruses so far. However, we
recently presented retrospective (1987 and 1991) evidence of what
might be the first clinical description of insectivore-borne human
hantavirus disease, both with mainly renal involvement. One patient
was bitten by a water shrew (_Neomys fodiens_), the other splashed in
the face and on his clothes with blood of a common mole (_Talpa
europaea_), decapitated with his spade. Remarkably, in an IFA battery
with several species of the then different pathogens (Hantaan [virus],
SEOV and PUUV), PUUV yielded the highest titers (manuscript in
preparation).

There are several relatively simple and quick lab tests to support a
suspicion of an ongoing hantavirus infection, such as initial
proteinuria and thrombocytopenia, high leukocytosis with a left shift,
elevated levels of LDH and CRP (surprisingly for a virus infection),
and the "lipid paradox" consisting of very low serum cholesterol,
contrasting with high triglycerides. A very peculiar and pathognomonic
clinical sign, present in 50 per cent of hanta [virus], and 25 per
cent of PUUV cases, is blurred vision by acute myopia, noted shortly
after the onset of fever, but never reported so far in American HPS
cases. Paradoxical bradycardia (under 60 beats/min) despite the fever,
might be another sign.

Our National Reference Laboratory for Hantavirus Infections offered
last year to Indian health authorities and doctors different screening
and confirmation techniques such as ELISA, different forms of RT-PCR
(including pan-hanta PCR), and a new variant of neutralisation test
(NT), based on PCR, but Indian sera appeared difficult to obtain.
Moreover, we are also ready to perform on short notice a very
demanding new technique, called pyrosequencing. However, this test
requires fresh serum samples, sent in optimal conditions on dry ice,
but requires above all a high degree of familiarity with the many
fallacies of hantavirus results interpretation. If the Nellore health
authorities are willing to send us fresh serum samples of recent
suspect cases, we are willing to help them.

--
J. Clement, P. Maes, M. Van Ranst, K. Lagrou
National Reference Laboratory for Hantavirus Infections,
University Hospital Gasthuisberg, Leuven, Belgium


[ProMED thanks Dr. Clement and colleagues for this interesting
discussion and evaluation of current and past hantavirus infection
cases in India. One hopes that Indian Health authorities will take
advantage of their very generous offer of help with laboratory
diagnosis of these cases. Isolation of the virus (or viruses) involved
in these cases would be of particular interest, as it would provide an
opportunity for comparative genetic studies of the viruses circulating
in India and their relationships to other hantaviruses. Building on
Dr. Clement's and colleagues' previous hantavirus studies in India
cited below, that would make a significant contribution to our
understanding of the bio-geography of hantaviruses in the Indian
subcontinent and Asia in general.

Reference:
Clement J, Maes P, Muthusethupathi M, Nainan G, Van Ranst M. First
evidence of fatal hantavirus nephropathy in India, mimicking
leptospirosis. Nephrol Dial Transplant. 2006; 21(3): 826-7;
http://ndt.oxfordjournals.org/cgi/content/full/21/3/826.

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

JAPANESE ENCEPHALITIS AND OTHER - INDIA (29): (DELHI, 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


In this update:
[1] Delhi
[2] Eastern Uttar Pradesh
[3] Uttar Pradesh (control measures)

******
[1] Delhi
Date: Tue 25 Oct 2011
Source: IBN Live, Press Trust of India (PTI) report [edited]
http://ibnlive.in.com/generalnewsfeed/n ... 75227.html


Two children have tested positive for the killer Japanese encephalitis
(JE) [virus infection], taking the number of cases of this deadly
mosquito-borne disease [virus] to 7 in the city. According to the
Municipal Corporation of Delhi [MCD], one of the 2 new cases is
'indigenous', indicating that "virus is multiplying in the city".

The blood sample of an 11-year-old child, a resident of Kanti Nagar,
and a 4-year-old child, who lives in Trilokpuri, tested positive for
JE virus. While the former is undergoing treatment at Chacha Nehru Bal
Chikitsalya, the other is admitted with Lal Bahadur Shastri hospital,
VK Monga, chairman of the MCD health committee said today [25 Oct
2011].

