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DENGUE/DHF UPDATE (64): ASIA
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Pakistan (Sindh province). 2 Aug 2013. Dengue 555 cases. Municipality most affected: Karachi 542 cases.
http://www.thenews.com.pk/article-11212 ... 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]

India (Odisha state). 30 Jul 2013. Dengue 318 cases. District most affected: Cuttack 222 cases.
http://zeenews.india.com/news/odisha/fi ... 65495.html

[Maps of India can be seen at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/4Jpo. - Mod.TY]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (30): ASIA
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[1] Cholera - India (Orissa State)
Date: Sun 4 Aug 2013
Source: The Hindu [edited]
http://www.thehindu.com/news/national/o ... epage=true


Cholera has resurfaced in Orissa's tribal dominated Rayagada as 9 out of 10 samples of rectal swab of patients in the district were found to have the _Vibrio cholerae_ bacterium. The samples collected from patients since 27 Jul 2013 were examined at the Regional Medical and Research Centre (RMRC) field unit in Rayagada, which confirmed the presence of the organism, officials said on Sun 4 Aug 2013.

"Cholera affected patients are being treated and no casualty has been reported. We are closely monitoring the situation," said Chief District Medical Officer (CDMO) (Rayagada) PK Das. 5 out of the 9 affected samples are from Padmapur block, 3 from Pitamahal on the outskirts of Rayagada town and 1 from Srinivasnagar, he said.

Cholera had erupted in the Rayagada district in 2010 and 2012 affecting many people. Cholera and gastroenteritis had earlier struck Rayagada, Koraput, and Kalahandi districts in 2007.

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[Maps of India can be seen at http://www.mapsofindia.com/ and http://healthmap.org/r/1pSH. - Mod.LL]

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[2] Cholera - India (Maharashtra State)
Date: Sat 31 Jul 2013
Source: Mumbai Mirror [edited]
http://www.mumbaimirror.com/mumbai/civi ... 496208.cms


For the 1st time in the last 5 years, BMC [Brihanmumbai Municipal Corporation, formerly known as the Bombay Municipal Corporation - Mod.LL] has acknowledged cholera in the city of Mumbai, with 52 cases reported in 2013. Of these, 42 were reported in July [2013] and 12 in June. Transmitted through contaminated water and food, the increasing number of cholera cases has now sent alarm bells ringing at the civic body.

"Cholera is a concern right now. Our lookout is to detect cases at the earliest so that there are no fatalities," said additional municipal commissioner Manisha Mhaiskar.

All these cases were detected through culture tests. A hanging drop test can also be conducted to detect the disease but BMC officials rely on only the culture tests. Senior physician Dr Pratit Samdani, however, said that if a patient had classic symptoms such as acute gastroenteritis, severe diarrhea and vomiting, and if the hanging drop test was positive, he or she should be counted as a cholera patient.

[Byline: Jyoti Shelar]

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[3] Cholera - India (Gujarat State)
Date: Sat 20 Jul 2013
Source: One India [edited]
http://news.oneindia.in/2013/07/20/two- ... 64175.html


District administration has declared 2 villages in the district as cholera-hit. Cholera cases were found at Boria and Silvai villages of Petlad tehsil, district health officer RB Patel said. At Boria, the surrounding area of up to 10 km [6 mi] has also been declared as cholera-prone. As many as 261 cases of diarrhea and vomiting were reported at Boria yesterday, 19 Jul 2013, of which 2 were confirmed to be cholera cases, he said. Government medical teams found that drinking water sources were contaminated after the rains. Alternative drinking water arrangements were made for the village and the teams were engaged in treating the victims, the officer said. Patel said, last week more than 50 cases of diarrhea and vomiting were reported at Silvai, of which one was confirmed as cholera.

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DENGUE/DHF UPDATE (66): ASIA
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- Pakistan (Sindh province). 5 Aug 2013. Dengue 549 cases; Increasing slowly.
http://www.thefrontierpost.com/article/31839/

[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 (Pune, Maharashtra state). 5 Aug 2013. Dengue in July 2013 only 44 cases; Deaths in all of 2013, 6.
http://articles.timesofindia.indiatimes ... ngue-cases

[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]

CHIKUNGUNYA (17): INDIA (KARNATAKA) SUSPECTED
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Date: Fri 31 May 2013
Source: Deccan Herald [edited]
http://www.deccanherald.com/content/335 ... agiri.html


The village on the Chikkaballapur-Devanahalli border is in the clutches of chikungunya and the number of patients as well as the fear of death are only rising by the day.

Doctors and medical staff have been treating the citizens ceaselessly the last about 15 days, but have been unable to control the spread of the disease. More than a 100 people are being treated at the government and private hospitals near Venkatagiri Kote on a daily basis, but many are now taking help from the hospitals at Chikkaballapur, Devanahalli, and Bangalore since the situation has not improved.

