India Encephalitis 2015, 1,324 fatalities

[Ronan Kelly]

Uttarakhand
After the killer knock of dengue encephalitis in Haridwar
ETV UP / Uttarakhand | ashish mishra | Wed Oct 07, 2015 | 22:46 IST
# # Uttarakhand Haridwar Haridwar after dengue encephalitis (brain fever) have started the leg reaches more. The two men in the field Kankhal meningitis symptoms after they have been admitted to a private hospital.
One of them is 15-year-old age of 35, while the second. Encephalitis has ventured the first time in Haridwar. District malaria officer confirmed Japanese encephalitis.
Encephalitis outbreak swung into action after the health department patients reached the house around Kankhal areas examined.
Health Department has no mechanism to deal with encephalitis. The number of patients in the future may do so here.
After the killer knock of dengue encephalitis in Haridwar
Symptoms of Encephalitis
15 days remain until the start of the common flu. Fever, headache, vomiting, diarrhea and colds etc. complaint. After the stroke patient to come in, hang fainting. Memory loss and be practical change. Some patients paralysis.
The way to prevent encephalitis
Use insecticide for protection against mosquitoes. Use mosquito nets while sleeping at night. Which causes encephalitis mosquito bite in the evening only, so going out in the evening to get the body covered only say. Children should take Encephalitis vaccine course. The vaccine consists of three doses. It is applied to children from zero to 15 years.

http://hindi.news18.com/news/uttarakhand/encephalitis-case-in-haridwar-855131.html

Uttar Pradesh
12 new patients admitted to BRD, Gorakhpur, death of a 3 year old reported. 96 patients still under treatment. Cumulative for BRD: 1,260 cases with 271 fatalities. At least 318 fatalities state wide.

http://www.jagran.com/uttar-pradesh/gorakhpur-city-12998505.html

[Ronan Kelly]

Published Date: 2015-10-08 08:37:46
Subject: PRO/AH/EDR> Acute encephalitis syndrome - India (02): (UP)
Archive Number: 20151008.3698951
ACUTE ENCEPHALITIS SYNDROME - INDIA (02): (UTTAR PRADESH)
************************************************** *******
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Tue 6 Oct 2015
Source: a correspondent who has requested anonymity [edited]


The Gorakhpur encephalitis (AES) [acute encephalitis syndrome] mystery has been [resolved]. It is scrub typhus, a mite-borne bacterial disease, caused by _Orientia tsutsugamushi_.

An ICMR [Indian Council of Medical Research] sponsored investigation during August-September 2014 identified the etiology. Out of 249 acute encephalitis syndrome (AES) cases investigated, 152 (61 percent) of the cases were attributable to scrub typhus either by IgM ELISA, IFA or PCR. A pathognomonic eschar was evident in 20 per cent of the AES cases we investigated.

Scrub typhus is generally an acute febrile illness involving multiple organs. Encephalitis is a late manifestation with high mortality. Scrub typhus is a treatable bacterial disease with excellent clinical response from doxycycline and azithromycin treatment. If left untreated for over a week, scrub typhus may lead to encephalitis, myocarditis, or multi-organ failure. Early administration of doxycycline during the 1st week of the febrile phase can prevent clinical complications in scrub typhus. In severe cases of scrub typhus, early and appropriate administration of intravenous azithromycin or doxycycline may save lives.

Seasonality of scrub typhus in Gorakhpur coincides with monsoon (July-September). Scrub vegetation during this season enhances transmission.

Early case identification and appropriate doxycycline therapy at community levels during monsoon will reduce the incidence of encephalitis.

--
Communicated by:
ProMED-mail


[This report adds another dimension to the etiologies of acute encephalitis syndrome (AES) in northeastern India. A 22 Sep 2015 report indicated that there were 10 834 AES cases in 2014. That report describes AES as, "a group of clinical neurologic manifestations caused by a wide range of viruses, bacteria, fungi, parasites, spirochetes, chemicals and toxins" (http://zeenews.india.com/news/health...4_1800724.html). Previous ProMED-mail posts have implicated Reye syndrome, consumption of lychees, and heat stroke, as well as Japanese encephalitis virus infections, as responsible for AES. Now, scrub typhus is added to the list. Although "gold standard" diagnostic tests for scrub typhus were employed in the above study, there is no mention that these other etiologies were ruled out. One should note that 61 percent of the samples tested were scrub typhus positive, leaving 39 percent of the AES cases without a diagnosis.

