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JAPANESE ENCEPHALITIS AND OTHER - INDIA (07): (BIHAR) REQUEST FOR INFORMATION
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Date: Thu 6 Jun 2013
Source: Rediff News [edited]
http://www.rediff.com/news/report/encep ... 130606.htm


The dreaded encephalitis, a mosquitoborne disease, has claimed the lives of over 20 children in Bihar, health officials have said.

A 2 year old and an 11 year old have died of the disease in Bihar's Muzaffarpur district in the last 24 hours, taking the toll from the deadly disease in the past month to 20 in the state. More than a dozen have been admitted to hospitals in Muzaffarpur and other district headquarters, officials said on Thursday [6 Jun 2013].

"Both children died of suspected acute encephalitis syndrome [AES]," a district health official said [and] 2 days ago, a 5 year old and a 2 year old died due to AES, hours after they were admitted at the hospital in Muzaffarpur.

Earlier this week [week of 3 Jun 2013], 4 children died of suspected AES at the Sri Krishna Medical College and Hospital and Kejriwal Hospital in Muzaffarpur, about 70 km [43 mi] from Patna. Alarmed by the number of children dying of AES in Muzaffarpur, a team of experts from the National Centre for Disease Control and CDS [communicable disease surveillance] have arrived in Muzaffarpur on Wednesday [5 Jun 2013] to identify the cause of the AES.

"The team has begun studies to identify the cause," BN Jha, a district health official said. Most of the victims of AES belong to the poorest families, who are living without basic facilities such as safe drinking water, shelter, and food.

According to health experts, AES is a severe case of encephalitis characterised by inflammation of the brain. The effect on the patient's central nervous system results in fever and/or sudden onset of symptoms such as seizures, confusion, and disorientation. It can be caused by bacterial or viral infections of the brain, toxic substances, or complications of an infectious disease.

[byline: MI Khan]

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[The report above as well as the 31 May 2013 ProMED-mail report (archive no. 20130601.1748963] provide no indication of the etiological agent responsible for these encephalitis cases in Bihar state. In previous reports, acute encephalitis syndrome [AES] in north eastern India has been attributed in part or entirely to Japanese encephalitis [JE] virus infections. However, in some instances, JE virus infections are reported to be responsible for a minority of the cases.

Without knowing the specific etiology of the encephalitis cases above, targeted control measures will not be possible. ProMED-mail would appreciate receiving reports of the conclusions of the team of experts from the National Centre for Disease Control. If some or all of the cases above are due to JE virus infections, administration of an effective JE virus vaccine would provide an opportunity for prevention of some of these cases, if applied before the main transmission season arrives.

So far this year (2013), AES has claimed lives and affected over 100 people even before the onset of the usual disease season in north eastern India. Interestingly, cases of encephalitis have occurred this year (2013) in several locations in eastern India. At the beginning of April 2013 a ProMED-mail post (archive no. 20130402.1615081) stated: "Encephalitis cases have already been reported from Andhra Pradesh, Assam, Uttar Pradesh, and West Bengal in India this year [2013], totalling 228 cases and 49 fatalities up to 19 Mar 2013. Of those cases, 7, all from West Bengal, were classified as Japanese encephalitis [virus infections]. There have also been cases in neighboring Bangladesh this year (2013)."

Maps of India and Bihar state can be seen at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/77fN. - Mod.TY]

DENGUE/DHF UPDATE (47): ASIA
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India:
- Karnataka state. 6 Jun 2013. Dengue 3882 suspected cases, 984 confirmed cases; deaths 2; increasing.
http://timesofindia.indiatimes.com/city ... 435749.cms

[Maps of India can be seen at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/1pSH. - Mod.TY]

- Pathanamthitta district, Kerala state. 3 Jun 2013. Dengue 410 suspected cases, 189 confirmed cases; deaths suspected 2.
http://www.thehindu.com/todays-paper/tp ... 777118.ece

- Kottayam district, Kerala state. 2 Jun 2013. Dengue at least 816 cases; increasing.
http://articles.timesofindia.indiatimes ... t-hospital

Pakistan
- (Karachi, Sindh province). 4 Jun 2013. DHF/serious 183 cases.
http://pakobserver.net/detailnews.asp?id=208772

[Maps of Pakistan can be accessed at http://www.ezilon.com/maps/images/asia/ ... kistan.gif and http://healthmap.org/r/1kc-. - Mod.TY]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (21): ASIA
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Cholera - Nepal (Banke District)
Date: Mon 10 Jun 2013
Source: eKantipur [edited]
http://www.ekantipur.com/2013/06/10/top ... 73071.html


An outbreak of a disease symptomatic of cholera has affected local residents of Nepalgunj [Banke District] and the town's adjoining areas, downing more than 200 people as of Sunday [2 Jun 2013].

