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BRUCELLOSIS - KYRGYZSTAN: (NARYN)
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ProMED-mail is a program of the
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Date: Mon 29 Dec 2008
Source: FarmingUK [edited]
<http://www.farminguk.com/news/Kyrgzstan ... s.9548.asp>


[An] epidemic of brucellosis in Kyrgyzstan has affected 2000 humans.
The Red Cross and the World Health Organization (WHO) are at a loss
knowing what to do as the hospitals fill up and nothing is being done
to prevent the spread of the disease.

The small former Soviet nation of Kyrgyzstan that gained independence
in 1991 is showing in the Naryn region, a 10 percent incidence of
brucellosis in the human population according to the WHO. Brucellosis
in humans causes loss of weight, followed by a slow agonizing death
and abortion in women.

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

[The 10 percent incidence of brucellosis in Naryn reported in the
news release above has been denied by the Ministry of Health Care of
Kyrgyzstan. The director of the Republican Center of quarantine and
dangerous infections, J Gaibulin, told the correspondent from the
Kabar Agency that 404 cases [about 15 cases per 10 000 population] of
brucellosis were registered this year [2008] in Naryn oblast and 444
cases last year [2007] (see
<http://74.125.47.132/search?q=cache:C1d ... cd=1&gl=us>).

Brucellosis in humans is a zoonotic infection caused mainly by one of
3 species of _Brucella_, namely B. melitensis_, _B. suis_, and _B.
abortus_. Brucellosis is transmitted to humans either by direct
contact with tissues of infected animals or their
post-partum/post-abortion secretions, or by the ingestion of
contaminated, unpasteurized food products, mainly dairy products.
Direct person-to-person transmission from an infected mother to infant
can occur by means of breast-feeding. Sexual transmission has also
been reported. _B. melitensis_, which causes the most severe
infections in humans, is maintained in small ruminants (sheep and
goats), though cases in cattle and buffalo may occur sporadically. _B.
abortus_ is maintained mainly in large bovines (cattle and buffalo).
The _Brucella_ species that are causing brucellosis in Kyrgyzstan are
not given in the news release.

Brucellosis in humans causes fever, sweating, weakness, headaches,
depression, and muscle and joint pains, the duration of the which can
vary from a few weeks to many months or even years. Mortality is low
(less than 2 percent), and is usually associated with endocarditis.
Focal complications include sacroiliitis, endocarditis,
epididymoorchitis, and meningitis. Diagnosis is based on isolation of
the organism and/or serology.

Brucellosis in humans can be prevented by eradication of brucellosis
in animals and by pasteurization of milk. Brucellosis control
programs in animals involve test-and-slaughter, and/or vaccination.

_Brucella_ can also be used as a bioweapon, in which the
microorganism is delivered as an aerosol. An outbreak following
aerosolization would be initially difficult to detect because the
earliest indications of infection are non-specific flu-like symptoms.

The current situation with brucellosis in Kyrgyzstan is likely a
continuation of a prior outbreak that was noted in ProMED-mail post
archive number 20060924.2725. In this post, Dr Steve Berger said
that: "[Kyrgyzstan] may have the highest rate of brucellosis in the
world. Annual rates exceed those of adjacent countries and even
traditional "hot-spots" in southern Europe. See:
<http://exhibit.gideononline.com/Brucellosis-Kyrg.jpg>."

The rates of brucellosis for Kyrgyzstan [extracted by Mod.LL] ranged
from 15 to 24 cases per 10 000 in the 1990's and rose to 50 in 2003
and 43 in 2004.

According to another prior ProMED-mail post, archive number
20060923.2715 that concerned brucellosis in Kyrgyzstan, Mod.NP noted,
"...hygienic standards are frequently not observed in the sale of meat
and dairy products. The population quite often does not hand over
sick animals to veterinarians for slaughter." Also see
<http://www.irinnews.org/report.aspx?reportid=20842>.

Kyrgyzstan is a mountainous, landlocked Central Asian country, west
of China, that is divided into 2 administratively independent cities
(Bishkek, the capital, and Osh) and 7 provinces (oblasts), one of
which is Naryn. The provincial capital of Naryn is about 350 km (218
mi) from Bishkek and 200 km (124 mi) from the Chinese border. The
town of Naryn has a population of about 50 000 (there are about 260
000 inhabitants in the whole of the Naryn oblast) and is separated
from the rest of Kyrgyzstan by mountain ranges
(see <http://www.advantour.com/kyrgyzstan/naryn.htm> and
<http://en.wikipedia.org/wiki/Naryn>).
Sheep, raised on the extensive steppe and alpine pastures, are the
mainstay of the economy.

For maps of Kyrgyzstan see
<http://www.lib.utexas.edu/maps/commonwe ... pol_05.jpg>
and the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/promed/en?g=152759 ... 3,75.967,6>. - Mod.ML]

BRUCELLOSIS - KYRGYZSTAN (02): (NARYN)
**************************************
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ProMED-mail is a program of the
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Date: Mon 12 Jan 2009 22:38:09 -0800 (PST)
From: Joldoshbek Kasymbekov <joldoshbekk@yahoo.com>


The recent ProMED-mail report on brucellosis in Kyrgyzstan (2 Jan 2009)
[archive no. 20090102.0010] appears to be somewhat misleading, outdated,
and incomplete. The government of Kyrgyzstan is well aware of the
brucellosis situation in animals and humans and is treating this as an
urgent national issue.

A national control program for brucellosis has been set in motion with
multi-donor assistance from the World Bank, the Swiss Development
Cooperation (SDC), the EU, the Swedish International Development Agency,
and others. Kyrgyzstan is recognized as a country having one of the highest
rates of brucellosis in animals and humans. Naryn has been the focus for
much of the surveys and initial pilot work. Based on the results of the
initial survey work, the Government has instituted a national vaccination
program in 2008 to control the disease at source in the livestock
population. This has been combined with a public awareness campaign to
improve personal hygiene and prevent human exposure through direct contact
(that is, during lambing, care after animals) or consumption of
contaminated food products.

It is likely that the 10 per cent incidence of brucellosis reported in
humans in the province of Naryn, and refuted by the Ministry of Health,
actually refers to a 10 per cent Rose Bengal test [RBT] seroprevalence
found in small ruminants in a recent randomized survey of animals in 13
villages in Ak-Talaa, a district in Naryn. A seroprevalence of 1.7 per cent
was found in cattle. The final seroprevalence will depend on results of
indirect ELISAs [enzyme-linked immunosorbent assay] on all RBT reactors.