The contributor of this report is thanked, and one hopes that this study will lead to testing for scrub typhus as other AES cases occur.

Scrub typhus occurs sporadically in India. There was a significant outbreak of scrub typhus in Rajasthan in 2014.

Mod.ML commented in ProMED post archive no. 20150821.3582448: "Outbreaks of scrub typhus have previously been reported from South India (http://link.springer.com/article/10....098-012-0721-0). Because scrub typhus can present in a non-specific manner, its diagnosis can be difficult and sensitive, and specific diagnostic tests may not be widely available.

"Scrub typhus is caused by the rickettsia-like bacterium _Orientia tsutsugamushi_ that is transmitted by the bite of a chigger mite present in shrubberies. Symptoms develop 6 to 21 days after the chigger bite. Fever, headache, lymphadenopathy, and myalgias are common. A characteristic black eschar that is useful for making the diagnosis may be seen at the site of a chigger bite and a maculopapular rash may also be present. A picture of the eschar can be found athttp://medind.nic.in/icb/t10/i8/icbt10i8p918.pdf.

"Pneumonitis, meningoencephalitis, jaundice, renal failure, and myocarditis can develop if treatment is delayed. Because death rates for untreated scrub typhus patients are 1-30 per cent, treatment with doxycycline should begin immediately upon suspicion of scrub typhus without awaiting laboratory confirmation (http://wwwnc.cdc.gov/eid/content/12/2/pdfs/v12-n2.pdf). Treatment with azithromycin has been found to be equally effective (http://aac.asm.org/content/51/9/3259.full,http://cid.oxfordjournals.org/content/39/9/1329.full, and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3957884/)."

Mod.ML indicated: "The gold standard for the diagnosis of scrub typhus has been the indirect fluorescent antibody (IFA) assay to detect _O. tsutsugamushi_-specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies (see ProMED-mail archive 20150821.3582448)." These are the tests used in the above study.



[Scrub typhus is known to involve the central nervous system as part of systemic infection, causing meningo-encephalitis with neck stiffness, tremor, delirium, seizures, and coma in some patients (1,2). Cerebrospinal fluid pleocytosis, usually with an increase in mononuclear cells, has been described (1). Scrub typhus as one of several causes of acute encephalitis syndrome (AES) in India has been described before. Among 20 consecutive patients with AES, scrub typhus was diagnosed in 6 (30%) based on scrub typhus immunoglobulin M enzyme-linked immuno-sorbant assay (ELISA) (3).

1. Mahajan SK, Rolain J-M, Kanga A, Raoult D. Scrub typhus involving central nervous system, India, 2004-2006 [letter]. Emerg Infect Dis 2010; 16 (10).
2. Viswanathan S, Muthu V, Iqbal N, Remalayam B, George T. Scrub Typhus Meningitis in South India -- A Retrospective Study. PLoS One. 2013; 8(6): e66595.
3. Kar A, Dhanaraj M, Dedeepiya D, Harikrishna K. Acute encephalitis syndrome following scrub typhus infection. Indian J Crit Care Med. 2014 Jul; 18(7): 453-455. - Mod.ML



See Also

Japanese encephalitis & other - India (15) 20150930.3681239
Undiagnosed illness - India (02): (KA) febrile, children, scrub typhus susp, RFI 20150821.3582448.
Leptospirosis & scrub typhus - India: (KL) 20150723.3531275
Acute encephalitis syndrome: India (Bihar) RFI 20150606.3413785
Undiagnosed illness - India: (KA) febrile RFI 20150504.3339281
Scrub typhus - India: (TN) 20150405.3277670
.................................................l m/ty/msp/ml

http://www.promedmail.org/?p=2400:1000

[Ronan Kelly]

Updated NVBDCP figures;

http://nvbdcp.gov.in/Doc/je-aes-cd-Sep15.pdf

Arunachal Pradesh has now reported 3 deaths, Haryana has reported 1 death, Jharkhand 2, Maharashtra 2, Punjab 1, Tamil Nadu 3, Uttarakhand 11, Gujarat 3, and Puducherry 1 death. All are documented in this thread, but for some reason not included in NVBDCP figures. As of October 7th, the death toll in Uttar Pradesh is at least 318. All in all at least 932 deaths so far this year. An increase of 237 in the past 30 days.- Ro