"JE virus is multiplying in the city. The 4 year-old is an example of
that. She is an indigenous case. All these days we could not trace the
source of the JE cases that have been reported till date. Her blood
sample was one of the 10 samples collected from Lal Bahadur Shastri
hospital as part of the routine random checking for JE cases in the
city," he said. "With these 2 new cases the total count of JE cases in
Delhi now stands at 7," he said.

Japanese encephalitis [virus], which cripples the brain and is more
common in Uttar Pradesh, was reported in the city the 1st time this
year on 21 Sep [2011]. "We have to increase surveillance, check for
more cases, and put them on immediate treatment and take all vector
control measures," a health ministry official said. "No deaths have
been reported till now as all are mild cases and not
life-threatening," Monga said.

--
Communicated by:
ProMED-mail from HealthMap alerts


[Curiously, no mention is made of vaccination against JE virus
infection as a control measure, in addition to vector control. Perhaps
there are not enough cases in Delhi to justify a vaccination campaign
there.

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

******
[2] Eastern Uttar Pradesh
Date: Tue 25 Oct 2011
Source: Kaumudi [edited]
http://kaumudiglobal.com/innerpage1.php?newsid=11579


With 10 more persons succumbing to encephalitis, the death toll in the
viral disease in eastern Uttar Pradesh has climbed to 488 this year
[2011], health officials said on Tuesday [25 Oct 2011]. In the last 4
days, 10 persons suffering from the disease died in various hospitals
in the region, they said.

Over 280 people suffering from encephalitis are undergoing treatment
at the BRD Medical College here besides in some other district
hospitals.

As many as 3088 patients were admitted to government hospitals in the
region this year of which 488 have died, they said.

--
Communicated by:
ProMED-mail from HealthMap alerts


[The number of hospitalized encephalitis cases in eastern Uttar
Pradesh continues to climb, from the 474 on 21 Oct 2011 (cited in the
report below), to 488 cited above. The specific etiologies in the
cases above is not stated.

A HealthMap/ProMED-mail interactive map showing the location of Uttar
Pradesh state can be accessed at http://healthmap.org/r/1i16. -
Mod.TY]

******
[3] Uttar Pradesh (control measures)
Date: Fri 21 Oct 2011
Source: Outlook India, Press Trust of India (PTI) report [edited]
http://news.outlookindia.com/items.aspx?artid=739036


With the encephalitis toll in eastern Uttar Pradesh [UP] mounting to
474 this year, the Centre today [21 Oct 2011] announced setting up of
a coordination committee of different Union ministries and said it was
mulling short, middle, and long-term plans to control the epidemic. "A
coordination committee comprising union ministries of Health, Water
Resources and Irrigation, Social Justice, and Women and Child Welfare
would be formed after discussion with the Prime Minister. The
committee will make a coordinated effort to tackle the problem," Union
Health Minister Ghulam Nabi Azad said. He was talking to reporters
after visiting some of the affected areas. Azad was accompanied by
Union Minister of State for Petroleum RPN Singh, Congress General
Secretary Digvijay Singh and scientists from Indian Council of Medical
Research. Official sources said Azad's visit came in the wake of a
request by Congress General Secretary Rahul Gandhi. Azad said the
short, middle, and long-term plans to control the epidemic will be
worked out soon.

Terming the deaths in Gorakhpur Medical College Hospital as
unfortunate, he said, "It seems that vaccination drives are not
carried out in a transparent manner from time to time or else the
situation would have been better." He said cooperation from all
quarters was necessary to check spread of the epidemic and expressed
concern over the shortage of para-medical staff.

The Union minister said the central government has also sanctioned 44
nursing schools in the state to overcome the problem.

"Japanese encephalitis cases in eastern UP have come down from 36 per
cent in 2005 to 10 per cent this year [2011], due to repeated
vaccination drives but the cases of water-borne encephalitis are
mounting," he said.

Earlier, the minister reviewed the situation with the doctors and
administrative staff of the district hospital [in Gorakhpur].