Ram Bahadur Chand of the Banke Distric Public Health Office (DPHO) said they were waiting for a lab report from the National Public Health Laboratory to confirm the disease. "We suspect that polluted drinking water may be the primary cause for the disease but we are not quite sure if it is cholera," Chand said.

The cholera-like disease has mostly affected the residents of 6 wards in Nepalgunj. It has also been reported in Fattepur and Indrapur VDCs. As of Sunday [2 Jun 2013], the Bheri Zonal Hospital received 290 patients suffering with the disease, said Dr Sarwesraj Sharma.

A cholera epidemic 3 years ago in Nepalgunj afflicted more than 1500 people and claimed 8 lives.

[byline: Rajendra Natho]

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[An interactive map of Nepal can be found at: http://healthmap.org/r/1COd. - Mod.LL]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (08): (BIHAR)
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Date: Thu 13 Jun 2013
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... an-bhushan


Acute encephalitis syndrome (AES) has killed 7 children at S K Medical College Hospital (SKMCH) and Kejriwal Hospital in the last 12 hours, taking the toll to 39 in 35 days. Of the 7 who died in the last 12 hours, 6 children died at Kejriwal Hospital and one at SKMCH. So far, a total of 21 children have died at Kejriwal Hospital and 18 at SKMCH.

Official sources revealed that a total of 122 children were admitted, including 64 at Kejriwal and 58 at SKMCH for treatment during the past 35 days. Even on Wednesday [12 Jun 2013], 14 patients were getting treatment at Kejriwal and 10 at SKMCH. The condition of 6 of them was stated to be very serious till Wednesday afternoon [12 Jun 2013].

[byline: Priti Nath Jha]

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[The report above as well as the previous ones this year (2013) provide no indication of the etiological agent responsible for these encephalitis cases in Bihar state. In reports from previous years, acute encephalitis syndrome [AES] in north eastern India has been attributed in part or entirely to Japanese encephalitis [JE] virus infections. However, in some instances, JE virus infections are reported to be responsible for a minority of the cases. There is no indication in these or previous reports this year [2013] whether the children have been vaccinated against Japanese encephalitis virus infection.

Without knowing the specific etiology of the encephalitis cases above, targeted control measures will not be possible. ProMED-mail would appreciate receiving reports of the conclusions of the team of experts from the National Centre for Disease Control that went to the affected areas on 5 Jun 2013.

Maps of India and Bihar state can be seen at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/77fN. - Mod.TY]

HERPESVIRUS ENCEPHALITIS - INDIA: (WEST BENGAL)
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Date: Sat 15 Jun 2013
Source: Hindustan Times [edited]
http://c.moreover.com/click/here.pl?z90 ... D123456789


Darjeeling Hills is in the grip of an encephalitis outbreak characterised by high fever, headaches, and behaviour disturbances and personality changes, which lead to coma in extreme cases. Three deaths have been reported. In the last 24 hours, the Darjeeling Sadar Hospital has received around 100 patients with very high fever.

Cases of herpetic meningoencephalitis, a form of encephalitis caused by the herpes simplex Type 1, Type 2 virus, have been confirmed. The disease has a high mortality rate if not diagnosed quickly.

"Since many of the early symptoms are flu-like (headache, dizziness, vomiting), it is easy to misdiagnose the condition until it is too late. If there is a wrong diagnosis, the chances of death are as high as 70 per cent," said Dr Plaban Das, director, Darjeeling and Dooars Medical Association (DDMA).

The DDMA has had 3 deaths in the past 3 weeks. "These patients were brought to the DDMA in the coma stage. The 1st case was registered on 18 May [2013] when a 54-year-old man was admitted. He was in coma. We diagnosed him with herpectic meningoencephalitis and administered Acyclovir injection. The blood samples were sent to Delhi for confirmatory tests. The test results were positive. However, the patient responded to treatment and recovered. He has now been discharged," said Das.

Around 20 patients have been cured and discharged in the last 3 weeks. The dead include a 58-year-old from Jorebungalow who died on 13 Jun [2013] and a 73-year-old from Lebong who died 2 weeks ago. The 1st death registered was a 50-year-old about 2 weeks ago.

"Last year [2012], there was a similar outbreak in September 2012. The change in weather triggers a mutation in viral morphology, and as the human immunity system cannot counter this changed morphology, there is an outbreak," said Das. He has already notified the district magistrate, the chief medical officer of health [CMOH] and the chairman of the Darjeeling Municipality [There is no evidence that weather alters virus morphology or antigenicity. Weather can alter human behavior in a way that facilitates person-to-person transmission of viruses, however. - Mod.TY].

When contacted, chief medical officer of health Subir Bhowmik said: "We have large number of cases with symptoms of high fever. At this time, such outbreaks usually occur but are self limiting. Children are vulnerable. We have taken all necessary steps to counter this outbreak." However, the CMOH did not categorise the outbreak as herpectic meningoencephalitis.