"Virtually all of Venkatagiri Kote is suffering from chikungunya [virus infections]. Visit any house and you will find at least a couple of residents being treated for the disease," say the worried residents of the village.

In Gangabhavani (Ambedkar) Colony itself there are more than 100 residents, including children aged 2 or 3 years, infected. The colony mostly houses manual workers and is majorly deprived of basic facilities, especially hygiene. With the fear of the fever diffusing its tentacles to everyone in the area spreading fast, residents say, "If one member of the family gets ill, it takes barely a couple of days for the fever to spread to the others. Passing each day is a difficult job."

Speaking to Deccan Herald, a resident of Venkatagiri Kote said, "The reason for the speed at which the infection is spreading is still not known to the doctors. The most prevalent symptoms of those ill in the village are those that come with an attack of chikungunya [virus]. There is fever, body ache, and weakness. Yet, the medical authorities are not sure of the type of fever or why there has been such a widespread attack." He also expressed the fear prevalent among the residents of Venkatagiri Kote of the disability to attend work, due to the illness: "The temporary state of joblessness because of the fever attack has added to our worries."

He rued, however, the lack of concern among the elected representatives towards the condition of the village residents. "On learning that Venkatagiri Kote was under attack of the fever for about a fortnight, the district health officer and the Devanahalli legislator visited us. If they are unable to control the spread of the disease none of us will feel like remaining in the village," he said.

The patients spend INR 500 [USD 8.85] to INR 700 [USD 12.39] a day for treatment at the private hospitals and clinics. "The doctors at some clinics fleece us giving the spread of the disease as a reason," said the citizens.

The doctors and medical staff have been struggling to simultaneously treat the ill residents and prevent further cases of illness. They have remained at the village, working at the treatment centre through the day. "The fever cannot be specified as chikungunya or dengue. It is a viral fever and it spreads through _Aedes_ mosquitos," said Dr Yadupathi, medical officer at the primary health centre, Karahalli.

"The blood samples of the patients have already been sent to Bangalore Public Health Institute (PHI) and we are yet to receive the report. Only after we receive their take on the illness can we say for sure what kind of fever the residents of are suffering from," he added.

[byline: Rahul Belagali]

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[Curiously, no mention is made of acute arthralgia, a common symptom of most chikungunya virus infections. Joint pain can be so severe that it is incapacitating, and may last for weeks or months. The results of laboratory tests would be of interest, to know if this outbreak is really due to chikungunya virus or to dengue virus infections, or to a mixed outbreak of both.

Chikungunya virus is endemic in India, and causes sporadic cases around the country. There is no commercially available vaccine available, so mosquito vector control is the only feasible preventive measure.

A HealthMap/ProMED-mail map showing the location of Karnataka state can be accessed at http://healthmap.org/r/77wE and of the Chikkaballapur district at http://en.wikipedia.org/wiki/Chikkaballapur. - Mod.TY]

CHIKUNGUNYA (18): INDIA (KARNATAKA) SUSPECTED
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Date: Sat 1 Jun 2013
Source: The Times of India, Times News Network (TNN) [edited]
http://timesofindia.indiatimes.com/city ... 386735.cms


As many as 8 suspected cases of chikungunya were reported from 4 villages of Hukkeri Taluk on Saturday [1 Jun 2013]. District health officials have taken all precautionary measures to control the disease.

According to district health official sources, there have been no cases of chikungunya [virus infections] in the district for the past 2 years, but this year [2013] already the district has reported 6 cases. There are 8 suspected chikungunya cases in 4 villages of Hukkeri Taluk: Gejapati, Guthugutti, Rajagatti, and Yellapur villages with populations of 1200, 2700, 2000, and 600 people respectively. The 4 villages come under the care of Islamphur Public Health Centre.

When many people came to the health centre with similar symptoms, health officials became alert and when they inspected the villages [they suspected] cases of chikungunya [virus infections]. The district administration has taken all precautionary measures to tackle the disease. The district health officer Dr Dileep Kumar Munoli, Dr Jagadish Nuchin, district surveillance officer, and Dr Rajanish Meti, district epidemiologist visited the villages, [assessed the situation], and made necessary arrangements to tackle the disease. The health officials also conducted house-to-house larvae surveys and fogging. The health department has also set up mobile clinics in the villages.

Due to the scarcity of water, people in villages store water for longer periods without proper cover, which favors mosquito [reproduction]. Hence, health officials have called upon the people to keep water containers properly and tightly closed.