Brucellosis in humans in Naryn province during 11 months of 2-8 [?2008]
appeared to be 151.3 per 100 000 population [from] recently conducted
[studies] in the high risk area of Naryn [that is, the incidence of
brucellosis in Naryn is actually about 0.15 per cent instead of 10 per cent
indicated in the ProMED-mail report]; the incidence of brucellosis in
humans has been stabilized and is reduced.

The Government of Kyrgyzstan takes this situation very seriously, is
committed to a long term strategy for reducing the incidence of brucellosis
in animals and humans, and has moved to a risk-based approach. This
includes high-coverage vaccination of small ruminants, control programs for
cattle, awareness campaigns, and public involvement at the village level.
In fact, the brucellosis program has evolved from donor supported projects
for community and village health and also bird flu control and is an
important part of the comprehensive approach to "One Health". This effort
is coordinated through the deputy prime minister and with uniquely close
cooperation between the MAWRPI [Ministry of Agriculture, Water Resources
and Processing Industry] and the Ministry of Health for the control of
zoonotic diseases. The program is also consistent with the Government's
very close collaboration with the OIE [World Organisation for Animal
Health] in upgrading its veterinary services to meet international
standards in accordance with its WTO [World Trade Organisation] commitments.

It should also be recognized that this work is being carried out during a
very difficult period of fiscal crisis and with considerable limitations on
the national budget and resources.

Nurlan Dyusheev
First Deputy Director General of the State Veterinary Department
MAWRPI [Ministry Agriculture, Water Resources and Processing Industry]
Kyrgyz Republic
Jalalidin Gaibulin
Director of the Centre of Quarantine and Dangerous Infection
MoH [Ministry of Health]
Kyrgyz Republic

--
Joldoshbek Kasymbekov
Chief of the Information and Communication Unit
State Veterinary Department (SVD)
(MAWRPI)
Kyrgyz Republic
<joldoshbekk@yahoo.com>

[ProMED-mail thanks Nurlan Dyusheev, first deputy director general of the
State Veterinary Department and Jalalidin Gaibulin, director of the Centre
of Quarantine and Dangerous Infection of the Ministry of Health, Kyrgyz
Republic, for their clarification of the situation in Kyrgyzstan and
explanation of data presented in ProMED-mail posting archive 20090102.0010.

MENINGITIS, MENINGOCOCCAL - INDIA: (MEGHALAYA)
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Date: Tue 13 Jan 2009
Source: The Assam Tribune [edited]
<http://www.assamtribune.com/scripts/det ... an1409/ne4>


After meningococcal meningitis claimed 132 lives in Meghalaya, the Centre
has rushed in a team from the National Institute of Communicable Diseases
(NICD) to assist the health officials. The NICD team is being led by joint
director[s? - Mod.SH] Jagdir Singh and S Gupta to help the Meghalaya Health
department to combat the disease.

"NICD with its expertise would help the State Health department to tackle
the disease," director of health services (DHS) Dr A Kynjing said.

Cases of meningococcal meningitis have been reported from all parts of the
state but mostly from areas like Jhalupara, Mawlai, Lumparing and
Nongmynsong in East Khasi Hills here and in areas in Garo Hills from last
year [2008]. The death toll has reached 132 according to the health
department. However, unconfirmed reports put the death toll much higher.

Meningitis affects the membrane around the brain called the meninges.
Infected fluid from meninges run into the spinal cord causing stiff neck,
fever and rash. If left untreated the disease can be fatal.

The health department has been accused of not keeping enough stock of the
anti-meningococcal meningitis vaccines for the affected people. The vaccine
costs about Rs 360 [USD 7.38] in private hospitals.

Dr Kynjing refuted the allegation, saying there were "enough stock of the
vaccines" in the health department. "We get the vaccines from the Centre
and as of now we have enough stock and people should not panic," he
assured. The health official added that a massive public awareness campaign
has been launched to emphasise the importance of cleanliness to prevent
spread of this airborne disease. Dr Kynjing further urged the public to
join in and help the Health department to help prevent further spread of
the disease.

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

[An outbreak of meningococcal meningitis was previously reported in
Meghalaya in April 2008 that involved 300 cases with 30 deaths
(<http://www.theshillongtimes.com/a-29-April.htm>). In an undated article
from the same website (<http://www.theshillongtimes.com/shillong.html>),
the state Health Department was said to be "considering the option of mass
vaccination to control this disease but added that it would involve huge
financial implications and manpower. In view of limited supply of vaccines
in the market, the government may provide vaccines only to the age group
that has been worst affected by meningococcal meningitis. 'So far,
preventive medicines [chemoprophylaxis] have been provided only to those
families having one of its members infected with the virus. To a certain
extent, preventive medicines have also been provided in a number of
schools,' sources said."

Chemoprophylaxis is used to prevent secondary cases of _Neisseria
meningitidis_ infection, which usually occur within 10 days of the primary
cases among certain high-risk groups. These groups include household
contacts, closed populations living with cases in college dormitories,
long-term care institutions, nursery schools, or military barracks, and
close social contacts who are directly exposed to a case's oral secretions,
for example by kissing, sharing eating utensils, or toothbrushes, in the
week prior to onset of illness in the primary case. Appropriate
chemoprophylactic drugs include rifampin, ciprofloxacin, or ceftriaxone.

To control an outbreak, WHO recommends mass vaccination with the
appropriate serogroup-specific meningococcal vaccine, depending on
availability, in every involved district in an attempt to induce herd
immunity (whereby transmission is blocked when a critical percentage of the
population have been vaccinated
(<http://www.who.int/mediacentre/factsheets/fs141/en/>). However, the
serogroup(s) of _N. meningitidis_ involved in the current or past outbreaks
in Meghalaya is not specified in the above news releases.