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[Herpes simplex encephalitis (HSE) is a life-threatening result of herpes simplex virus (HSV) infection of the central nervous system (CNS). HSE is rare, but mortality rates can reach 70 per cent. Without therapy, a minority of individuals who survive return to normal function. Antiviral therapy is most effective when started early, necessitating prompt diagnosis.

It seems unusual that there has been a cluster of reported herpesvirus encephalitis cases seasonally this year (2013) and last (2012), raising questions about the etiology in all these cases as indicated by the local CMOH. ProMED-mail moderators DK and MPP noted that all age groups are susceptible to herpesvirus encephalitis, but the frequency of occurrence is low (perhaps one case per million population, see ProMED-mail archive no. 20061105.3179). The mention of the vulnerability of children to encephalitis in the report above suggests another viral etiology, such as Japanese encephalitis virus.

References:
Najioullah F, Bosshard S, Thouvenot D, Boibieux A, Menager B, Biron F, Diagnosis and surveillance of herpes simplex virus infection of the central nervous system. J Med Virol. 2000;61:468-73.

Roos KL. Encephalitis. Neurol Clin. 1999;17:813-33.

Rajnik M, Ottolini MG. Serious infections of the central nervous system: encephalitis, meningitis, and brain abscess. Adolesc Med. 2000;11:401-25. PubMed.

A HealthMap/ProMED-mail map showing the location of West Bengal state can be accessed at http://healthmap.org/r/2iyC. - Mod.TY]

DENGUE/DHF UPDATE (50): ASIA
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Pakistan (Sindh province). 12 Jun 2013. Dengue 254 cases. City most affected: Karachi 246 cases.
http://www.thenews.com.pk/article-10492 ... -Karachi--

[Maps of Pakistan can be accessed at http://www.ezilon.com/maps/images/asia/ ... kistan.gif and http://healthmap.org/r/2NT8. - Mod.TY]

India
- Mandla District, Madhya Pradesh state. 14 Jun 2013. Dengue (susp.) 100 cases, (conf.) 18 cases; deaths (susp.) 2.
http://timesofindia.indiatimes.com/city ... 581231.cms

[Maps of India can be seen at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/1pSH. - Mod.TY]

- Dakshina Kannada, Karnataka state. 13 Jun 2013. Dengue (conf.) 92 cases; deaths (susp.) 3, (conf.) 1.
http://www.deccanherald.com/content/338 ... cases.html

RABIES - INDIA (05): (MANIPUR) CANINE HUMAN
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Date: Fri 14 Jun 2013
Source: E-Pao.net, The Sangai Express report [edited]
http://e-pao.net/GP.asp?src=2..150613.jun13


Quoting reports of the Medical Department, an official of the Veterinary and Animal Husbandry Services [V&AH], while speaking to The Sangai Express, confirmed that 6 persons have died of rabies in the State [of Manipur] in the last month. Among the 6 dead, 3 are said to be from Phumlou Siphai, 2 from Achanbigei, and one each from Kongba and Ahallup.

Against this backdrop, experts have mooted urgent formulation of specific measures to tackle prevalence of rabies in the State. Putting the figure of dogs in the State at 182 000, the V&AH official further said that there has been no specific policy for prevention of diseases relating to animals in the State. As a measure to prevent rabies in the State the department has today administered anti-rabies vaccination to 80 000 dogs, the official said while also adding that the department is planning more such vaccination programmes by procuring 30 000 doses of anti-rabies vaccine.

He further cautioned that if a person is bitten by a dog, the dog should be kept under observation for 10 to 14 days. In case the dog dies during the observation period, it should be taken to the V&AH department for necessary testing. Stating that a single vaccination of anti-rabies can be effective for 12 months, the official said there is no need to panic if dogs are vaccinated regularly.

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[Manipur (or Maneepo) is a state in northeastern India, with the city of Imphal as its capital. Manipur can be located in the maps of India at http://www.mapsofindia.com/maps/india/i ... dunion.htm and http://healthmap.org/r/4816.

This report seems to indicate that control of canine rabies relies on vaccination of urban dogs, but this is not undertaken in a regular manner. The occurrence of 6 human deaths in a month, apparently following dog bites, is alarming and indicates that the attempt to control rabies in dogs by vaccination has been ineffective.

The high death rate in the human population suggests that the availability of vaccine for post-exposure prophylaxis of human victims has been inadequate. The typical incubation period following a dog bite is usually 3 to 8 weeks, but it can be as little as 9 days or as long as several years in rare cases. The incubation period depends on several factors, including the location of the wound. Post-exposure prophylaxis should be implemented immediately. Curiously in this report there is little information on the extent of human exposure. Little seems to have changed in Manipur since a previous report in ProMED-mail in 2006 [see below]. - Mod.CP]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (22): ASIA
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[1] Cholera, prisoners - India (Goa State)
Date: Sun 16 Jun 2013
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city ... 612214.cms


It was not food poisoning that left the 128 inmates of central jail at Aguada and the judicial lock-up at Mapusa sick 2 weeks ago. It was a cholera outbreak. Senior sources at the Goa Medical College and Hospital, Bambolim, where 15 prisoners from the central jail were admitted on 31 May 2013, told STOI that all the prisoners displayed symptoms of cholera and were treated accordingly.