--
Communicated by:
ProMED-mail from HealthMap alerts


[The occurrence of water-related cases is mentioned in passing in this
report, and is frequently mentioned in previous ones. A more
comprehensive JE virus vaccination campaign should help to reduce
cases due to infection with that virus. Preventing water-associated
cases, presumably due to enteroviruses, will be more difficult, as it
will require an ongoing surveillance effort, timely laboratory support
for diagnosis, a public education campaign and costly improvement in
infrastructure to provide safe drinking water and sanitary disposal of
human wastes. - Mod.TY]

CRIMEAN-CONGO HEMORRHAGIC FEVER - PAKISTAN (02): (KHYBER PAKHTUNKHWA),
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: Tue 25 Oct 2011
Source: Dawn [edited]
http://www.dawn.com/2011/10/26/with-den ... fever.html


If you thought dengue was the final blow that nature could inflict on
Pakistanis for this year [2011], you were wrong. In a cruel twist of
fate, the country is now expected to be plagued by a wave of the
high-fatality tick-bite disease, Crimean-Congo Haemorrhagic fever
(CCHF). The National Institute of Health's (NIH) warning on the latest
infectious disease comes a week after its 1st victim [this year?]
succumbed to it at the Pakistan Institute of Medical Sciences (PIMS).

"An adult patient from Haripur district of Khyber Pakhtunkhwa has died
due to CCHF. The patient came with massive bleeding and was admitted
at the isolation ward. We immediately sent his samples to NIH, but he
died during the course of his treatment due to massive bleeding," Prof
Mehmood Jamal, executive-director of Pims, stated.

Though the report from NIH came 8 days later, Prof Jamal clarifies
that the death of the patient from CCHF was no secret, and no attempts
were made to hide anything from the public. He does admit that doctors
feel the pressure of expectations of dealing with CCHF patients
alongside dengue cases.

Meanwhile, the NIH in a quick move has issued an advisory, saying:
"Provinces have been advised to take special measures in view of the
upcoming Eidul Azha, as there will be massive movement of sacrificial
animals from one province to another." [Eid-ul-Adha (Festival of
Sacrifice), also known as the Greater Eid, is the 2nd most important
festival in the Muslim calendar, falling this year on 6 Nov 2011, The
festival remembers the prophet Ibrahim's willingness to sacrifice his
son when God ordered him to do this. - Mod.CP]

A senior official of the NIH added that since a cattle market had
already been established in Saidpur village, their department had also
issued a similar warning to local health authorities [Saidpur is a
historic Pakistani village built on the slopes of the Margalla Hills
which overlook Islamabad and is a popular site for celebrations. -
Mod.CP].

The NIH has also asked the provincial health authorities to establish
isolation wards. "Even physicians and medical staff treating [CCHF]
patients have to avoid direct contact with a CCHF-positive patient,
because even the blood secretion from the patient is deadly," said one
official.

As a preventive measure, the NIH official suggested that butchers and
cattle handlers needed to be trained in the de-ticking of animals
before moving cattle from one place to other. "Preventive measures
such as body inspection of cattle are needed by the relevant
veterinary health officials working with the local district
administrations before transporting the cattle from farm to slaughter
house or cattle market," suggested the official.

But with most cattle herders paying little heed to inspectors or rules
and the movement of cattle between provinces uncontrolled, prevention
of an epidemic during Eid will require enhanced vigilance.

[Byline: Imran Ali Teepu]

--
Communicated by:
ProMED-mail

[Crimean-Congo haemorrhagic fever (CCHF) is a viral haemorrhagic fever
caused by a Nairovirus. Although primarily a zoonosis, sporadic cases
and outbreaks of CCHF affecting humans do occur. The disease is
endemic in many countries in Africa, Europe and Asia.

The geographical distribution of the virus, like that of its tick
vector (_Hyalomma_ spp.), is widespread. Evidence of CCHF virus has
been found in Africa, Asia, the Middle East and Eastern Europe.
Healthcare workers in endemic areas should be aware of the illness and
the correct infection control procedures to protect themselves and
their patients from the risk of nosocomial (hospital-acquired)
infection.

Humans who become infected with CCHF acquire the virus from direct
contact with blood or other infected tissues from livestock, or they
may become infected from a tick bite. The majority of cases have
occurred in those involved with the livestock industry, such as
agricultural workers, slaughterhouse workers and veterinarians.
Nosocomial transmission of CCHF virus infection has been recorded in
Pakistan and elsewhere in the past and is a known hazard.