Outbreaks of serogroup A meningococcal meningitis in and around Delhi,
India, have been documented in 1966, 1985, and 2005
(<http://www.who.int/csr/don/2005_05_09/en/index.html>). To the north,
there was an epidemic of serogroup A meningococcal meningitis in the
Kathmandu valley of Nepal from 1982-84
(<http://www.who.int/csr/don/2005_05_09/en/index.html>). In 1984, a
widespread vaccination program prevented a 2nd epidemic
(<http://ije.oxfordjournals.org/cgi/conte ... ct/16/1/91>). Cases of
meningococcal meningitis occurred in foreigners in Nepal at the time,
mostly in trekkers that led to the CDC to issue a travel advisory notice
recommending the meningococcal meningitis vaccine for all travelers to
Nepal that was later lifted
(<http://wonder.cdc.gov/wonder/prevguid/p ... 000259.asp>).
Meningococcal meningitis was also noted in Bhutan from 1985-1986
(<http://web.gideononline.com/abstract.ph ... untry=G122>).
Meghalaya, a mountainous Indian state, is located between the north eastern
border of Bangladesh and the Indian state of Assam. Meghalaya consists of
the 7 districts: East Garo Hills, East Khasi Hills, Jaintia Hills, Ri-Bhoi,
South Garo Hills, West Garo Hills and the West Khasi Hills
(<http://en.wikipedia.org/wiki/Meghalaya>). Its capital and largest city is
Shillong. A map of India can be found at
<http://healthmap.org/promed/en?v=22.9,79.6,5>. - Mod.ML]

MALARIA, FALCIPARUM - EUROPEAN UNION ex INDIA (GOA)
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[1] Switzerland - Bern
[2] United Kingdom - England (Manchester)

******
[1] Switzerland - (Bern)
Date: 25 Jan 2009
Source: TropNetEurop [edited]


A patient with falciparum malaria was seen in Bern. A 44-year-old
Swiss male traveled to Goa for 14 days and returned on 29 Dec 2008.
He received no prophylaxis or pre-travel counseling.

The patient was admitted at Bern with fever upon return and was
hospitalized on 2 Jan 2009 with parasitemia of 5.1 percent, which
increased to 7.1 percent on 3 Jan 2009. There was no organ failure.

Initial therapy was with quinine/doxycycline, which after 3 days was
changed to artemether/lumefantrine. There was parasite clearance at
day 6 and no complications.

[Christoph Hatz; University of Zurich Travel Clinic, Institute for
Social and Preventive Medicine]

--
Communicated by:
Thomas Jelinek
TropNetEurop
Berlin Center for Travel & Tropical Medicine
Berlin, Germany
<jelinek@bctropen.de>

******
[2] United Kingdom - England (Manchester)
Date: 25 Jan 2009
Source: TropNetEurop [edited]


A patient was admitted at a hospital in Manchester with _P.
falciparum_ malaria after visiting Goa.

[Andrew Ustianowski; North Manchester General Hospital and Manchester
Royal Infirmary]

--
Communicated by:
Thomas Jelinek
TropNetEurop
Berlin Center for Travel & Tropical Medicine
Berlin, Germany
<jelinek@bctropen.de>

[Reports of _P. falciparum_ malaria in visitors to Goa have appeared
at regular intervals since autumn 2006. The Swiss traveler had not
taken prophylaxis. We do not know whether the British traveler took
prophylaxis. The steady trickle of patients back to Europe shows that
malaria transmission is still ongoing in and around Goa and
emphasizes that local malaria control programs are not working and
that travelers still need chemoprophylaxis when visiting Goa.

Goa is on the west coast. Kerala in southwestern India can be located
on the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/promed?v=22.9,79.6,5>. - Mod.EP]

MENINGITIS, MENINGOCOCCAL - INDIA (02): (NORTH EASTERN), BANGLADESH SPREAD
**************************************************************************
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ProMED-mail is a program of the
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<http://www.isid.org>

Date: Tue 10 Feb 2009
Source: Xinhua News Agency [edited]
<http://news.xinhuanet.com/english/2009- ... 796190.htm>


At least 165 people have died of meningitis and over 2000 were taken ill
with the contagious disease in north eastern India bordering Bangladesh and
Myanmar over the past one month, the local Indo-Asian News Service said on
Tuesday [10 Feb 2009].

The epidemic has taken place in the states of Meghalaya, Tripura, and
Mizoram, with Meghalaya reporting 140 death cases, said the report. The 3
north eastern states have borders with the Chittagong Hill Tracts of
Bangladesh, where meningococcal meningitis is spreading in an epidemic
form, the report quoted the National Institute of Communicable Diseases as
saying. Two doctors from New Delhi have been dispatched by the authorities
to the disease-stricken areas in Meghalaya to help doctors deal with the
disease on a through vaccinations and treatment on a round-the-clock basis,
said the report.

[byline: Deng Shasha]

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

[The outbreak of meningococcal meningitis in the Indian state of Meghalaya
this year (2009) was recently reported by ProMED-mail (Meningitis,
meningococcal - India: (ML) 20090117.0206). At that time the outbreak was
said to have claimed 132 lives "according to the health department.
However, unconfirmed reports put the death toll much higher."

From the news report above, the number of deaths in Meghalaya has
increased slightly to 140, but the outbreak has now been reported to have
spread to neighboring Indian states of Tripura and Mizoram, and the
Chittagong Hill Tracts in Bangladesh, which borders Mizoram. The serogroup
of _Neisseria meningitidis_ is still not specified.

From Mod.ML's comments in the prior ProMED-mail post (Meningitis,
meningococcal - India: (ML) 20090117.0206): "In April 2008 a meningococcal
meningitis outbreak in Meghalaya] involved 300 cases with 30 deaths
(<http://www.shillongonline.com/index.php ... e&sid=1446>).
In an undated article from the same website
(<http://www.theshillongtimes.com/shillong.html>), the state Health
Department was said to be "considering the option of mass vaccination to
control this disease, but added that it would involve huge financial
implications and manpower. In view of limited supply of vaccines in the
market, the government may provide vaccines only to the age group that has
been worst affected by meningococcal meningitis. 'So far, preventive
medicines [chemoprophylaxis] have been provided only to those families
having one of its members infected with the virus. To a certain extent,
preventive medicines have also been provided in a number of schools,'
sources said.""