[byline: R Uday Kumar]

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[No mention is made of the clinical symptoms observed in these cases, and especially of acute arthralgia, a common symptom of most chikungunya virus infections. Joint pain can be so severe that it is incapacitating, and may last for weeks or months. It is not stated if samples have been sent for laboratory tests. This is important to know if this outbreak is really due to chikungunya virus or to dengue virus infections, or to a mixed outbreak of both. Interestingly, there is another outbreak of chikungunya virus infections in south east Karnataka state, far from the one described above.

A HealthMap/ProMED-mail map showing the location of Karnataka state can be accessed at http://healthmap.org/r/77-T and a map showing the location of Hukkeri Taluk in north western Karnataka state at http://en.wikipedia.org/wiki/Hukeri. - Mod.TY]

CHIKUNGUNYA (30): INDIA (GUJARAT)
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Date: Wed 7 Aug 2013
Source: India.com Health [edited]
http://health.india.com/news/chikunguny ... ahmedabad/


Has chikungunya [virus] made a comeback in the city [Ahmedabad]? After the civic body and the government tried their best to control the figures, the disease seems to be back again. Members of the Ahmedabad Municipal Corporation's (AMC) health committee on Monday [5 Aug 2013] discussed how the various diseases were increasing in the city.

According to figures obtained from the civic body, the city witnessed 43 cases of chikungunya [virus infections] last year (January 2012-December 2012). Surprisingly, 20 cases of chikungunya were reported this July [2013] alone, which is nearly 50 per cent of last year's total in just one month! Also, 39 cases of chikungunya have been reported from January to July this year [2013]. However, no deaths have been reported this year.

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[The report above does not indicate if these reported cases have been confirmed by laboratory. There have been outbreaks of chikungunya virus infection in Karnataka state this year (2013). The virus is endemic in India, so it is not surprising that there are sporadic outbreaks in various parts of the country.

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

SCRUB TYPHUS - INDIA (02): (RAJASTHAN)
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Date: Tue 13 Aug 2013
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city ... 790657.cms


Three people have tested positive for scrub typhus at Sawai Man Singh (SMS) hospital between 5 and 11 Aug 2013. According to hospital officials, one of them was brought from Alwar and 2 from Dausa. All 3 were suffering from fever, chills, and other symptoms of scrub typhus. Suspecting that the patients might be suffering from scrub typhus, the doctors advised them to undergo the test, which is available at the SMS hospital. The patients were tested positive for the deadly disease. Mortality is high with scrub typhus if patients fail to get immediate treatment. At least 14 people died of the disease in 2012, and more than 140 cases were reported from different parts of the state.

The deadly disease was 1st reported 3 years ago in Alwar. In 2012, it spread to 10 different districts. Some cases were reported from Jaipur as well. An SMS hospital official said that the 3 cases reported now are the 1st cases of scrub typhus of the season [2013] in the state.

Health officials said that, mostly, those in rural areas are likely to fall victim to the disease, as there are mites, known as chiggers, which are found in grass and green areas. The chiggers are found in scrub vegetation. The mites bite a person and leave behind a black spot (eschar) on the body.

Apprehensive about the spread of the disease, the health department has started taking all precautionary measures in the area where the scrub typhus cases were reported in 2012.

Dr Bairwa said that since mortality among scrub typhus cases can be high, they are administering doxycycline tablets for those coming with fever, as it is the best available medicine for the disease.

[byline: Syed Intishab Ali]

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[There are a number of diseases with typhus literally, or figuratively, in their names, including epidemic typhus, Brill-Zinsser disease (recrudescent epidemic typhus), murine typhus, scrub typhus, and typhoid (so-called because it is typhus-like and sometimes called abdominal typhus). The term typhus comes from the Greek, _typhein_ (to smoke), which may refer to the smoky or clouded mental status that patients present with.

Typhus fever, the classical epidemic typhus, is a vectorborne disease with a complex epidemiology. Lice, the vectors, live in clothing; therefore, weather, humidity, and hygiene determine their prevalence. Consequently, the body or clothing louse is more prevalent during the colder months, and epidemic typhus is more frequently reported during the winter and early spring.

The permanent foci of the body louse exist in regions subject to cold weather, where inhabitants need to wear multiple layers of clothes, and in poverty-stricken communities whose inhabitants lack multiple sets of clothes. Such populations are most common in mountainous regions of countries in intertropical zones, including Ethiopia, Burundi, and Rwanda in Africa, Peru in South America, and Nepal and Tibet in central Asia. The prevalence of body lice increases with altitude. Infestation with lice is more frequent during wars, in trenches, and in jail, where conditions are cramped, when it is cold, and where hygiene is limited. Large outbreaks of lice have been associated with the recent civil wars in Burundi. An outbreak of typhus occurred in a jail in Burundi, and subsequently, a huge outbreak of typhus occurred in several refugee camps, where nearly all inhabitants were louse-infested.