The length of the incubation period for the illness appears to depend
on the mode of acquisition of the virus. Following infection via tick
bite, the incubation period is usually one to 3 days, with a maximum
of 9 days. The incubation period following contact with infected blood
or tissues is usually 5-6 days, with a documented maximum of 13 days.

The mortality rate from CCHF is approximately 30 percent, with death
occurring in the 2nd week of illness. In those patients who recover,
improvement generally begins on the 9th or 10th day after the onset of
illness. A detailed account of the disease and its biology can be
found in the WHO web-site at:
http://www.who.int/mediacentre/factshee ... index.html.

A map showing the provinces of Pakistan can be accessed at:
http://www.asiawaves.net/pakistan-map.htm - Mod.CP]

CHIKUNGUNYA (23): INDIA (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: Thu 27 Oct 2011
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... -operation


After the onset of dengue and spurt in malarial cases in the
post-monsoon season, the city is now witnessing a sudden rise in cases
of chikungunya [virus infection], a vector-borne disease [virus]
causing sudden bout of fever accompanied with pain in the joints.

While the out patient departments (OPDs) of government hospitals
including DDU and SPG divisional hospital are reporting more than a
dozen cases of the vector borne disease per day in the festive season,
the health experts are also sounding precautions to curb the spread of
the disease.

As per Sudhakar Pandey, senior doctor in the epidemic cell of CMO
office, the disease witnesses sudden onset of high fever with pain in
the joints and usually make the body weak. The immune system of the
patient is affected and sometimes it proves fatal especially in young
children [This is not accurate; see comments below - Mod.TY]. "The
best prevention against the disease is curbing the growth of
mosquitoes, the vectors for the disease. Apart from maintaining good
personal and community hygiene, prevention against attack of
mosquitoes hold the key," he added.

According to MA Khan, district malaria officer, sporadic cases of
chikungunya have been witnessed in the past and the cases have been
found to swell in the post monsoon season. The fogging operation is
generally held to curb the growth of mosquitoes that tend to swell in
the festive season. "We have already carried anti-larval spray and
outdoor residual spray in sensitive rural pockets and close vigil is
maintained in the urban areas too," he informed.

Meanwhile, sensing the spurt in the cases of vector-borne diseases,
Varanasi Nagar Nigam also intensified the fogging operation carrying
it in the residential colonies to curb the menace of mosquitoes. The
health department under VNN besides covering the main routes in the
city intensified the operation with bicycle mounted fogging machine in
different parts of the city.

--
Communicated by:
ProMED-mail from HealthMap Alerts


[The case fatality rate for chikungunya virus infections is extremely
low, and has only been documented in some 200 cases -- statistically
in the massive outbreak on Reunion Island in 2005 (see ProMED-mail
archive no. 20061224.3598) and associated with chikungunya virus
infection in India (especially in Tamil Nadu, Karnataka, Kerala, and
Andhra Pradesh). The European Network for Diagnostics of Imported
Viral Diseases (ENIVD) claims that new phylogenetic variants of virus,
which are fatal, have also been identified on Reunion (see
http://www.enivd.org/). It would be of interest to know which
chikungunya virus variant is circulating in the above outbreak, and if
there are any documented fatalities.

In 2007, there were focal chikungunya virus outbreaks around India
(see ProMED-mail archives cited below).

Sudhakar Pandey's statement about reducing or eliminating mosquito
vector breeding sites as the best preventive measure is important.
Fogging for adult mosquito control provides only temporary population
reduction unless larviciding is also done.

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

CHIKUNGUNYA (23): INDIA (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: Thu 27 Oct 2011
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... -operation


After the onset of dengue and spurt in malarial cases in the
post-monsoon season, the city is now witnessing a sudden rise in cases
of chikungunya [virus infection], a vector-borne disease [virus]
causing sudden bout of fever accompanied with pain in the joints.

While the out patient departments (OPDs) of government hospitals
including DDU and SPG divisional hospital are reporting more than a
dozen cases of the vector borne disease per day in the festive season,
the health experts are also sounding precautions to curb the spread of
the disease.