Meghalaya, a mountainous Indian state, is located between the north eastern
border of Bangladesh and the Indian state of Assam. A HealthMap/ProMED-mail
interactive map of India that shows the states of Meghalaya, Tripura, and
Mizoram can be found at <http://healthmap.org/promed/en?v=22.9,79.6,5>. A
map of Bangladesh showing the location of the Chittagong Hill Tracts that
borders the Indian state of Mizoram can be found at
<http://www.traveljournals.net/explore/b ... tract.html>.
- Mod.ML]

HEPATITIS D VIRUS - INDIA (GUJARAT), REQUEST FOR INFORMATION
***********************************************
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Date: Fri 13 Feb 2009
Source: Thaindian News [edited]
<http://www.thaindian.com/newsportal/hea ... 54892.html>


A total of 11 deaths due to hepatitis-D were reported so far in
Modasa taluka of Gujarat's Sabarkantha district in the last 5 days,
health officials here said. Officials said 21 patients are admitted
to various hospitals in the area so far, and 5 were rushed to the
civil hospital in Ahmedabad Friday [13 Feb 2009].

"We have asked for a central team from the National Institute of
Communicable Diseases (NICD) and the Director General of Health
Services (DGHS), and the team is arriving shortly," said Chief
District Health Officer (CDHO) H.F. Patel.

A 3-member team from the B.J. Medical College, Ahmedabad, led by
Nayan Qadri, has already arrived in Modasa Thursday [12 Feb 2009].
"At present, 5 doctors and 27 paramedics are in the area," Patel said.

The hepatitis-D virus (also called delta virus) is a small circular
RNA virus and affects humans only in the presence of hepatitis-B
infection. It is transmitted by blood and blood products. The risk
factors for infection are similar to those for hepatitis-B virus
infection. The hepatitis-D virus most often infects intravenous drug
users, Patel said. "We have published 25 000 pamphlets, and we are
circulating them as part of our awareness campaign," he said.

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[In ProMED archive no. 20030712.1718, Mod.CP wrote the following
about Hepatitis D virus infections: Because hepatitis delta virus
(HDV) is dependent on hepatitis B virus (HBV) for replication,
HBV/HDV co-infection can be prevented with either pre- or
post-exposure prophylaxis for HBV. HDV infection can be acquired
either as a co-infection with HBV or as a superinfection of persons
with chronic HBV infection. Persons with HBV/HDV co-infection may
have more severe acute disease and a higher risk of fulminant
hepatitis (2-20 percent) compared with those infected with HBV alone;
however, chronic HBV infection appears to occur less frequently in
individuals with HBV/HDV co-infection. Chronic HBV carriers who
acquire HDV superinfection usually develop chronic HDV infection. In
long-term studies of chronic HBV carriers with HDV superinfection,
70-80 percent have developed evidence of chronic liver diseases with
cirrhosis compared with 15-30 percent of patients with chronic HBV
infection alone. Thus, prevention of HDV superinfection depends
primarily on education to reduce risk behaviors. In some Latin
American countries in the Amazon River Basin, periodic epidemics of
HDV infection have occurred among chronic HBV carriers in relatively
isolated regions. Disease related to HDV infection in these outbreaks
has been very severe, with rapid progression to fulminant hepatitis
and case-fatality rates of 10-20 percent. The cause of the atypical
course of HDV infection in these populations is unknown.

The modes of HDV transmission are similar to those for HBV, with
percutaneous exposures the most efficient. Sexual transmission of HDV
is less efficient than for HBV. Perinatal HDV transmission is rare.
The serologic course of HDV infection varies depending on whether the
virus is acquired as a co-infection with HBV or as a superinfection
of a person with chronic HBV infection. In most persons with HBV/HDV
co-infection, both IgM antibody to HDV (anti-HDV) and IgG anti-HDV
are detectable during the course of infection. However, in about 15
percent of patients, the only evidence of HDV infection may be the
detection of either IgM anti-HDV alone during the early acute period
of illness or IgG anti-HDV alone during convalescence. Anti-HDV
generally declines to sub-detectable levels after the infection
resolves, and there is no serologic marker that persists to indicate
that the patient was ever infected with HDV. Hepatitis Delta antigen
(HDAg) can be detected in serum in only about 25 percent of patients
with HBV-HDV co-infection. When HDAg is detectable, it generally
disappears as HBsAg disappears, and most patients do not develop
chronic infection. - Mod.CP]

[The basis on which the HDV diagnosis was made in this Indian
outbreak was not indicated in the above report. ProMED requests
information about any laboratory tests done in these cases and
further information about the outbreak as it becomes available.

The administrative headquarters of the Sabarkantha district is
Himmatnagar, 80 km (50 miles) from Ahmedabad. The District has a
population of over 2 million in its 7390 sq km (2853 sq mi) area.

A map showing the location of Sabarkantha district in Gujarat state
can be accessed at
<http://en.wikipedia.org/wiki/File:Map_GujDist_North.png>.
A HealthMap/ProMED-mail interactive map of India showing the location
of Gujarat state can be accessed at
<http://healthmap.org/promed/en?v=22.9,79.6,5>.
- Mod.TY]

MENINGITIS, MENINGOCOCCAL - INDIA (03): (NORTH EASTERN), REQUEST FOR
INFORMATION
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<http://www.isid.org>

Date: Sat 14 Feb 2009
Source: Bengal News [edited]
<http://bengalnewz.blogspot.com/2009/02/ ... nt_14.html>


Health authorities have put Dhalai district in Tripura on high alert
after nearly a dozen people died mysteriously in the last fortnight.
The state health department has sent a medical team to the affected areas.

The medical officers have reported that the disease was marked by a
sudden onset of fever. "When we went for field visit, we found that
people died within 10 to 24 hours after experiencing high fever and
some red spots on their bodies," said Paul N Darlong, a medical
officer. The epidemic is affecting the people living in impoverished
tribal hamlets with scant health facilities. At least 70 more people
are suffering from a similar disease in Longhthorai Valley, an
inaccessible area dominated by tribal people, which is some 90 km
away from the state capital Agartala.

The federal health department has reported that at least 165 people
have died of meningocococcal meningitis, a contagious disease, in 3
of India's northeastern states -- Meghalaya, Tripura and Mizoram --
in the past one month.

--
Communicated by:
ProMED-mail Rapporteur Susan Baekeland

[ProMED-mail has heard unofficially that the cause of the meningitis
epidemic in the northeastern Indian states of Tripura, Mizoram and
Meghalaya, as well as Delhi, is said to be serogroup A _Neisseria
meningitidis_.