Speaking to STOI, albeit on condition of anonymity, a senior doctor said, "It was not a case of simple food poisoning as is being made out, nor was the sickness caused by _E. coli_ bacteria. The initial clinical examinations of the prisoners pointed towards cholera."

Sources further said that the prisoners who complained of diarrhea were brought to the GMC only after jail authorities realized the seriousness of what was happening following the death of a prisoner.

Central jail prisoners are presently being given bottled water and are being served food from the Sada sub-jail, while the Mapusa judicial lock-up authority has appointed a contractor to supply food to the prisoners.

[Byline: Bindiya Chari]

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[An interactive HealthMap of the country can be found at: http://healthmap.org/r/1pSH . - Mod.LL]

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[2] Cholera - India (Madhya Pradesh State)
Date: Fri 21 Jun 2013
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city ... 695013.cms


A day after a suspected cholera patient was found in an Indore city hospital, the health department on Thu 20 Jun 2013 found a confirmed case of cholera in a patient who was admitted to Maharaja Yeshwantrao Hospital (MYH) on 17 Jun 2013. The patient has been identified as a 2-year-old resident of Kadav Ghat area who had complained of stomachache and vomiting.

The doctors had sent sample for investigations, which confirmed that the patient was suffering from cholera. However, by the time the health department got the confirmatory report, the patient was discharged from the hospital after treatment.

District health officer Dr G L Sodhi said: "The patient was admitted in MYH. The medical test report has confirmed that he was suffering from cholera. We have written to the zonal medical officer and civil surgeon to send a team to check the contamination in water source."

On Wed 19 Jun 2013, a 61-year-old, resident of Brahmbag Colony, Marimata area was admitted with complaints of stomachache and diarrhea. The doctors after examination found him suffering with cholera. Another confirmatory report from MYH biochemistry lab is pending.

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[An interactive map of the country can be found at: http://healthmap.org/r/1pSH . - Mod.LL]

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[3] Diarrhea - Nepal (Nuwakot District)
Date: Sun 16 Jun 2013
Source: The Himalayan Times [edited]
http://www.thehimalayantimes.com/fullNe ... sID=380295


The Okharpauwa VDC in Nuwakot has been gripped by diarrhea and vomiting coupled with fever for the past few days. Over 50 people have been affected by the disease that spread from Seudeni since last Fri 14 Jun 2013. Consumption of polluted drinking water is believed to be the reason behind the outbreak of the disease.

Of the affected, some have been taken to the capital for treatment. A health team headed by Dr Gopi Nepal from the District Health Office has reached the village Sunday [16 Jun 2013] to examine the patients and assess the situation, District Health Office Chief Bal Bahadur Mahat said.

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[An interactive map of the country can be found at: http://healthmap.org/r/1COd. - Mod.LL]

DENGUE/DHF UPDATE (52): ASIA
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- Pakistan (Sindh province). 22 Jun 2013. Dengue 303 cases. City most affected, Karachi 294 cases. Increasing.
http://www.thenews.com.pk/Todays-News-4 ... ed-in-city

[Maps of Pakistan can be accessed at http://www.ezilon.com/maps/images/asia/ ... kistan.gif and h<ttp://healthmap.org/r/2NT8>. - Mod.TY]

India
- Karnataka state. 21 Jun 2013. Dengue 1493; deaths 6. Cities most affected: Mysore 224 cases, Bangalore 163 cases. Increasing.
http://www.deccanherald.com/content/340 ... state.html

[Maps of India can be seen at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/1pSH. - Mod.TY]

- Kerala state. 20 Jun 2013. Dengue 153 cases; deaths (susp.) 2. Increasing.
http://www.thehindu.com/news/national/k ... 833134.ece

LEPTOSPIROSIS - INDIA: (ANDHRA PRADESH) SUSPECTED
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Date: Tue 25 Jun 2013
Source: The New Indian Express [edited]
http://newindianexpress.com/cities/hyde ... 651492.ece


On the advice of the professors of virology of Sri Venkateswara University, tests were conducted on patients [with mystery fever in Chittoor district and other parts of Rayalaseema region in Andhra Pradesh state] for leptospirosis. Around 120 cases of leptospirosis were suspected in the district when tests were carried out in Tirupati.

Leptospirosis is another mystery fever, [which is] caused by _Leptospira_. [It] is spread through urine of [chronically infected] rodents. It is prevalent in rat-infested areas and can spread through contaminated food or water. Even pets [and] farm animals can spread the disease; however, person-to-person transmission is rare. [The professor] advises people to have their pets examined, avoid contact with animal urine or body fluids, and not to swim, walk or consume water that may contain animal urine.