[Ronan Kelly]

Uttar Pradesh
Encephalitis 6 killed in 24 hours
13:18:44, 10-10-2015 Uttar Pradesh No comments

10 Lucknow, Uttar Pradesh 10 Aktubrःpurvi encephalitis or meningitis menace had grown. 6, some men were killed in the past twenty-four hours. This year so far 281 have died of some men. (comment: This figure is 10 more than the most recent update from BRD of 271 deaths to Wed Oct 7)

According to official sources, since January 1293 (33 new cases since Wed) has arrived for patient treatment, 24 hours of which 6 in 18 were admitted to the new some men have died of some men. Most affected were found innocent of encephalitis in children but also older, this disease is affecting people that have grown in the number of large-Bujrgo. Medical College Principal Mr R 0 p 0 Sharma Medical College of free Shukla claims and give some men are examined facilities. Everyone is engaged on a war footing for its dismantling.

http://tahlkanews.com/archives/38178

navbharattimes.com reporting two more deaths (aged 8 and 12 years old) from Balrampur hospital in Lucknow district. This increases the deaths reported from outside Gorakhpur to at least 49 and raises the state toll to at least 330.
http://navbharattimes.indiatimes.com...w/49292779.cms

This may be a little more detail of the two children in Lucknow

http://navbharattimes.indiatimes.com/metro/lucknow/other-news/two-deaths-from-meningitis/articleshow/49304119.cms

[Ronan Kelly]

Death toll due to JE rises to 282
Gorakhpur, Oct 10 (UNI) With one more child succumbing to dreaded disease Japanese Encephalitis(JE) the death toll climbed to 282 in the district.
Superintendent of Baba Raghav Das Medical College, B N Shukla, here said that the deceased hailed from Balrampur district.
Read more at http://www.uniindia.com/death-toll-d...BzewImEG8pp.99

[Ronan Kelly]

Fever death in hospital of a child victim, two recruitment
Saturday, October 10th, 2015
Lakhimpur KheriUpdated @ 7:54 PM IST

Japanese encephalitis and acute encephalitis syndrome (AES) remains deadly for innocent as serious illness, which came under the cheek upon innocent times are premature. Saturday afternoon Frdhan region suffering from a high fever, a two-year-old innocent village Prsehra elderly died during treatment at the district hospital. While the village of Hyderabad region Bllia Mituli elderly and living in the village Pakria one child suffering from fever were admitted.


Frdhan area Jamshed Ali's two-year-old resident of the village elders Prsehra Adil son is suffering from fever on Friday night, was admitted to the District Hospital Children's Ward. Doctors began treating the child, but to detect the disease Pathaloji test could not be made. Assuming the doctor who treated the child Pirksia symptoms were treated, but Saturday afternoon at around quarter past 12 pm Adil died. So in this case the child could not confirm the JE or AES symptoms. Also Saturday, the village of Hyderabad region's three-year-old son Amjad Ali Rafiq Bllia elderly resident suffering from a high fever and was admitted, the doctors are telling signs of Pirksia Mituli field three-year-old son of the village chief resident Pakria morning Coming up with a high fever, shock-ing. Family the child is admitted to the children's ward, where her condition remains critical.

http://www.amarujala.com/news/city/lakhimpur-kheri/lakhimpur-kheri-crime-news/fever-death-in-hospital-of-a-child-victim-two-recruitment-hindi-news/

[Ronan Kelly]

From Week 36 IDSP Report: http://idsp.nic.in/idsp/IDSP/outbreaks.htm

Uttar Pradesh
Lakhimpur Kheri
xlvi. Japanese Encephalitis 06 cases 00 fatalities 23-08-15 Under Control
Cases reported from PHC Phoolbehar, CHC Ramiabehar. District RRT
investigated the outbreak. House to house survey done. All 06 serum samples
tested positive for JE. All cases treated symptomatically. Source reduction
activities undertaken. Health education given.