As per Sudhakar Pandey, senior doctor in the epidemic cell of CMO
office, the disease witnesses sudden onset of high fever with pain in
the joints and usually make the body weak. The immune system of the
patient is affected and sometimes it proves fatal especially in young
children [This is not accurate; see comments below - Mod.TY]. "The
best prevention against the disease is curbing the growth of
mosquitoes, the vectors for the disease. Apart from maintaining good
personal and community hygiene, prevention against attack of
mosquitoes hold the key," he added.

According to MA Khan, district malaria officer, sporadic cases of
chikungunya have been witnessed in the past and the cases have been
found to swell in the post monsoon season. The fogging operation is
generally held to curb the growth of mosquitoes that tend to swell in
the festive season. "We have already carried anti-larval spray and
outdoor residual spray in sensitive rural pockets and close vigil is
maintained in the urban areas too," he informed.

Meanwhile, sensing the spurt in the cases of vector-borne diseases,
Varanasi Nagar Nigam also intensified the fogging operation carrying
it in the residential colonies to curb the menace of mosquitoes. The
health department under VNN besides covering the main routes in the
city intensified the operation with bicycle mounted fogging machine in
different parts of the city.

--
Communicated by:
ProMED-mail from HealthMap Alerts


[The case fatality rate for chikungunya virus infections is extremely
low, and has only been documented in some 200 cases -- statistically
in the massive outbreak on Reunion Island in 2005 (see ProMED-mail
archive no. 20061224.3598) and associated with chikungunya virus
infection in India (especially in Tamil Nadu, Karnataka, Kerala, and
Andhra Pradesh). The European Network for Diagnostics of Imported
Viral Diseases (ENIVD) claims that new phylogenetic variants of virus,
which are fatal, have also been identified on Reunion (see
http://www.enivd.org/). It would be of interest to know which
chikungunya virus variant is circulating in the above outbreak, and if
there are any documented fatalities.

In 2007, there were focal chikungunya virus outbreaks around India
(see ProMED-mail archives cited below).

Sudhakar Pandey's statement about reducing or eliminating mosquito
vector breeding sites as the best preventive measure is important.
Fogging for adult mosquito control provides only temporary population
reduction unless larviciding is also done.

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

HANTAVIRUS - INDIA (03): (ANDHRA 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: Sat 29 Oct 2011
Source: The Times of India [edited]
http://timesofindia.indiatimes.com/city ... 529188.cms


A 52-year-old man hailing from Karimnagar district was diagnosed as
suffering from the relatively lesser known hantavirus [infection] at a
private hospital in the city.

Terming this as the 1st case of hantavirus in the state at a press
conference on Friday [28 Oct 2011], specialists at Yashoda hospital
said that the patient, a man who works in the postal department in
Karimnagar, was admitted to the hospital on 15 Oct [2011] with a
history of fever and dry cough associated with mild shortness of
breath. A day after he was admitted, his condition deteriorated and he
suffered a sudden cardiac arrest. He was revived and put on ventilator
support and showed signs of improvement gradually.

Meanwhile, the man developed a state of unresponsiveness as he lost
eye contact. While several tests for other viral infections came out
as negative, Dr M V Rao, general physician said that all the features
were connecting to [a] hantavirus [infection] and based on suspicion,
his samples were sent to a lab at Mumbai for confirmation. The tests
confirmed that Rao was suffering from the life threatening disease
that is carried by rodents, especially deer mice. [This is not
correct. Deer mice, _Peromyscus maniculatus_, occur in North America
and are not found in India. - Mod.TY]

According to Dr M V Rao, general physician, it is caused due to [virus
is transmitted by] rodent urine and droppings. "Although it is a
non-transferable disease but the complications may also lead to
kidney, lung or heart failure," said Dr M V Rao, senior general
physician, Yashoda hospital, Somajiguda adding that there is no
effective treatment for hantavirus infection involving the lungs.

The early symptoms of hantavirus disease include chills, fever and
body ache. If treatment is delayed, within one or 2 days the patient
may also develop breathing problems. "To avoid the disease, people
have to avoid rodent dens, drink disinfected water and clear out
potential nesting sites in their surroundings," Rao added.

--
Communicated by:
ProMED-mail


[This is the 3rd case of a hantavirus infection in Andhra Pradesh
state this month (October 2011). The specific hantavirus involved in
this case is not stated and it would be of interest to know which
tests were used to establish the diagnosis of hantavirus infection.