The body louse attaches its eggs to clothing, not to the body or hair, often on the inner belts of underwear, pants or skirts. When removed from the body, even in the absence of insecticides, the unwashed clothes will [lose all] viable lice and eggs within 7 days. Raoult and Roux (1) cite Maunder (2), who hypothesized that religious Sabbath and Sunday ritual days of rest with a change of clothes could [have contributed] to a delousing cycle. _Rickettsia prowazekii_, the causative agent of typhus fever, is considered a category B biowarfare agent because of the propensity for infective louse feces to be aerosolized.

Scrub typhus is spread to humans as a zoonosis by the bite of the larval stage of trombiculid mites (chiggers). The term scrub comes from the type of local vegetation, scrub, between forests and cleared areas, where the vector is found. The disease is also referred to as tsutsugamushi fever. The organism, _R. tsutsugamushi_, or _Orientia tsutsugamushi_, causes natural disease in eastern Asia and in the western Pacific. In any area, because of high rates of transovarian transmission in the mite, highly focal areas of high risk exist. Symptoms are often nonspecific, but severe headache and myalgias (common in rickettsioses), and an eschar [dry scab] with regional lymphadenopathy [swollen lymph nodes in the same area], can be helpful to diagnosis in endemic areas. The diagnosis can be made serologically, although early treatment (doxycycline) may blunt the antibody response.

Weil and Felix described the classical assay for rickettsial antibody detection in 1916. The methodology took advantage of heterophilic (cross-reacting) antigens of members of the genus _Rickettsia_ and several species of the Gram negative bacillus _Proteus_. In the Weil-Felix test, bacteria of _Proteus vulgaris_ OX-19 agglutinate with sera of those infected with the typhus group organisms and with the Rocky Mountain Spotted Fever (RMSF) organism _R. rickettsii_. Cells of _P. vulgaris_ OX-2, on the other hand, agglutinate with sera from individuals with spotted fever infection, except RMSF. The OX-19 agglutination is seen in epidemic typhus, but usually not in Brill-Zinsser recrudescent disease. _P. mirabilis_ OX-K can be similarly used in the serological diagnosis of scrub typhus. Because of the relatively poor sensitivity, and specificity, of this test, more specific assays can be used for diagnosis, including complement fixation. Dipstick enzyme-linked immunosorbent assays (ELISA) (3) and polymerase chain reactions (PCRs) (4) have now been added to potential diagnostic tests.

References
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1. Raoult D, Roux V. The body louse as a vector of reemerging human diseases. Clin Infect Dis. 1999; 29: 888-911.
2. Maunder JW. The appreciation of lice. Proc Roy Inst Great Britain. 1983; 55: 1-31.
3. Pradutkanchana J, Silpapojakul K, Paxton H, et al. Comparative evaluation of 4 serodiagnostic tests for scrub typhus in Thailand. Trans R Soc Trop Med Hyg. 1997; 91: 425-8.
4. Manosroi J, Chutipongvivate S, Auwanit W, Manosroi A. Early diagnosis of scrub typhus in Thailand from clinical specimens by nested polymerase chain reaction. Southeast Asian J Trop Med Public Health. 2003 Dec; 34(4): 831-8. - Mod.LL

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

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (33): AFGHANISTAN (BADAKHSHAN)
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Date: Tue 13 Aug 2013
Source: CBC (Canadian Broadcasting Corporation) News, Associated Press (AP) [edited]
http://www.cbc.ca/news/world/story/2013 ... llage.html


A cholera outbreak at a village in north east Afghanistan has infected 1492 people, killed a young woman, and left another 100 in critical condition, a provincial official said on Tue 13 Aug 2013.

Abdul Marouf Rasekh, a spokesman for the governor of Badakhshan province, said the outbreak began 3 days ago and was restricted to one town that has been quarantined. When it first appeared in the mountainous village of Chappa [also spelled Chapa - Mod.LL] in the Darayen district, Rasekh said it infected 850 people but quickly spread until the quarantine was put in place.

Rasekh said the source of the infection had been traced to a single spring of water that supplies the entire town's drinking water. Health authorities were bringing in water from nearby towns until the problem was solved. He said that 36 of the most serious cases have been taken to a hospital in the provincial capital of Faizabad and that the sole death so far was an 18 year old woman.

Afghanistan has had cholera outbreaks in the past but they are not common. Typhoid and other intestinal diseases and parasites are far more common but not as deadly if left untreated. Access to clean drinking water is a problem in rural Afghanistan and health care is rudimentary in large parts of the country, which has one of the world's lowest life expectancies at 50. Only 12 per cent of Afghans living in rural areas have access to clean drinking water, according to the US Agency for International Development.

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[Maps of Afghanistan can be seen at http://www.un.org/Depts/Cartographic/ma ... is-reg.pdf and http://healthmap.org/r/4H4g.