Arunachal Pradesh
Papumpare, Lower Subansiri, Upper Subansiri, East Kameng, East Siang, Naharlagun
i. Japanese Encephalitis

30 cases 02 fatalities 04-07-15 Under Surveillance
30 cases and 02 deaths were reported till 36th week ending on 06th September 2015
from 05districts, namely Papumpare Lower Subansiri, Upper Subansiri, East
Kameng and East Siang. District RRT investigated the outbreak. Majority of cases
reported from Papumpare, Lower Subansiri and Upper Subansiri. Active case
search done in the community.109Serum sample were tested at DPL Arunachal
State Hospital, Naharlagun; out of which 30samples were found to be positive for
JE IgM NIV Mac ELISA and 25 samples were found to be equivocal. All cases
treated symptomatically. Source reduction activities undertaken. Health education
regarding personal protection given

[Ronan Kelly]

Published Date: 2015-10-11 10:54:14
Subject: PRO/AH/EDR> Acute encephalitis syndrome - India (03): (UP) comment
Archive Number: 20151011.3707371
ACUTE ENCEPHALITIS SYNDROME - INDIA (03): (UTTAR PRADESH) COMMENT
************************************************** ***************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Thu 8 Oct 2015
From: T. Jacob John [edited]


Re: ProMED-mail post Acute encephalitis syndrome - India (02): (UP) 20151008.3698951
------------------------------------------------------------------------------------------------------
In ProMED-mail Archive Number: 20151008.3698951, the statement: "The Gorakhpur encephalitis (AES) [acute encephalitis syndrome] has been [resolved]. It is scrub typhus, a mite-borne bacterial disease caused by _Orientia tstsugamushi_" is unscientific and misleading.

The report says: "An ICMR [Indian Council of Medical Research] sponsored investigation during August-September 2014 identified the etiology. Out of 249 acute encephalitis syndrome (AES) cases investigated, 152 (61 percent) of the cases were attributable to scrub typhus either by IgM ELISA, IFA or PCR. A pathognomonic eschar was evident in 20 per cent of the AES cases we investigated."

Finding that 61 per cent of cases initially considered acute encephalitis syndrome were actually misclassified and were not encephalitis but scrub typhus does not resolve the so-called mystery of the remaining really problematic cases.

Obviously, the correspondent (if the same person was also the investigator) does not know how to investigate an outbreak. One does not put together all illnesses remotely resembling each other for outbreak investigation but uses a strict case definition to include cases in the study; had that been done, scrub typhus cases would automatically have been excluded from study samples as they would not fit a case definition demanding specificity. Many investigators have opted for criteria chosen for high sensitivity and have landed in trouble, like this one study well illustrates.

Scrub typhus is widely prevalent in most parts of India, and its clinical presentation is not like that of acute encephalitis at all. It is not at all surprising that scrub typhus occurs in Gorakhpur. Had the investigator discussed this issue with local physicians, they would have clarified that the disease occurs in adults also. Scrub typhus is not confined to children, whereas acute encephalitis is mostly only in children.

What seems to have misguided this investigator is the diagnostic term "acute encephalitis syndrome." While most pediatricians would use that term only for clinically proven encephalitis but without aetiology determined, others use that term to cover bacterial meningitis, cerebral malaria, typhoid encephalopathy, Reye's syndrome, acute hypoglycemic encephalopathy, etc. If we drop the syndrome part, and use the term acute encephalitis, the situation may improve; then only what fits with the well known criteria of encephalitis would be included for investigation and not any acute febrile illness presenting with headache, lethargy or drowsiness, which are characteristic of uncomplicated scrub typhus.

--
Dr. T Jacob John
Formerly (Retired) Professor and Head, Departments of Clinical Virology & Clinical Microbiology,
Christian Medical College,
Vellore, India


[Dr. John makes a compelling case for the need for a more precise case definition of acute encephalitis syndrome (AES). As things stand now, the etiology is unclear. As noted in a 22 Sep 2015 report, there were 10 834 AES cases in 2014. That report describes AES as, "a group of clinical neurologic manifestations caused by a wide range of viruses, bacteria, fungi, parasites, spirochetes, chemicals and toxins" (http://zeenews.india.com/news/health...4_1800724.html).

Previous ProMED-mail posts have implicated Reye's syndrome, consumption of lychees, and heat stroke, as well as Japanese encephalitis virus infections, as responsible for AES. One hopes that a specific case definition, as Dr. John proposes, and prospective studies may help identify the etiologies of these cases so that appropriate treatment as well as targeted control and preventive measures may be taken.