Previously, Dr J. Clement and colleagues of the National Reference
Laboratory for Hantavirus Infections, University Hospital
Gasthuisberg, Leuven, Belgium, found evidence in India of the murine
Seoul virus (SEOV) infection, and also of the arvicoline Puumala virus
(PUUV) infection, the latter in 2 fatal cases (from the Cochin,
respectively Chennai region) with acute respiratory syndrome --
symptoms similar to those in the recently described Nellore cases (see
ProMED-mail archive no. 20111026.3187) as well as in the case
described above. Puumala virus occurs in Europe and Russia and the
rodent host is the bank vole, _Myodes glareolus_, which does not occur
in India.

It would be of interest to conduct a field study in the area where
these cases have occurred to determine which animals are reservoir
hosts of the virus accompanied by virus isolations to determine the
similarity of these viruses to Seoul and Puumala viruses.

Reference
---------
Clement J, Maes P, Muthusethupathi M, Nainan G, Van Ranst M. First
evidence of fatal hantavirus nephropathy in India, mimicking
leptospirosis. Nephrol Dial Transplant. 2006; 21(3): 826-7;
http://ndt.oxfordjournals.org/cgi/content/full/21/3/826.

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

MALARIA - INDIA (19): (NEW DELHI)
*********************************

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


Date: Sat 29 Oct 2011
Source: IBN Live [edited]
http://ibnlive.in.com/generalnewsfeed/n ... 78954.html


Mosquito borne infections in New Delhi: Malaria
-----------------------------------------------
237 cases of malaria have been reported from New Delhi.

--
Communicated by:
ProMED-mail from HealthMap alerts


[The report contain no time period during which the cases are
reported, but we presume it to be over the past few weeks. New Delhi
is usually regarded as malaria free. So it is important to know
whether the cases represent individuals infected outside of New Delhi
travelling into New Delhi, or whether they were infected in New Delhi.
- Mod.EP

The interactive HealthMap/ProMED map for New Delhi is available at:
http://healthmap.org/r/1nSV - CopyEd.EJP]

ANTIBIOTIC RESISTANCE, SALMONELLA TYPHI - INDIA: (MUMBAI)
FLUOROQUINOLONES
**************************************************************************

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 27 Oct 2011
Source: DNA (Daily News & Analysis) [edited]
http://www.dnaindia.com/mumbai/report_m ... ls_1603881


Come the time of indulgence and typhoid rears its ugly head. This
festival season is no different. Worse, about 70 percent of [Mumbai]
city residents suffering from it are not responding to oral medication
and have had to be hospitalised.

Dr Pratit Samdhani, consulting physician at the Jaslok Hospital, said,
"Of the typhoid cases treated in the last few months, 70-80 percent
have shown high resistance towards drugs from the quinoline family
that are given orally. So, many had to be hospitalised for intravenous
treatment."

Dr Anil Ballani, consulting physician at the Lilavati Hospital,
agreed. "The severity of typhoid has increased of late. We have to
hospitalise patients because they are not responding to oral drugs.
These are culture-positive typhoid cases caused by the salmonella bug
[_Salmonella enterica_ serovar Typhi, also called _Salmonella typhi_].
Some take more than 5 days of hospitalisation and most of them
initially don't respond to even IV antibiotic treatment."

Dr Khusrav Bhajan, intensivist of the PD Hinduja Hospital, said the
trend has been consistent across the city. "In most of these cases,
the fever does not subside for the 1st 10 days." Over 100 people
sought admission in several hospitals for typhoid this month but
private doctors say the "numbers are under-reported".

Doctors' orders: keep a watch on what you dig your teeth into. Dr ND
Moulick, head of the Sion Hospital, said, "People need to maintain
levels of hygiene. Eat healthy food. It is wise to stay off street
food. Eating contaminated food can lead to diarrhoea, vomiting,
gastroenteritis, and jaundice."

There has also been a rise in the number of cases of gastroenteritis
and viral fever in the city following the receding of the monsoon.