However, the cause of the outbreak in Tripura of a rapidly fatal
illness with fever and "red spots" (i.e., petechial rash) that is
mentioned in the news report above could be due to either certain
viral infections, rickettsial infections, or bloodstream infection
with a variety of bacteria, for example, commonly _Neisseria
meningitidis_. ProMED requests information about any laboratory tests
done in these cases in Tripura and further information about the
outbreak as it becomes available.

Patients with acute meningococcal infection can present clinically
with meningitis, meningitis with meningococcemia, or meningococcemia
without obvious meningitis. Up to 95 percent of patients with
meningococcal disease have meningococcemia and/or meningitis. The
case-fatality rate is up to 10 percent for meningococcal meningitis
and up to 20 percent for meningococcemia despite therapy with
antimicrobial agents
(<http://emedicine.medscape.com/article/221473-overview>).

Fulminant meningococcemia with bleeding into the skin (purpura
fulminans) and elsewhere, low blood pressure, and multi-organ failure
occurs in up to 15 percent of individuals with meningococcal disease
(<http://emedicine.medscape.com/article/221321-overview>)
and has a mortality rate that can be as high as 70 percent in
developing countries.

A HealthMap/ProMED-mail interactive map of India that shows the
states of Meghalaya, Tripura, and Mizoram can be found at
<http://healthmap.org/promed/en?v=22.9,79.6,5>.
- Mod.ML]

HEPATITIS D VIRUS - INDIA (02): (GUJARAT), HEPATITIS B, REQUEST FOR INFORMATION
*****************************************
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<http://www.isid.org>

Date: Mon 16 Feb 2009
Source: Thaindian News, Indo-Asian News Service (IANS) report [edited]
<http://www.thaindian.com/newsportal/unc ... 55987.html>


The central government has dispatched 3 medical teams to Gujarat's
Modasa sub-district where 22 people have died of hepatitis B and many
others are suffering from the infection, state Congress chief
Siddharth Patel said Monday [16 Feb 2009]. Addressing media persons
here, Patel said: "Our own team has visited the affected places. It
is quite serious that 22 deaths have occurred, yet the patients have
no recourse to proper treatment. All of them are being sent out of
Modasa for treatment."

In Sabarkantha district 6 talukas, village blocks, -- Malpur,
Meghraj, Bhiloda, Mansura, Dhansura, and Modasa -- are in the grip of
the deadly hepatitis virus. No district health officer has been
appointed so far, Patel said.

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[The number of deaths in this report, 22, has increased from the 11
reported just 3 days ago (see ProMED-mail archive no. 20090216.0651).
The situation is confusing. The previous report implicated hepatitis
D virus (which is transmitted with hepatitis B virus), but only
hepatitis B is mentioned in the current report, above. No laboratory
confirmation of the etiological agent is given in either report, so
additional information will be of interest. A more complete
description of hepatitis D is given in ProMED-mail archive no. 20090216.0651.

A map showing the location of Sabarkantha district in Gujarat state
can be accessed at
<http://en.wikipedia.org/wiki/File:Map_GujDist_North.png>.
A HealthMap/ProMED-mail interactive map of India showing the location
of Gujarat state can be accessed at
<http://healthmap.org/promed/en?g=126295 ... 467,73.3,5>. - Mod.TY]

MENINGITIS, MENINGOCOCCAL - INDIA (04): (NORTH EASTERN)
*******************************************************
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 16 Feb 2009
Source: Sify News [edited]
<http://sify.com/news/fullstory.php?id=14857020>


At least 230 people have died of meningitis in the north eastern
states of Tripura, Meghalaya, and Mizoram, officials said on Monday
[16 Feb 2009]. The situation is alarming in Meghalaya and Tripura,
they said. "We have asked the National Institute of Communicable
Diseases (NICD) in New Delhi to send necessary vaccine and drugs to
control the disease that has assumed an epidemic proportion in the
Longtharai Valley tribal areas of Dhalai district," said Tripura
health service director Satya Ranjan Debbarma.

The NICD last week asked the 3 north eastern states to keep a close
surveillance in remote locations, especially where the outbreak of
meningococcal meningitis was reported. "Over 230 people including
children and women died in the disease in Meghalaya (165 deaths),
Tripura (55 deaths), and Mizoram (10 deaths) over the past one
month," a senior health official told reporters [in Agartala,
Tripura]. Over 2500 people, including children and women, were taken
ill in the 3 states.

"The 3 north eastern states have borders with the Chittagong Hill
Tracts (CHT) of south east Bangladesh where meningococcal meningitis
is spreading in an epidemic form," said an official of the NICD.

The Tripura government has taken a slew of measures to control the
disease by setting up makeshift health centres in the affected
Longtharai Valley, 135 km [84 mi] north of the capital Agartala.
"Several medical teams [are] working in the affected areas
round-the-clock and preventive medicines were being given to 140 000
people in the tribal dominated areas," said RK Dhar, director of the
family welfare and preventive medicine.

A 2-member team of NICD led by joint director Jagdir Singh visited
the affected East Khasi Hills and Garo Hills areas of Meghalaya and
helped doctors in the region deal with the disease. "We have enough
anti-meningococcal meningitis vaccines and a number of medical teams
are working round-the-clock to deal with the situation," said
Meghalaya health service director A Kynjing. "Like the other north
eastern states, we have launched a massive public awareness campaign
on the need for cleanliness as it is an airborne disease," said YP
Singh, principal secretary of the Tripura government in-charge of
health department.

After visiting the affected areas, RK Dhar, an expert on communicable
diseases, said: "Meningococcal meningitis is a communicable disease
that is spread through droplets of respiratory or throat secretions.
The most common symptoms are stiff neck, high fever, headache, and
vomiting. Even when the disease is diagnosed early and adequate
therapy instituted, 5 to 10 percent of the patients die typically
within 24 to 48 hours of onset of symptoms," he said. Tripura Health
Minister Tapan Chakraborty, who is also camping in the affected
tribal areas for the past few days, held meetings with the village
heads of 40 affected villages and asked them to help health officials
and paramedics.