[Byline: S Guru Srikanth]

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[Leptospirosis is a zoonotic spirochetal infection that is distributed throughout the world in warm climates and is transmitted to humans by direct contact of abraded skin or mucous membranes with the urine of infected animals, or by contact with wet soil, vegetation, or water that has been contaminated with infected animal urine. These animals are mostly asymptomatic but chronically infected with one of the several hundred serovars of pathogenic _Leptospira_. Different leptospiral serovars are prevalent in particular geographical regions. In carrier animals with chronic renal infections, leptospiruria persists for long periods or for life.

_Leptospira_ bacteria shed in urine may survive in water or moist soil for weeks to months. Many species of wild and domestic animals (including dogs, cattle, swine, and especially rodents) are susceptible to chronic urinary infection with pathogenic _Leptospira_. Outbreaks of leptospirosis frequently follow heavy rainfall, flooding with fresh water, and increasing rodent numbers.

Because of the relatively nonspecific nature of the clinical presentation of leptospirosis, its diagnosis cannot be made confidently without laboratory confirmation.

Rayalaseema is a geographic region in the state of Andhra Pradesh in India (http://en.wikipedia.org/wiki/Rayalaseema). It includes the southern district of Chittoor, which has a population of 4 170 468 according to the 2011 census of India (http://en.wikipedia.org/wiki/Chittoor_district). For a map of Rayalaseema showing the district of Chittoor, see http://en.wikipedia.org/wiki/File:Rayalaseema.png. A map of India showing the central location of the state of Andhra Pradesh is accessible at http://www.mapsofindia.com/maps/india/i ... al-map.htm. Tirupati is a major pilgrimage and cultural city in the Chittoor district of India. It is the largest city in the Rayalaseema region (http://en.wikipedia.org/wiki/Tirupati_(city)). - Mod.ML

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/2JmE.]

SCRUB TYPHUS - INDIA: (ANDHRA PRADESH) SUSPECTED
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Date: Tue 25 Jun 2013
Source: The New Indian Express [edited]
http://newindianexpress.com/cities/hyde ... 651492.ece


Monsoon has arrived, spreading infectious diseases like dengue and Japanese encephalitis. But, this time, the people of the state [of Andhra Pradesh] have to be a little more cautious since there is likelihood of mystery fevers gripping the state, say experts.

Both rural and urban areas are prone to these fevers, as can be deduced from the rising number of such cases in the recent past. With the symptoms of these fevers being similar to infectious diseases such as dengue and Japanese encephalitis, the doctors are facing a major challenge to zero in on a correct diagnosis. Unfortunately, in some cases these fevers also lead to multiple organ failure.

Last month [May 2013], several cases were reported in Chittoor district and other parts of Rayalaseema region. On the advice of the professors of virology of Sri Venkateswara [SV] University, tests were conducted on patients for scrub typhus (mite-borne) infection. Around 80 cases of scrub typhus were suspected in the district when tests were carried out in Tirupati.

In the same month [May 2013], there were reports of an increasing number of cases of scrub typhus in Tamil Nadu [state], and even deaths were reported in Chennai due to that viral infection. [Scrub typhus is caused by a rickettsia-like bacterium, _Orientia tsutsugamushi_, not a virus.] In September last year [2012], there were reports of scrub typhus cases in Hyderabad [in Andhra Pradesh state] also.

SV University virology professor DVR Sai Gopal has launched an awareness campaign [for scrub typhus] recently through pamphlets and radio programmes explaining this disease in Tirupati and other parts of Chittoor district.

"A person can get scrub typhus if he is bitten by a chigger (mite) that is infected with the bacteria. On being bitten by the mite, the bacteria are transmitted from the host to the victim," he explained.

The disease manifests 1-3 weeks after the bite of an infected chigger. Initial symptoms include moderate fever, severe headache, shaking chills, cough, conjunctivitis, gastrointestinal symptoms, abdominal pain and nausea.

An eschar is formed like a cigarette burn on the part of the skin bitten by the mite. During the 2nd and 3rd week, if untreated, additional symptoms can include splenomegaly (enlargement of spleen), pneumonitis (lung infection), myocarditis (inflammation of heart muscle), encephalitis (infection of brain), meningitis (infection of the covering of brain), increased pulse rate, loss of consciousness and delirium.

The diagnosis of scrub typhus is based on the patient's exposure history, the clinical features and the results of serological tests like Weil-Felix text, ELISA [enzyme-linked immunosorbent assay], western blot, immunoperoxidase, immunofluorescence and PCR [polymerase chain reaction].

"Early detection and necessary treatment can cure the patient by killing the bacteria. However, it will take time to become completely healthy again as the damaged tissue needs to recover," Sai Gopal said.