[Byline: Somita Pal]

--
Communicated by:
ProMED-mail from HealthMap alerts


[Although unusual in the United States, typhoid fever caused by
_Salmonella enterica_ serovar Typhi, also called _Salmonella typhi_,
remains common in many developing countries. In the United States
about 400 cases of typhoid fever occur each year, and 75 percent of
these cases are acquired while traveling abroad
(http://www.cdc.gov/nczved/divisions/dfb ... oid_fever/),
mainly to southern Asia
(http://wwwnc.cdc.gov/eid/article/17/6/1 ... rticle.htm).
Fluoroquinolones, such as ciprofloxacin, orally or intravenously, or
ceftriaxone intravenously have been the drugs of choice for treatment
of typhoid fever. Azithromycin is an alternative. However,
ciprofloxacin resistance is an increasing problem, especially in the
Indian subcontinent and Southeast Asia.

Mechanisms responsible for resistance to fluoroquinolones in _S.
typhi_ are mainly: mutations in the quinolone resistance-determining
region (QRDR) of the genes that encode DNA gyrase or topoisomerase IV,
which decrease their binding affinity to fluoroquinolones, and thereby
decrease the drugs' effectiveness; and efflux pumps that decrease
intracellular fluoroquinolone concentration
(http://www.im.microbios.org/1301/IM1301_0015.pdf). Plasmid-mediated
fluoroquinolone resistance genes have been described in non-typhi
salmonella (http://aac.asm.org/cgi/reprint/53/5/2142 and
http://wwwnc.cdc.gov/eid/article/16/11/ ... rticle.htm). The
plasmid-mediated fluoroquinolone resistance _qnr_ gene encodes
proteins that can bind to DNA gyrase, protecting it from the action of
fluoroquinolones. QepA is a plasmid-encoded efflux pump that
significantly affects susceptibility to norfloxacin and aac(6')-Ib-cr
is a modified aminoglycoside N-acetyltransferase that acetylates some
fluoroquinolones, including ciprofloxacin.

Treatment failures with fluoroquinolones are commonly reported from
South Asia, where the incidence of typhoid fever is high and
antimicrobial agents are widely available without prescription,
providing the opportunity for the development and selection of
resistant strains. An increased risk for fluoroquinolone treatment
failure has been demonstrated in typhoid fever from strains of _S.
typhi_ with decreased susceptibility to ciprofloxacin (minimum
inhibitory concentration or MICs 0.125 to 1 mg/L)
(http://wwwnc.cdc.gov/eid/article/17/6/1 ... rticle.htm). The
ciprofloxacin MICs of these isolates nevertheless are considered to be
in the susceptible range. In vitro resistance to nalidixic acid has
been used to predict reduced susceptibility to ciprofloxacin in vitro
in these isolates. However, isolates have been reported, mainly from
South Asia, that have reduced susceptibility to ciprofloxacin (MICs
0.125-1.0 mg/L), but are susceptible to nalidixic acid
(http://www.ncbi.nlm.nih.gov/pmc/article ... =pmcentrez).

In addition, strains resistant to both nalidixic acid and
ciprofloxacin (MICs greater than 4 mg/L), some of which are also
resistant to ceftriaxone, have been reported from India (Kownhar H,
Shankar EM, Rajan R, Rao UA: Emergence of nalidixic acid-resistant
_Salmonella enterica_ serovar Typhi resistant to ciprofloxacin in
India. J Med Microbiol 2007; 56(Pt.1): 136-7
http://jmm.sgmjournals.org/content/56/1/136.full; Capoor MR, Nair D,
Deb M, Aggarwal P: Enteric fever perspective in India: emergence of
high-level ciprofloxacin resistance and rising MIC to cephalosporins.
J Med Microbiol 2007; 56(Pt.8): 1131-2
http://jmm.sgmjournals.org/content/56/8/1131.long). 9
ciprofloxacin-resistant (MICs greater than 4 mg/L) and nalidixic
acid-resistant (MICs greater than 32 mg/L) _S. enterica_ serotype
Typhi isolates have been detected in the United States during
1999-2008
(http://wwwnc.cdc.gov/eid/article/17/6/1 ... rticle.htm). All
were susceptible to ceftriaxone. 8 of the 9 patients had traveled to
India within 30 days before illness onset.