Badakhshan Province (http://en.wikipedia.org/wiki/Badakhshan_Province) is one of the 34 provinces of Afghanistan, located in the north eastern part of the country between the Hindu Kush mountains and the Amu Darya River. It is part of a broader historical Badakhshan region. In the east of the province a long spur called the Wakhan Corridor extends above northern Pakistan's Chitral and Northern Areas to a border with China.

Contaminated water is a common vehicle for transmission of _Vibrio cholerae_. Since the infection is uncommon in the country, one would wonder how the water source became contaminated. - Mod.LL]

TYPHOID FEVER UPDATE (06): AUSTRALIA ex INDIA, TRAVELERS
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Date: Mon 12 Aug 2013
Source: News ninemsn, Australian Associated Press (AAP) report [edited]
http://news.ninemsn.com.au/health/2013/ ... phoid-home


An increasing number of travelers are bringing typhoid home with them to Australia, prompting a call for people not to neglect pre-departure vaccinations.

Many of the cases are from Australians of Indian descent returning from visiting family and friends on the subcontinent, says Dr Anita Heywood, an infectious disease expert and lecturer at the University of NSW (UNSW). She says pre-travel immunization helps to not only prevent diseases in individuals but also protects the general population once the traveler returns.

Typhoid is a potentially dangerous bacterial disease contracted from contaminated food or water. The number of cases reported to the Department of Health has doubled in the past 5 years. Before 2007, there were 50 to 70 cases a year. In 2008, 100 were reported. There were 135 in 2011, 123 in 2012, and there have been 101 cases so far in 2013. There were 32 in January alone.

"Immunity to typhoid wanes and migrants to Australia who return home may not be aware of the risk to themselves and their children," Dr Heywood has told a stakeholder workshop on immunization for refugees, migrants, and travelers held at UNSW by the Centre for Research Excellence in Immunization. "The disease is vaccine preventable and prevention is particularly important with an increase in antibiotic-resistant strains."

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[Typhoid fever is the classical human infection caused by _Salmonella enterica_ serotype Typhi. Unlike most salmonellas, _S._ Typhi is not zoonotic, being a pathogen only of humans, and may cause constipation and not diarrhea.

As a reminder, the term abdominal typhus is still used in some places to refer to typhoid fever, since typhus (caused by _Rickettsia prowazekii_) and typhoid fever (caused by _Salmonella_ Typhi) present quite similar symptoms, such as the fever pattern, the rash, and the cloudy mental state (also called coma vigil).

For travelers to the developing world, especially VFRs (visitors to friends or relatives), there are 2 basic modalities to avoid this infection:
1. avoidance of risky drinks and foods and
2. vaccination.

CDC summarizes these modalities on its website (http://www.cdc.gov/nczved/divisions/dfb ... oid_fever/):
1. "Boil it, cook it, peel it, or forget it"
- If you drink water, buy it bottled or bring it to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water.
- Ask for drinks without ice unless the ice is made from bottled or boiled water.
- Avoid popsicles and flavored ices that may have been made with contaminated water.
- Eat foods that have been thoroughly cooked and that are still hot and steaming.
- Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well.
- When you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.) Do not eat the peelings.
- Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors.

2. Vaccinations
If you are traveling to a country where typhoid is common, you should consider being vaccinated against typhoid. Visit a doctor or travel clinic to discuss your vaccination options.

Remember that you will need to complete your vaccination at least 1-2 weeks (dependent upon vaccine type) before you travel so that the vaccine has time to take effect. Typhoid vaccines lose effectiveness after several years; if you were vaccinated in the past, check with your doctor to see if it is time for a booster vaccination. Taking antibiotics will not prevent typhoid fever; they only help treat it.

The chart below provides basic information on typhoid vaccines that are available in the USA.
Vaccine name / How given / # Doses / Time between doses / Booster
------------------------------------------------------------------
Ty21a / 1 capsule orally / 4 / 2 days / 5 years
Typhim Vi / Injection / 1 / N/A / 2 years
(The old parenteral heat-phenol-inactivated vaccine (manufactured by Wyeth-Ayerst) has been discontinued.)
- Mod.LL

JAPANESE ENCEPHALITIS AND OTHER - INDIA (13)
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[1]
Date: Mon 19 Aug 2013
Source: The Telegraph [edited]
http://www.telegraphindia.com/1130819/j ... hT2ja7th9E


Poor surveillance, incomplete diagnosis and unsubstantiated scientific claims have stymied India's efforts to control the mystery encephalitis that has killed 3000 children in eastern India over the past 3 years, health researchers have said.

A new study has warned that low-quality surveillance appears to be obstructing attempts to understand the cause of the acute encephalitis syndrome (AES) observed mainly in Assam, Bengal, Bihar and Uttar Pradesh with sporadic cases in other states.