The mites can be present anywhere, even in air conditioned rooms, as the moisture levels in those rooms are high where mites can thrive. They could be present in carpets and on lawns outside.

"Since there is no vaccine to protect against scrub typhus, it is advisable for the people to adhere to hygiene. Avoid walking barefoot, do not sit or lie on bare ground or grass, and ensure the environs are clean and free of rubbish and dust," he said.

[Byline: S Guru Srikanth]

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[_Orientia tsutsugamushi_, a rickettsia-like microorganism that is the cause of scrub typhus, is transmitted by the bite of a chigger. Chiggers are the 6-legged juvenile form (larvae) of an 8-legged mite. The 6-legged parasitic larvae feed on skin cells of their animal hosts. After feeding, the larva drops to the ground, becomes a nymph, and then matures into an adult. In the post-larval stage, they are not parasitic and feed on plant materials. The mites live in the forests and grasslands and are also found in low vegetation of lawns, golf courses, and parks (http://en.wikipedia.org/wiki/Trombiculidae#Distribution). Rodents may serve as reservoirs, although transovarial transmission in mites is the dominant mechanism for maintenance of _O. tsutsugamushi_ (http://www.cdc.gov/ncidod/EID/vol9no12/03-0212.htm). Humans become infected when they accidentally encroach on an area where the chigger-rodent cycle is occurring, most often areas of low-lying scrub brush or transitional vegetation. Patients with severe scrub typhus can develop multiorgan failure and disseminated intravascular coagulopathy with hemorrhage. Establishing the diagnosis and initiating prompt antimicrobial drug therapy are important, because death rates for untreated scrub typhus patients are 1-30 per cent (http://wwwnc.cdc.gov/eid/content/12/2/pdfs/v12-n2.pdf). Scrub typhus is effectively treated with doxycycline, and treatment should begin immediately upon suspicion of illness without awaiting laboratory confirmation.

The Weil-Felix test, an agglutination test for the diagnosis of rickettsial disease, is based on the detection of antibodies to various _Proteus_ species, which contain antigens that cross-react with rickettsial antigens. This test has poor sensitivity and specificity, but continues to be used in resource-poor regions (http://www.japi.org/august2006/O-619.pdf).

Rayalaseema is a geographic region in the state of Andhra Pradesh in India (http://en.wikipedia.org/wiki/Rayalaseema). It includes the southern district of Chittoor, which has a population of 4 170 468 according to a 2011 census of India (http://en.wikipedia.org/wiki/Chittoor_district). For a map of Rayalaseema showing the district of Chittoor, see http://en.wikipedia.org/wiki/File:Rayalaseema.png. A map of India showing the central location of the state of Andhra Pradesh is accessible at http://www.mapsofindia.com/maps/india/i ... al-map.htm. Tirupati is a major pilgrimage and cultural city in the Chittoor district of India. It is the largest city in the Rayalaseema region (http://en.wikipedia.org/wiki/Tirupati_(city)). - Mod.ML

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/2JmE.]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (09): (ASSAM)
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Date: Thu 27 Jun 2013
Source: Zee News, Press Trust of India (PTI) report [edited]
http://zeenews.india.com/news/assam/enc ... 58292.html


Since January this year [2013], 53 have died due to encephalitis and 362 others have suffered from acute encephalitis syndrome (AES) in Assam.

Another 24 positive cases of Japanese encephalitis were detected during the period, NRHM [National Rural Health Mission] state surveillance officer Dr B C Bhagabati told PTI.

Dibrugarh district in upper Assam accounted for the maximum deaths (13), he said; 10 of the deaths were reported this week, he said, with 3 deaths reported in Dibrugarh, 2 each in Sonitpur and Darrang, and one each in Jorhat, Lakhimpur and Morigaon districts.

Kamrup (Metro), where Guwahati is situated, had 29 incidences of the disease during the last 6 months.

As preventive measures, he said, the government has stepped up fogging and DDT spraying and intensified the ITBN (Insecticide Treated Bednet) scheme, besides holding awareness programmes in villages.

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[The number of Japanese encephalitis virus (JEV) infection cases in this report is not clear. Are the 24 JEV positive cases in addition to or a part of the 53 total cases? The report indicates that the 53 cases are acute encephalitis, a term that often includes JEV infection in some or in all instances. Emphasis on mosquito control implies that JEV is responsible for these cases. In reports from previous years, acute encephalitis syndrome [AES] in north eastern India has been attributed in part or entirely to JEV infections. However, in some instances, JEV infections are reported to be responsible for a minority of the cases. There is no indication in these or previous reports this year [2013] whether individuals, especially the children, have been vaccinated recently against JEV infection. Without knowing the specific etiology of the encephalitis cases above, targeted control and prevention measures will not be possible.