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

[An outbreak of a rapidly fatal illness in remote, impoverished
tribal areas of the Indian state of Tripura was characterized as
mysterious in a news release reported in the previous ProMED-mail
post Meningitis, meningococcal - India (03): (NE), RFI 20090216.0657.
From the news report above, it is apparent that this outbreak is now
thought to be part of the ongoing epidemic of meningococcal disease
in north eastern Indian states of Tripura, Mizoram, and Meghalaya
that has spread to neighboring Chittagong Hill Tracts of Bangladesh.
ProMED-mail has heard unofficially that the cause of the meningitis
epidemic in the north eastern Indian states of Tripura, Mizoram, and
Meghalaya, as well as Delhi, is said to be serogroup A _Neisseria
meningitidis_.

A HealthMap/ProMED-mail interactive map of India that shows the
states of Meghalaya, Tripura, and Mizoram can be found at
<http://healthmap.org/promed/en?g=126320 ... &v=23,93,5>.
A map of Bangladesh showing the location of the Chittagong Hill
Tracts that borders the Indian state of Mizoram can be found at
<http://www.traveljournals.net/explore/b ... tract.html>.
- Mod.ML]

MENINGITIS, MENINGOCOCCAL - INDIA (05): (NORTH EASTERN, 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: Fri 13 Feb 2009
From: Sunil Gupta [edited]
<sunil_guptadoc@yahoo.co.uk>


This is regarding information on meningococcal disease in India and
is to inform you that in the cases of meningococcal disease that are
being reported in Delhi and Meghalaya states of the country, the
causative microorganism in both the places has been identified as
Group A meningococcus.

--
Dr Sunil Gupta
Joint Director
National Institute of Communicable Diseases, Delhi
<sunil_guptadoc@yahoo.co.uk>

[_Neisseria meningitidis_ is divided into 13 serogroups, defined by
specific capsular polysaccharides, of which 4 are known to cause
epidemics: A, B, C and W135. Group A strains have caused epidemics of
meningococcal meningitis throughout the world. Serogroups A and C
predominate throughout Asia and Africa and serogroups B and C are
responsible for the majority of cases in Europe and the Americas.
Recently, serogroup W135 has been associated with meningococcal
disease amongst Hajj pilgrims and in sub-Saharan Africa. In India
serogroup A has been associated with all outbreaks of meningococcal
disease, although serogroup B and C have been detected in a few sporadic cases.

A HealthMap/ProMED-mail interactive map of India that shows the
states of Meghalaya, Tripura, and Mizoram can be found at
<http://healthmap.org/promed/en?g=126320 ... &v=23,93,5>.
- Mod.ML]

HEPATITIS D VIRUS - INDIA (03): (GUJARAT), HEPATITIS B, REQUEST FOR FURTHER
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: Fri 20 Feb 2009
Source: Times of India online [edited]
<http://timesofindia.indiatimes.com/Ahme ... 157500.cms>


Bad medical practices could have led to outbreak
------------------------------------------------
State health minister Jay Narayan Vyas on Thursday [20 Feb 2009] indicated
that spread of the hepatitis B outbreak could get bigger. Already 7 doctors
in Sabarkantha have been booked for bad medical practices.

Responding to the issue raised by BJP MLA Dilipsinh Parmar in the state
Assembly on Thursday [19 Feb 2009], Vyas said of the 150 642 people checked
in 227 villages in the district, it was found that 459 people had taken
injections, 1883 people had undergone surgeries, another 152 had taken
dental treatment and 25 people had under gone blood transfusion. All of
these could cause transmission of the deadly virus if care was not taken by
medical practitioners. Vyas indicated that these could be the possible
reason for the outbreak.

He said that 11 medical teams are in the area and are collecting blood
samples for further analysis. In addition, 2 members from National
Institute of Virology, Pune, are also camping here studying the outbreak.

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

[Previously ProMED-mail requested information justifying diagnosis of
hepatitis D virus infection (which can only occur in the presence of
hepatitis B virus infection) as the cause of deaths in the hepatitis
outbreak in Gujarat. The above report mentioned only hepatitis B virus
infection as the the cause of additional deaths. Now the outbreak and the
fatalities are being attributed to transmission of hepatitis B virus
infection by improper medical procedures.

It is unclear whether hepatitis D virus infection or hepatitis B virus
infection alone is responsible for the deaths of some patients. As a large
number of people have been identified as possible recipients of
contaminated blood through lax medical procedures, further deaths are to be
expected. Information on the progress of the outbreak and confirmation, or
not, of involvement of heatitis D virus is requested from any informed
source. - Mod.CP

A map showing the location of Sabarkantha district in Gujarat state can be
accessed at <http://en.wikipedia.org/wiki/File:Map_GujDist_North.png>. A
HealthMap/ProMED-mail interactive map of India showing the location of
Gujarat state can be accessed at
<http://healthmap.org/promed/en?g=126295 ... 467,73.3,5>. - Mod.TY]

RABIES, HUMAN - UNITED ARAB EMIRATES ex INDIA
*********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Tue 17 Feb 2009
Source: Gulf News online [edited]
<http://www.gulf-news.com/nation/Health/10287111.html>


Patient's death is 1st rabies fatality in UAE in 10 years
---------------------------------------------------------
A man being treated for rabies at a local hospital died on Monday [16 Feb
2009], the 1st such death in the United Arab Emirates (UAE) in a decade.
Gulf News reported the labourer from India was admitted to Al Baraha
Hospital on 8 Feb 2009 after he started showing symptoms. Rabies is
transmitted through saliva and blood from an infected animal. The most
common method of transmission is through bites, and globally more than 90
per cent of infections come from bites from rabid dogs.

Dr Ali Al Marzouqi, director of public health at the Department of Health
and Medical Services, told Gulf News it was the 1st rabies case in the UAE
in a decade. "The last case was 10 or more years ago. I have been in the
public health sector for 9 years and this is the 1st case we've got," he said.

Dr Ali Shakar, director-general at the Ministry of Health, told Gulf News
the man's hand was bitten 6 months ago, prior to his arrival in the UAE.
"If he had sought treatment immediately after the bite, or even after he
arrived in the UAE, maybe he would have been okay," he said.

Treatment for rabies involves cleaning and disinfecting the wound, and
giving the victim a post-exposure vaccination as soon as possible. Rabies
is almost always fatal when symptoms show up. Dr Shakar said there was no
need to vaccinate anyone as the man's contacts in the UAE have not shown
signs of exposure to the virus. Exposure refers to a case where infected
saliva enters an open wound. "The main thing is this is not a public health
scare so there is no need to panic. It can happen anytime, anywhere in the
world," he said. "It doesn't transfer like other [infectious] diseases.
It's not bird flu," he added.