Typhoid fever caused by _S. typhi_ is not a zoonotic disease. _S.
typhi_ is transmitted only from human to human and prevention of its
transmission involves stopping human fecal contamination of food and
drinking water. Endemic antibiotic resistance among _S. typhi_ in
developing countries emphasizes the importance of ensuring food
safety, safe water, sanitary disposal of human excrement, and
immunization in these countries.

A HealthMap/ProMED-mail interactive map of India, showing the location
of Mumbai, can be accessed at http://healthmap.org/r/1iZ2. - Mod.ML]

DENGUE/DHF UPDATE 2011 (43)
***************************

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 (Karachi, Sindh province). 26 Oct 2011. The total number of
cases in Sindh province is 806 out of which the majority, or 609, were
reported from Karachi and 197 from other parts of the province.
http://tribune.com.pk/story/282052/at-t ... le-digits/

[The 26 Oct 2011 edition of Dawn reported that a teenager from
Mirpurkhas, who was admitted to the Jinnah Postgraduate Medical Centre
on 22 Oct [2011], became the 12th fatal victim of the dengue virus
[infection] in the province. 3 people from the interior of Sindh and 9
from Karachi have died so far due to dengue.
http://www.dawn.com/2011/10/26/another- ... engue.html

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

- Pakistan (Khyber Pakhtunkhwa province). 29 Oct 2011. Directorate
General Health Services Peshawar Khyber Pakhtunkhwa [province] has
issued the latest updates regarding dengue fever in Khyber
Pakhtunkhwa. According to the report as of the 28 Oct 2011, 9
suspected cases of dengue fever were reported out of which only one
was confirmed. Moreover 25 patients were still admitted in various
hospitals. Overall 848 suspected cases were reported throughout the
province till date, out of which 352 were confirmed as dengue
positive. Similarly 7 persons have so far died in Khyber Pakhtunkhwa
while 101 patients have travel link with Punjab [province].
http://www.thefrontierpost.com/?p=73560

[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 (Lahore, Punjab province). 29 Oct 2011. On Friday [28 Oct
2011] 2 people, including a woman, lost their battle against dengue
[virus infection] at Services Hospital, raising the death toll to 253
in the city while 291 [died] in Punjab. In the past 24 hours, 201 new
cases of dengue were confirmed raising the number of patients to 19
506 in the province [in 2011]. In Lahore, 161 cases were confirmed
increasing the number of affected persons to 16 492. Health Department
told that currently 909 patients are getting treatment for the virus
[infection] while 19 216 have recovered.
http://www.thenews.com.pk/NewsDetail.aspx?ID=25547

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

- Pakistan (Rajanpur district, Punjab province). 28 Oct 2011. A
teenager from the Rajanpur district, Punjab, died of dengue viral
fever at the Aga Khan University Hospital (AKUH), bringing the number
of deaths due to the disease in Karachi to 11, the Provincial Dengue
Surveillance Cell said on Thursday [27 Oct 2011]. The hospital
authorities reported the death to the Dengue Surveillance Cell on
Thursday, the cell authorities said, adding that total deaths due to
the dengue fever reached 13 in the province and 11 in Karachi.
http://www.thenews.com.pk/TodaysPrintDe ... 4840&Cat=4

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

- India (Delhi). 28 Oct 2011. Another dengue death was reported today
raising the toll due to the virus to 5 in the national capital, where
mosquito-borne diseases are yet to subside despite a chill in the air.
Doctors have diagnosed nearly 700 cases of dengue infection.
http://ibnlive.in.com/generalnewsfeed/n ... 78954.html

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

- India (Chandigarh, Haryana and Punjab states). 28 Oct 2011. 6 more
cases of dengue have been confirmed from the Tricity [Panchkula,
Mohali, Chandigarh], taking the total number of confirmed cases to 48.
All 6 patients have been admitted to the Government Medical College
and Hospital at Sector 32.
http://www.indianexpress.com/news/city- ... es/866306/

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

- India (Andhra Pradesh state). 27 Oct 2011. With a large number of
cases of dengue being reported from various parts of the state, Andhra
Pradesh health minister DL Ravindra Reddy today [27 Oct 2011] said the
government was taking concrete steps to check the spread of the
disease. About 630 dengue cases have been reported this year [2011] in
the state, the minister said, adding that the disease has claimed 3
lives so far.
http://ibnlive.in.com/generalnewsfeed/n ... 77976.html

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