Exclusion of scrub typhus from AES diagnosis does not diminish its importance as a public health problem in India. Prompt diagnosis and treatment are important. - Mod.TY



See Also

Acute encephalitis syndrome - India (02): (UP) 20151008.3698951
Japanese encephalitis & other - India (15) 20150930.3681239the
Undiagnosed illness - India (02): (KA) febrile, children, scrub typhus susp, RFI 20150821.3582448.
Leptospirosis & scrub typhus - India: (KL) 20150723.3531275
Acute encephalitis syndrome: India (Bihar) RFI 20150606.3413785
Undiagnosed illness - India: (KA) febrile RFI 20150504.3339281
Scrub typhus - India: (TN) 20150405.3277670
.................................................m l/ty/msp/ml

http://promedmail.org/direct.php?id=20151011.3707371

[Ronan Kelly]

13 year old died at BRD in Gorakhpur on Monday. 21 new patients admitted with a total of 123 under treatment. Cumulative 1,343 cases with 284 deaths at BRD this year.

http://www.jagran.com/uttar-pradesh/gorakhpur-city-13021308.html

State wide at least 332 deaths have been reported this year.

[Ronan Kelly]

Uttar Pradesh
40 year old woman died of "meningitis" in Shravasti. 4 fever deaths in the past 3 days. More than a dozen ill.
http://www.jagran.com/uttar-pradesh/...-13023530.html

[Ronan Kelly]

Japanese Encephalitis claims 4 more lives in Gorakhpur
Gorakhpur, Oct 14 (UNI) Four more children today succumbed to the dreaded Japanese Encephalitis at the Baba Raghav Das Medical College.
Superintendent of BRD Medical College here B N Shukla here said with these four more deaths of children the death toll has reached to 291.
Read more at http://www.uniindia.com/japanese-enc...2YlGjYWPs1Q.99
State wide at least 340 deaths have been reported this year.

[Ronan Kelly]

Uttar Pradesh
5 more died (aged 3,3,8,9 and 9 years) in BRD hospital Gorakhpur today with 9 new patients admitted. BRD has seen 1,386 encephalitis patients this year of whom 296 have died. 112 remain under treatment.
http://www.jagran.com/uttar-pradesh/...-13034855.html
State wide at least 345 deaths have been reported this year.

[Ronan Kelly]

Acute Encephalitis Syndrome		120 months	Male			Alive	October 17, 2015 Time : 5:36 pm	City : Bijnor Distt. : BIJNOUR State : UTTAR PRADESH
Acute Encephalitis Syndrome		72 months	Male			Alive	October 17, 2015 Time : 5:20 pm	City : Bijnor Distt. : BIJNOUR State : UTTAR PRADESH

Acute Encephalitis Syndrome

120 months

Male

Alive

October 17, 2015 Time : 5:08 pm

City : Bijnor Distt. : BIJNOUR State : UTTAR PRADESH

http://idsurv.org/display-data.php

[Ronan Kelly]

Uttar Pradesh
In the past 24 hours 9 new patients admitted to BRD hospital, Gorakhpur. 5 deaths (aged 6 months, 2, 2, 4 and 4 years). So far this year, BRD has seen 1,431 patients of whom 314 have died. 98 are still under treatment.

http://www.jagran.com/uttar-pradesh/gorakhpur-city-13060543.html

State wide at least 363 deaths have been reported.

[Ronan Kelly]

Uttar Pradesh
4 more children die due to Japanese Encephalitis in Gorakhpur
Posted On: 2015-10-21 Health & Lifestyle United News of India Newswire
Gorakhpur, Oct. 21 -- The death toll owing to Japanese Encephalitis today rose to 318 with four more children succumbing to the dreaded disease.

An official source of the Baba Raghav Das Medical College here said that these five children who died during the past 24 hours belonged to Gorakhpur, Kushinagar and Siddharthnagar districts.

Over 1441 patients, mostly children have been admitted to the hospital since January last and the treatment of about 100 patients was underway in the medical college....

http://www.htsyndication.com/htsportal/article/4-more-children-die-due-to-Japanese-Encephalitis-in-Gorakhpur/9636087

Stae wide toll is now at least 367 - Ro