He also said the body would be buried according to the World Health
Organisation (WHO) procedures, which dictates the immediate burial or
cremation of the body. No special containers are required for the body,
although embalming is discouraged. Despite the case, health authorities are
unlikely to require incoming residents and workers to be screened for rabies.

"We have other more important diseases to watch out for like HIV,
tuberculosis and sexually-transmitted diseases, which are more infectious,"
Dr Marzouqi said. "And if someone gets rabies here, so what? Transmission
is rare and we have vaccines to treat people after they are bitten," he said.

Facts about rabies: Rabies is a zoonotic disease that kills 55 000 people a
year worldwide, mostly in rural areas in Asia and Africa. It 1st shows up
with flu-like symptoms, including fever, headache, and fatigue. Then it
progresses to involve the respiratory, gastrointestinal, and the central
nervous systems. It also leads to hydrophobia or fear of water, due to
spasms in the throat. The patient develops hyperactivity, called furious
rabies, or paralysis, called dumb rabies.

UAE regulations: Pets are required to be vaccinated. Rabies is a notifiable
disease under the public health laws, requiring all sectors to report an
encounter.

[byline: Nina Muslim]

--
communicated by:
ProMED-Mail rapporteur Susan Baekeland

[An unfortunate accompaniment of the global migration of populations.

The HealthMap/ProMED-mail interactive map of the United Arab Emirates is
accessible at <http://healthmap.org/promed/en?v=23.9,54.3,5>. - Mod.CP]

HEPATITIS D VIRUS - INDIA (04): (GUJARAT), HEPATITIS B VIRUS, 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>

******
[1]
Date: Fri 20 Feb 2009
Source: BBC News online [edited]
<http://news.bbc.co.uk/1/hi/world/south_asia/7900910.stm>


Probe into India hepatitis deaths
---------------------------------
Health authorities in India have begun investigations into a number of
deaths caused by hepatitis B in the western state of Gujarat. A total of 25
people have died of the disease in the past 2 weeks in Sabarkantha
district. An official said early investigations pointed to the prevalence
of a "mutant virus" in affected patients.

Hepatitis B virus is transmitted through contact with the bodily fluids of
an infected person. The virus can be transmitted via unprotected sex or
sharing of contaminated needles. Pregnant mothers also tend to pass it on
to their babies.

Sabarkantha district official M Thennarasan told the BBC that another 26
people had been admitted to a local hospital with symptoms of hepatitis B.
Women and children have been among the dead. "We have had teams from Delhi
and the state who are investigating the cause of the spread of the
disease," he said. "Preliminary investigations show the presence of a
mutant virus in patients. But as of now we have no idea why hepatitis B has
spread in a number of adjoining areas."

Mr Thennarasan said there was "no pattern" in the class and work profile of
the patients, and that there was no information as to whether they had
taken similar injections recently. The virus can cause fever, fatigue,
muscle or joint pain, loss of appetite, nausea, and vomiting.

Chronic carriers have an increased risk of developing liver disease such as
cirrhosis or liver cancer, because the hepatitis B virus steadily attacks
the liver.

--
communicated by:
HealthMapAlerts
via ProMED-mail
<promed@promedmail.org>

******
[2]
Date: Sat 21 Feb 2009
Source: expressindia.com [edited]
<http://www.expressindia.com/latest-news ... sa/426382/>


More deaths reported in Modasa
------------------------------
The total number of patients affected by hepatitis B virus now stands at
108. Even as Modasa continues to be in the grip of the "mutated" hepatitis
B virus (HBV), 7 more deaths and 23 new cases were reported in Sabarkantha
district on Friday [20 Feb 2009]. The deaths, the largest number in a
single day so far, has taken the total death toll in the district to 34 and
the total number of people affected by the virus to 108, since the 1st case
was reported on 6 Feb 2009.

An expert team from the BJ Medical College in Ahmedabad, along with
Ahmedabad Civil Hospital superintendent M M Anchalia, and health
commissioner Amarjit Singh, reached Modasa on Friday to reinvestigate some
of the suspected cases. On Saturday [21 Feb 2009], a team from the National
Institute of Communicable Diseases (NICD), Delhi will revisit Modasa and
stay there for 10 days to carry out detailed investigations. Of the 7
deaths reported on Friday, 5 are from Modasa, while one each are from
Meghraj and Bayar. The new cases of HBV have been reported from Modasa,
Meghraj, Idar, Himmatnagar and Bayar. So far only one case has been
reported from neighbouring Banaskantha. Sabarkantha chief district health
officer HS Patel said: "The 2 teams are revisiting Modasa to carry out
investigations to guide us on the line of action to be adopted."

Initially, the outbreak, which started due to the use of infected needles
and syringes, was suspected to be that of hepatitis D, which has so far not
been reported in the country. But expert teams from Lucknow, Mumbai, NICD,
Delhi and the National Institute of Virology, Pune (NIV) had negated that
possibility. On Thursday though, the NICD team confirmed one positive case
of hepatitis D. State health minister Jay Narayan Vyas said they have now
deployed 4 additional ambulances at Modasa so that patients can be quickly
shifted to the Ahmedabad Civil Hospital.

--
communicated by:
ProMED-mail rapporteur Brent Barrett

******
[3]
Date: Sat 21 Feb 2009
Source: Times of India online [edited]
<http://timesofindia.indiatimes.com/Indi ... 164052.cms>


Reused syringes to blame for hepatitis outbreak in Gujarat
----------------------------------------------------------
In a startling revelation, officials investigating the outbreak of
hepatitis B virus infections in Sabarkantha, Gujarat, have found that one
out of 7 private doctors from Dhansura, booked for medical negligence, had
re-used syringes while treating patients. The disease on Friday [20 Feb
2009] claimed 3 more lives taking the official toll to 32. Reports reaching
Modasa said 23 patients were admitted to hospitals on Friday increasing the
number of such patients to 108.

On Friday, 5 of the 7 doctors booked were arrested. Officials also
confirmed the spread of hepatitis B virus infections to Malpur, Bayad and
Idar talukas (blocks) of Sabarkantha district. A truck driver from Modasa,
Bandi, lost his 13 year old son to hepatitis B virus infection at Ahmedabad
Civil Hospital. His wife died on 10 Feb 2009. Students staying in the
Sabarkantha government engineering college hostel on Friday vacated their
rooms and left for home. Officials of the food and drugs department also
raided pharmacies and chemists shops to find out if they were selling
expired drugs and reused surgical accessories.