A HealthMap/ProMED-mail map showing the location of Assam state in northeastern India can be accessed at http://healthmap.org/r/2yW8. - Mod. TY]

LEPTOSPIROSIS - INDIA (02): (GUJARAT) SUSPECTED, REQUEST FOR INFORMATION
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Date: Fri 28 Jun 2013
Source: The Times of India, Times News Network (TNN) [edited]
http://timesofindia.indiatimes.com/city ... 807802.cms


A major outbreak of jaundice and other water-borne diseases has taken place in Sama area of the city [Vadodara, Gujarat]. Nearly 150 people are ill in the area in various residential localities.

Water contamination that took place about 10 days ago is believed to be the reason for the outbreak. Residents of the area had complained regarding this to Vadodara Municipal Corporation (VMC) officials.

According to VMC officials, 61 cases of jaundice and 88 cases of diarrhoea and gastroenteritis have been detected in the area during the last 3 days. The localities that have been affected are located between Chanakyapuri crossroads and Narmada branch canal located ahead.

VMC teams have been conducting door-to-door surveys in the affected parts and have so far covered over 3200 houses.

VMC medical officer (health) Dr Devesh Patel said extensive screening of the residents had been done and they had been given chlorine tablets to purify water and oral rehydration solution packets. He added that the water samples collected now were uncontaminated.

Sources said that work on a pipeline was conducted in the area about 10 days ago. Even as this was being done there were heavy rains while the pipeline was still open and this may have contaminated water. Residents had complained of dirty water supply around the same time.

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[The news report above describes an outbreak that included 61 cases of jaundice 10 days after an incident of water contamination. A water-borne disease that produces jaundice with an incubation period of about 10 days suggests a diagnosis of leptospirosis. Hepatitis A and E, other water-borne infectious diseases that also produce jaundice, have longer incubation periods (such as 2 to 8 weeks).

Leptospirosis is a zoonotic spirochetal infection that is distributed throughout the world in warm climates and is transmitted to humans by direct contact of abraded skin or mucous membranes with the urine of infected animals, or by contact with wet soil, vegetation, or water that has been contaminated with infected animal urine. These animals are mostly asymptomatic but chronically infected with one of the several hundred serovars of pathogenic _Leptospira_. Different leptospiral serovars are prevalent in particular geographical regions. In carrier animals with chronic renal infections, leptospiruria persists for long periods or for life.

_Leptospira_ bacteria shed in urine may survive in water or moist soil for weeks to months. Many species of wild and domestic animals (including dogs, cattle, swine, and especially rodents) are susceptible to chronic urinary infection with pathogenic _Leptospira_. Outbreaks of leptospirosis frequently follow heavy rainfall, flooding with fresh water, and increasing rodent numbers. In fact, the news report above says that there were heavy rains during instillation of a water pipeline, while the pipeline was still open, which may have contaminated the water supply.

However, because of the relatively nonspecific nature of the clinical presentation of leptospirosis, its diagnosis cannot be made confidently without laboratory confirmation.

Vadodara, with a population of almost 1.6 million people in 2005, is the 3rd largest city in the Indian State of Gujarat (http://en.wikipedia.org/wiki/Vadodara). Gujarat is in western India and is bordered by the Indian states of Maharashtra to the south and Madhya Pradesh and Rajasthan to the east, the Pakistani province of Sindh on the north, and the Arabian Sea on the west. A map of Indian states is accessible at http://www.mapsofindia.com/maps/india/i ... al-map.htm. - Mod.ML]

[While leptospirosis is the more likely diagnosis given the probable incubation period of approximately 7-10 days, it is also possible that there was an ongoing background outbreak of hepatitis in the area (pre-dating the installation of the new water pipeline) that was unrecognized until after the identification of the acute diarrheal outbreak, which led to an investigation of water-borne diseases in the area. More information on the etiology of this outbreak of jaundice would be appreciated. - Mod.MPP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/7rEt.]

LEPTOSPIROSIS - INDIA (03): (GUJARAT), SUSPECTED, COMMENT
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Date: Sun 30 Jun 2013
From: Jan Clement <jan.clement.dr@telenet.be> [edited]


Heavy rains and beginning floods can result in an increased number of fleeing rodents, as mentioned by the moderator, resulting in yet another health risk and provoking localized outbreaks of similar symptoms after a similar incubation time of 7-10 days, such as with hantavirus infections.

Hantaviruses are spread to humans by aerosolized excreta of chronically infected rodents, which act as both reservoirs and carriers. In India, the only known rodent carrier of pathogenic hantaviruses is the wild rat (_Rattus rattus_ or _R. norvegicus_), carrying the only globally spread hantavirus species, called _Seoulvirus_ (SEOV), a result of the worldwide spread of the wild rat.

Moreover, of all pathogenic hantavirus species, SEOV has the most pronounced tendency to induce liver involvement, besides kidney and/or lung involvement. In the initial phase, this can result in easily detectable diarrhea, gastroenteritis, and jaundice, as noted in Gujarat, before the more unapparent renal and/or pulmonary impairment arise, which, however, can also occur in leptospirosis.