The Union health ministry documented more than 21 600 patients with AES, including 3171 deaths, most of them in the eastern states, between 2010 and 2012. A central government programme that tracks encephalitis, or brain inflammation, has claimed that waterborne enteroviruses have replaced the Japanese encephalitis virus as the main cause of encephalitis. But many scientists believe the identity of the viruses still remains hazy.

"In this time and age, there can be no excuse for failing to identify an unknown virus," said a senior government scientist who requested not to be named. "Technology exists today to sequence a virus in less than 6 hours," the scientist told The Telegraph.

The study on the quality of surveillance and diagnosis examined the case records of patients from Kushinagar district in Uttar Pradesh and suggested that assertions that waterborne enteroviruses are the dominant cause of encephalitis are not backed by adequate scientific evidence.

"Without reliable scientific evidence, it is very easy to shift the hypothesis (of the cause of the encephalitis)," said Manish Kakkar, a microbiologist and faculty member at the Public Health Foundation of India, New Delhi, a research and training institution.

Kushinagar has been among hubs of encephalitis in eastern India where the Japanese encephalitis virus picked up through mosquito bites had been considered the primary cause of encephalitis from the 1970s until about 2010.

The Union health ministry had introduced a mass vaccination campaign against the Japanese encephalitis virus in the affected states in eastern India in 2006 with a fresh campaign in 2010, but both Japanese encephalitis and AES have persisted.

Health ministry figures suggest that AES has outnumbered Japanese encephalitis (JE) [cases] over the past 3 years. During 2012, for instance, India had 745 cases of JE and 8344 cases of AES, with 140 deaths from JE and 1256 deaths from AES.

Kakkar and his colleagues have found that the results of diagnostic tests on samples or blood or cerebrospinal fluid from 590 (82 per cent) out of 721 encephalitis patients registered at a district hospital during 2011 were still awaited in July 2012, after virtually all the children had been discharged or died. In 80 per cent of the cases, health authorities had no idea whether patients had been vaccinated.

"These findings are shocking; with such gaps in information, it's hard to estimate the effect of the vaccination or to determine what might be causing the illness," said Kakkar, lead author of the study published in the journal Emerging Infectious Diseases [see below].

The National Institute of Virology (NIV), Pune, under the Indian Council of Medical Research has set up a surveillance centre in eastern Uttar Pradesh to help analyse samples from patients and try to identify the cause of the AES.

The NIV has said it has detected in samples of cerebrospinal fluid of patients with encephalitis genetic material resembling that of enterovirus 89 and enterovirus 76, and throat swabs of patients have turned up signatures of the coxsackievirus and 2 types of echovirus. "Enteroviruses are known to cause encephalitis, and our evidence is strong," a senior NIV scientist said.

But Kakkar and his colleagues say the focus of health authorities has shifted to enteroviruses even though the studies that found enteroviruses in patient samples have not demonstrated that waterborne pathogens are the main cause of the encephalitis.

"What Kushinagar shows is India's failure to establish a reliable public health surveillance network," said T. Jacob John, a senior virologist formerly with the Christian Medical College, Vellore.

"We don't need to pinpoint the cause to treat children with encephalitis, for the medical management of the illness," John said. "But to prevent new infections, we have to understand what's causing them."

[Byline: G.S. Mudur]

--
Communicated by:
ProMED-mail Rapporteur Kunihiko Iizuka

******
[2]
Date: Tue 20 Aug 2013
Source: Emerging Infectious Diseases, Volume 19, September 2013 [edited]
http://wwwnc.cdc.gov/eid/article/19/9/1 ... edcitation


Reference:
Kakkar M, Rogawski ET, Abbas SS, Chaturvedi S, Dhole TN, Hossain SS, et al. Acute encephalitis syndrome surveillance, Kushinagar District, Uttar Pradesh, India, 2011-2012. Emerg Infect Dis. 2013 Sep [date cited]. http://dx.doi.org/10.3201/eid1909.121855External DOI: 10.3201/eid1909.121855

Abstract:
In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011-June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23 per cent had illogical entries. AES incidence was highest among boys under 6 years of age, and cases peaked during monsoon season. Records for laboratory results (available for Japanese encephalitis but not AES) and vaccination history were largely incomplete, so inferences about the epidemiology and etiology of AES could not be made. The low-quality AES/Japanese encephalitis surveillance data in this area provide little evidence to support development of prevention and control measures, estimate the effect of interventions, and avoid the waste of public health resources.