--
communicated by:
HealthMapAlerts
via ProMED-mail
<promed@promedmail.org>

[This number of people affected by this outbreak has risen to 108 and the
death toll to 34. The cause has been attributed progressively to hepatitis
D virus infection (subsequently discounted), hepatitis B virus infection,
and the diagnosis of last resort "mutant virus". The alternative
explanation now advanced is spread of bloodborne infection by bad medical
practice [reuse of disposable syringes] involving at least 5 practitioners
in the district. In view of the large number of hospitalized patients and
the high death toll, it is unlikely that this is the final verdict. Further
information is awaited. - Mod.CP

A map showing the location of Sabarkantha district in Gujarat state can be
accessed at <http://en.wikipedia.org/wiki/File:Map_GujDist_North.png>. The
HealthMap/ProMED-mail interactive map of India showing the location of
Gujarat state can be accessed at
<http://healthmap.org/promed/en?g=126295 ... 467,73.3,5>. - Mod.TY]

HEPATITIS D VIRUS - INDIA (05): (GUJARAT), HEPATITIS B VIRUS, 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>

[1]
Date: Mon 23 Feb 2009
From: Jose Manuel Echevarria <jmecheva@isciii.es>


A comment
---------
As far as I know, no mutant hepatitis B virus (HBV) infection
producing 30 percent mortality among infected persons has ever been
reported to date anywhere. If a virus was involved, just
superinfection of HBV carriers by hepatitis D virus (HDV), also known
as hepatitis delta agent, would be responsible for an outbreak of
acute liver disease with such a high mortality rate, otherwise
additional symptoms may suggest yellow fever or other serious
diseases that may include hepatic involvement as a complication. This
possibility has been, however, apparently ruled-out by laboratory
studies. Since such mutant HBV would represent a novel and most
relevant viral agent, detailed information concerning laboratory
evidences that support such an explanation for the outbreak should be
given by regional or federal health authorities as soon as possible.

--
Jose M Echevarria, MSc PhD
Virologist
Head, Service of Diagnostic Microbiology
National Centre of Microbiology
Instituto de Salud Carlos III
Majadahonda, Madrid
Spain

[The most recently available statement from India, posted below,
gives the number of hospitalised cases in this outbreak as 108 and
the number of deaths as 35. There is no additional information on the
outcome of laboratory investigations. - Mod.CP]

******
[2]
Date Sun 22 Feb 2009
Source: Prensa Latina online (in Spanish, machine trans., edited]
<http://www.prensalatina.com.mx/Article. ... anguage=ES>


One of the 7 doctors arrested in the Indian state of Gujarat for
negligence in a fatal outbreak of hepatitis B, was prosecuted for
manslaughter, reports today's [22 Feb 2009] Times of India newspaper.

The researchers found that most patients who contracted the disease
and eventually died were treated by him. The outbreak was due to the
use of poorly sterilized syringes, experts noted. As of Saturday
night [21 Feb 2009], the death toll in Modasa had reached 35, while
108 others are hospitalized in that locality of Gujarat, said the
newspaper.

A doctor who runs a clinic opposite the Modasa public health centre
is the 1st doctor accused of murder, while 6 others face various
charges under the Medical Negligence Act. Health officials revealed
that the focus of this outbreak of liver disease has spread to
Malpur, Bayad, and Idar Taluka, all in Sabarkantha district, where
Modasa is also located.

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

[A map showing the location of Sabarkantha district in Gujarat state
can be accessed at
<http://en.wikipedia.org/wiki/File:Map_GujDist_North.png>.
The HealthMap/ProMED-mail interactive map of India showing the
location of Gujarat state can be accessed at
<http://healthmap.org/promed/en?g=126295 ... 467,73.3,5>. - Mod.CP]

HEPATITIS D VIRUS - INDIA (06): (GUJARAT), HEPATITIS B VIRUS
************************************************************
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 24 Feb 2009
From: Carla Osiowy
<Carla_Osiowy@phac-aspc.gc.ca>


A similar hepatitis B virus (HBV) outbreak occurred in 1997 in
Gujarat State, India, in the Mehasana district, which adjoins
Sabarkantha, the district experiencing the current outbreak (1). The
Mehasana outbreak involved a cluster of 15 cases of HBV infection,
with a case fatality rate of 46.7 percent (7/15 deaths). The median
age of cases was 35 years, and all cases were found negative for
markers of hepatitis A virus (HAV), hepatitis C virus (HCV) and
hepatitis E virus (HEV), although 3 cases were anti-hepatitis D virus
(HDV) positive, including 2 individuals that died. Through
epidemiological analysis, it was determined that the outbreak was
linked to the use of inadequately sterilized needles and syringes by
an unqualified medical practitioner. In order to better understand
the high mortality rate observed in both outbreaks, it is necessary
to investigate the molecular and phenotypic characteristics of the
outbreak HBV strains.

(1) Singh, J., Bhatia, R., Gandhi, J., Kaswekar, A., Khare, S.,
Patel, S., Oza, V., Jain, D., and Sokhey, J. (1998) Outbreak of viral
hepatitis B in a rural community in India linked to inadequately
sterilized needles and syringes. Bull World Health Organ 76(1):93-98.

--
Carla Osiowy, M.Sc., Ph.D.
Research Scientist, Bloodborne Pathogens and Hepatitis,
Public Health Agency of Canada,
Canadian Science Centre for Human and Animal Health
1015 Arlington St., Suite H4790
Winnipeg, MB R3E 3P6
CANADA

[ProMED-mail is indebted to Dr Osiowy for this informative response
to the request for information. History repeats itself and
surprisingly lessons were not learnt from the epidemiological
analysis of the earlier outbreak in the same region of the state of
Gujarat. We await the outcome of the investigation of the current
outbreak and in particular confirmation, or not, of the role of HDV
infection in affecting the severity of the transmitted disease.

The adjoining districts of Mehasana and Sabarkantha can be located in
the map of Gujarat state at:
<http://www.mapsofindia.com/maps/gujarat/gujarat.htm>. - Mod.CP]