Detecting, by means of specific serology, the difference between hantavirus disease, a viral, rodent-borne zoonosis, and its great mimicker, leptospirosis, a bacterial and again (mainly) rodent-borne zoonosis, is of prime importance, because only the latter is treatable with antibiotics, and because the clinical picture is undistinguishable, even with a kidney biopsy.

Failures of antibiotic treatment for leptospirosis are due, in most cases, to an administration of antibiotics too late in the clinical course but can also be attributed to a misdiagnosis, whereby the right underlying problem is, in fact, a missed hantavirus infection. Moreover, double concomitant human leptospirosis-hantavirus (SEOV) infections have also been reported, caused by the same rodent reservoir, the wild rat. So, in theory, a meticulous serological lab should always perform additional serological and/or RT-PCR testing for SEOV after positive findings for leptospirosis, particularly so in (sub)tropical regions.

India is a subcontinent heavily endemic for leptospirosis but where, up to now, only a very few SEOV cases have been documented so far serologically, despite the fact that the SEOV-rodent carrier, the wild rat, is omnipresent. A related murine rodent species, _Bandicota indica_, is likewise present and a carrier of another hantaviral pathogen, _Thailand virus_ (THAIV), of which, however, to our knowledge, no clinical cases have been documented so far in India.

Finally, fatal hantavirus cases with both severe kidney and lung involvement have been noted in south India, giving mainly _Puumalavirus_ (PUUV) reactions both in ELISA and immunoblot. However, PUUV is endemic only in Europe and European Russia due to the local presence of its rodent reservoir _Myodes glareolus_, which is completely absent in India. Thus, we have probably to deal with cross-reactions with an as yet unknown new hantavirus species in an as yet unknown rodent (or insectivore?) carrier in India. (Clement J, Maes P, Muthusethupathi M, Nainan G, Van Ranst M. First evidence of fatal hantavirus nephropathy in India, mimicking leptospirosis. Nephrol Dial Transpl 2006; 21: 826-7. http://ndt.oxfordjournals.org/cgi/conte ... 3/826?etoc). It should be remembered, however, that the 1st "new" fatal hantaviruses, discovered in 1993 in the New World (Four Corners, USA), were also 1st detected in the lab thanks to their serological cross-reactions with PUUV.

--
Jan Clement, MD
National Reference Centre for Hantavirus Infections
University Hospitals of Leuven, Belgium
<jan.clement@uzleuven.be>

[ProMED-mail thanks Dr. Clement for this interesting assessment of the outbreak in Vadodara, Gujarat, India. As also pointed out by Dr. Jan Clement in a prior ProMED-mail post "Leptospirosis - Jamaica (02) 20071018.3409," leptospirosis can mimic the clinical manifestations of hantavirus infection (1). Both diseases are transmitted by rats that can be unleashed by heavy rainfall. Dr. Clement and colleagues of the National Reference Laboratory for Hantavirus Infections, University Hospital Gasthuisberg, Leuven, Belgium found evidence of hantavirus infection in India mimicking leptospirosis (2).

Reference
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1. Clement J, Neild G, Lemos Hinrichsen S, et al: Urban leptospirosis versus urban hantavirus infection in Brazil. Lancet 1999; 354(9194): 2003-4. Available at http://www.thelancet.com/journals/lance ... 9/fulltext.
2. 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.

We await a more detailed description of the clinical manifestations in this outbreak, laboratory testing of infected individuals, and results of the ongoing epidemiologic investigations.

Dr. Clement makes a valid point about the need to include Seoul and other hantaviruses in diagnostic tests dealing with these types of outbreaks. It is important to consider that these outbreaks may be due to mixed infections, with more than one pathogen involved. - Mods.TY/ML

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1pSH.]

DENGUE/DHF UPDATE (54): ASIA
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*****
Nepal (Dang district, Midwestern region). 28 Jun 2013. Dengue one case. http://www.thehimalayantimes.com/fullNe ... sID=381790

[This is the 1st dengue case reported in Nepal since 2010. Assuming that the infection was locally acquired and not imported from India, there must be one other dengue virus infection there, and perhaps several more. The Dang district is in the southern Midwestern Region of Nepal, bordering Uttar Pradesh, India, and may be warm enough to support _Aedes aegypti_ vector mosquito populations.

Maps of Nepal can be accessed at http://ncthakur.itgo.com/map04.htm and http://healthmap.org/r/7slc. - Mod.TY]

Pakistan (Sindh province). 27 Jun 2013. Dengue 336 cases. Area most affected: Karachi 326 cases. Increasing. http://www.thenews.com.pk/article-10702 ... in-Karachi

[Maps of Pakistan can be accessed at http://www.ezilon.com/maps/images/asia/ ... kistan.gif and http://healthmap.org/r/2NT8. - Mod.TY]