Conclusion:
The current AES/JE surveillance system has a complicated specimen referral and reporting system at the district level, and the available line lists suggest that data are of low quality. Without evidence to estimate the effect of interventions, AES prevention and control measures may be ineffective, and public health resources may be wasted. In 2011, AES and JE were highlighted in the national media, leading to a declaration for several policy initiatives, including formation of a multi-sectorial and inter-ministerial National Encephalitis Control Programme. Despite the high profile of AES, the importance of surveillance data for guiding these initiatives has not been realized or translated to action. Gaps in surveillance capacity that were identified in this study indicate the need for a systematic evaluation of the AES/JE surveillance system in Kushinagar District and constitute key lessons that need to be incorporated as strategic planning is undertaken for this new initiative.

--
Communicated by:
ProMED-mail Rapporteur Kunihiko Iizuka

[These 2 reports underscore the need for establishing a reliable diagnosis for the etiology of the AES cases, as has been noted in the moderator comments in ProMED-mail posts over the past several years. As these 2 above reports indicate, as is usually the case for reports of encephalitis cases in India, the etiologies of these cases is not given. Sometimes, all these cases are attributed to Japanese encephalitis virus (JEV) infections, sometimes just a lesser proportion of them, and sometimes none of them. An earlier report attributed them to heat stroke.

Without knowing the specific etiology or etiologies of these encephalitis cases, targeted control and prevention measures will not be possible. An earlier report this year (2013) indicated that a team from the USA CDC was going to the endemic areas to assist in establishing the causal agent(s) responsible for these cases (see ProMED-mail archive no. 20130714.1824758). No further information has emerged concerning that badly needed effort.

A HealthMap/ProMED-mail map of India showing the location of the states mentioned above can be accessed at http://healthmap.org/r/1pSH. - Mod.TY]

DENGUE/DHF UPDATE (68): ASIA
****************************
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. 17 Aug 2013. Dengue 27 cases; Municipality most affected: Lahore; Increasing.
http://www.brecorder.com/pakistan/gener ... 31667.html

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

- Sindh province. 17 Aug 2013. Dengue 681 cases; Municipality most affected: Karachi 663 cases.
http://www.dailytimes.com.pk/default.as ... 013_pg12_7.

- India:
- Delhi. 12 Aug 2013. Dengue as of 10 Aug 2013, 41 cases.
http://www.business-standard.com/articl ... 242_1.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]

- Mysore district, Karnataka state. 14 Aug 2013. Dengue 224 cases; Deaths 9.
http://www.deccanchronicle.com/130814/n ... ases-month

- Pune, Maharashtra state. 13 Aug 2013. Dengue 1-13 Aug 2013, 33 cases.
http://articles.timesofindia.indiatimes ... ment-cases

- Odisha state. 11 Aug 2013. Dengue 893 cases; District most affected: Cutback 549 cases.
http://orissadiary.com/CurrentNews.asp?id=43129

GASTROENTERITIS - TURKEY: (ANTALYA) HOTEL GUESTS
************************************************
A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Thu 22 Aug 2013
Source: Mirror [summ., edited]
http://www.mirror.co.uk/news/world-news ... ak-2203585


Hundreds of British holidaymakers have been struck down by a virus at a Turkish seaside hotel. A baby and several adults required hospital treatment after the bug hit guests at the Sentido Perissia Hotel in Side [Antalya province]. Tour operator Thomas Cook said yesterday [21 Aug 2013] it was suspending bookings at the all-inclusive hotel for the next week and providing other accommodation for those due to stay there. The company has also flown out hygiene experts from the UK to investigate the cause of the outbreak, which causes vomiting and diarrhoea.

More than 100 British guests met hotel representatives on Tuesday [20 Aug 2013] to demand action over the virus, believed to have started several weeks ago. The hotel has closed the main swimming pool and advised people to stay in their rooms. Guests have posted warnings on holiday review website TripAdvisor, and a Facebook page for those affected has been set up.

Travel lawyer Nick Harris said: "They have told of widespread illness among hundreds of guests." Tour operator Thomas Cook said last night [21 Aug 2013]: "We can confirm that a number of customers at the Sentido Perissia, Turkey, have reported a stomach upset lasting 24-48 hours. "Preliminary indications suggest that this is of a viral nature. We immediately arranged for an independent UK hygiene consultant to carry out a comprehensive review of the hotel."

[Byline: Nigel Atkins]

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

[This outbreak of gastroenteritis has characteristics of norovirus infection -- sudden onset and rapid resolution. This outbreak, however, seems to have affected a large number of hotel residents over a period of days. There is no indication of the source of the outbreak, and the recommendation that guests should remain in their rooms is hardly realistic. Unfortunately, there is no specific treatment for norovirus infection.

Side is a city on the southern Mediterranean coast of Turkey, a resort town and one of the best-known classical sites in the country. It is located on the eastern part of the Pamphylian coast, which lies about 20 km (12 miles) east of the mouth of the Eurymedon River. Today, as in antiquity, the ancient city is situated on a small north-south peninsula about 1 km (0.6 mile) long and 400 m (0.2 mile) across. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/83lz.]

UNDIAGNOSED FEBRILE ILLNESS - INDIA (02): (GUJARAT) REQUEST FOR INFORMATION
***************************************************************************
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Date: Wed 21 Aug 2013
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... ver-dengue


Mystery fever mimicking dengue confounds doctors
------------------------------------------------
The sudden spurt in cases of a viral fever that is resistant to treatment has flummoxed doctors in the city [Ahmedabad, in Gujarat state]. Children are its easy prey. Constant high fever, body ache and -- in some cases -- declining blood platelet count, have made it difficult for doctors to diagnose the causative virus. The common adage, "4 days of rest for viral and then back to work", is now a concept of yesteryears.

Physicians across the city are encountering 30 to 40 such cases a day. Even municipal hospitals, like the VS Hospital in Paldi, are reporting 60 such cases every day.

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

[The etiology of these cases has not been determined. Dengue is mentioned in the headline, but it is not clear if it has been ruled out by laboratory tests, nor if have any other of the many pathogens associated with febrile disease. The limited information provided does not permit reasonable speculation concerning which agents might be involved in these cases. An earlier series of cases of undiagnosed febrile disease were reported in Tamil Nadu state this year (2013) and in December 2012. ProMED-mail would appreciate receiving more details, and especially any additional laboratory results for the current outbreak, as they become available.

A HealthMap/ProMED-mail map showing the location of Gujarat state can be accessed at http://healthmap.org/r/27Ix. - Mod.TY]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (14): (UTTAR PRADESH)
*************************************************************
A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
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Date: Thu 22 Aug 2013
Source: CNN-IBN Live [edited]
http://ibnlive.in.com/news/up-encephali ... 3-242.html


Gorakhpur district of Uttar Pradesh has been affected by encephalitis once again, with 30 children succumbing to the disease in the past 5 days. Almost 100 deaths have been reported in August [2013] alone with more than 300 children admitted to the BRD Hospital.

A water and mosquito-borne disease, encephalitis sees a peak during the monsoon.

In 2012, more than 500 deaths were reported officially due to the disease.

The government has set up a GOM [Group of Ministers] and sanctioned Rs 4000 crore [Rs 40 billion; approx. USD 632 million, which seems extremely high] to fight the killer disease.

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

[The mosquito-borne component of these cases is doubtless due to Japanese encephalitis virus (JEV) infections and the water-related to enteroviruses infections. No indication is given in the report above of whether the etiologies of these infections has been determined by laboratory tests, of the proportion of the cases that are due to JEV infections, or of the status of JEV vaccination efforts in this endemic area. As has been clearly pointed out in an international publication (see ProMED-mail archive no. 20130821.1892929], until there is adequate and specific diagnosis of these cases, it will not possible to design and implement effective prevention campaigns, and additional cases and fatalities can be expected.

A HealthMap/ProMED-mail map of India showing the location of Uttar Pradesh state can be accessed at http://healthmap.org/r/3h8J. - Mod.TY]

FOODBORNE ILLNESS - TURKEY: (ANTALYA), HOTEL
********************************************
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Date: Sat 24 Aug 2013
Source: Daily Mail [edited]
http://www.dailymail.co.uk/news/article ... oning.html


A father suffered _E. coli_ infection on a Thomas Cook family holiday at a 5-star Turkish hotel where hundreds of British tourists fell ill.

Guests at the all-inclusive Sentido Perissia Hotel in Side have been confined to their rooms because of a mass outbreak of sickness. The father, who was on holiday with his wife and 2 two children, had tests after returning to Britain which revealed he had contracted the _E. coli_ infection.

Thomas Cook said there has been an outbreak of norovirus at the hotel and that the food and hygiene standards are not to blame. The holiday company has suspended holidays at the resort after guests fell ill. It is also claimed that another guest had been infected by Giardia, a parasite that has been found in the water.

[Byline: Rob Cooper]

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

[ProMED reported the norovirus outbreak at this location. See: Gastroenteritis - Turkey: (AL) hotel guests. Archive Number: 20130822.1895920

Side (http://en.wikipedia.org/wiki/Side) is a city on the southern Mediterranean coast of Turkey, a resort town and one of the best-known classical sites in the country. It lies near Manavgat and the village of Selimiye, 75 km from Antalya in the province of Antalya.

Norvovirus outbreaks do not have to be food or waterborne and can easily spread from person to person. That being said, the epidemiology of this outbreak can assist in the determination based on the time course of the case numbers. However, with a case of _E. coli_ and one of giardiasis, it can be suggested that fecal contamination may have occurred. - Mod.LL

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