Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

[Ronan Kelly]

So I wrote a piece for The University of New South Wales School of Public Health and Community Medicine Disease Blog;

Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle.
image - India AES Cases
By Ronan Kelly.

Ronan Kelly (USA) is a Senior Moderator at www.FluTrackers.com, with an interest in outbreaks in India.

Past history of AES in India

Acute Encephalitis Syndrome (AES) is a growing problem in India. The first major outbreak was in West Bengal in 1973 involving 700 cases and over 300 deaths. Subsequent serological studies identified the Japanese Encephalitis (JE) virus as the cause. (1,2) Between 1978 and 2007, over 100,000 cases of AES with a case fatality rate (CFR) of almost 33% were reported from 13 different states. It was widely presumed that JE was the predominant aetiological agent in these outbreaks. (3,4) However, a study of patients admitted between 1985-1988 at King George’s Medical College (now Shahuji Maharaj Medical University) in Lucknow revealed bacterial meningitis as a diagnosis in 18% of apparent AES patients with JE indicated in only 12% of cases. Measles, Mumps, Malaria also played a part to some smaller degree, but 50% of the cases remained undiagnosed. Reye’s Syndrome was not found in any case.(5) An investigation of repeated AES outbreaks in Saharanpur in the early 2000s found that children were eating beans of the Cassia occidentalis plant which was causing acute hepatomyoencephalopathy. These patients were being misdiagnosed as AES cases. Local government organized removal of the plants and provided information programs for residents. As a result, fatalities in the district dropped from around 100 per year to zero in 2010. (6,7)

follow link for full article; https://sphcm.med.unsw.edu.au/infect...ongoing-puzzle

[sharon sanders]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

A very informative piece. Thank you.

[sharon sanders]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Wednesday, October 01, 2014

Referral: Ronan Kelly On AES In India




# 9033

One of the great things about this little part of the internet called Flublogia is that we are blessed with a great many very smart, dedicated, and talented participants. I’ve written in the past about the work done by volunteers on the flu forums (see Newshounds: They Cover The Pandemic Front), but they often do far more than just surf the internet and post reports.

Ronan Kelly, who is a senior moderator at FluTrackers, has devoted an incredible amount of time and effort focusing primarily on infectious diseases on the Indian Subcontinent.

He was recently contacted by the University of New South Wales and invited to put together a blog post on the – as yet unidentified and complicated AES (Acute Encephalitis Syndrome) epidemic– which occurs in the Northeastern states of that country every year.

So, without further ado, I invite you to follow the link below to read:

Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle.

By Ronan Kelly.
Ronan Kelly (USA) is a Senior Moderator at www.FluTrackers.com, with an interest in outbreaks in India.
Past history of AES in India
Acute Encephalitis Syndrome (AES) is a growing problem in India. The first major outbreak was in West Bengal in 1973 involving 700 cases and over 300 deaths. Subsequent serological studies identified the Japanese Encephalitis (JE) virus as the cause. (1,2) Between 1978 and 2007, over 100,000 cases of AES with a case fatality rate (CFR) of almost 33% were reported from 13 different states. It was widely presumed that JE was the predominant aetiological agent in these outbreaks. (3,4) However, a study of patients admitted between 1985-1988 at King George’s Medical College (now Shahuji Maharaj Medical University) in Lucknow revealed bacterial meningitis as a diagnosis in 18% of apparent AES patients with JE indicated in only 12% of cases. Measles, Mumps, Malaria also played a part to some smaller degree, but 50% of the cases remained undiagnosed. Reye’s Syndrome was not found in any case.(5) An investigation of repeated AES outbreaks in Saharanpur in the early 2000s found that children were eating beans of the Cassia occidentalis plant which was causing acute hepatomyoencephalopathy. These patients were being misdiagnosed as AES cases. Local government organized removal of the plants and provided information programs for residents. As a result, fatalities in the district dropped from around 100 per year to zero in 2010. (6,7)
(Continue . . . )

Posted by Michael Coston at <a class="timestamp-link" href="http://afludiary.blogspot.com/2014/10/referral-ronan-kelly-on-aes-in-india.html" rel="bookmark" title="permanent link"><abbr class="published" itemprop="datePublished" title="2014-10-01T08:30:00-04:00">8:30 AM</abbr>

[sharon sanders]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Acute encephalitis syndrome outbreaks in India – an ongoing puzzle

This is an article I've been waiting years for. Via the University of New South Wales School of Public Health and Community Medicine, an article by Ronan Kelly of FluTrackers: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle.Excerpt:

Between Jan 1, 2008 and Aug 27, 2014; 44,097 cases and 5,728 deaths were reported due to AES in India. This figure represents a significant increase in the recent annual number of reported cases even as the CFR has dropped to around 13%. An average of 8,139 cases per year have been reported for 2011-2013 an increase of 220% over the period 2003-2007.(8,9) This is likely an underestimate.

Government statistics do not generally include cases that never make it to hospital, and AES outbreaks predominantly affect rural communities with poor access to healthcare who are less likely to be notified as AES cases. Much of the recent increase is accounted for by a surge in reported cases in Assam (cases tripled in 2011 and stayed at that level ever since) and West Bengal (cases jumped sevenfold in 2011 and doubled again since then).

Nationally, since 2008, only 6,825 (15.5%) patients tested positive for JE. In many cases, the causative agent remains elusive.

The State of Uttar Pradesh has experienced periodic AES outbreaks since 1978, but following a major outbreak in 2006, the annual case load has exceeded 3,000 patients, three times the level prior to that year.(10) The State has accounted for almost half (over 20,000) of cases and 3,560 deaths since 2008. Only 8.1% of the cases have been confirmed for JE and the State has annually hosted a variety of investigative teams.

In recent years, various enteroviruses such as EV-76, EV-89 as well as coxsackievirus B5 and echovirus 19 have been found associated with AES cases.(11,12) It has been suggested that shallow wells pumping up contaminated drinking water are a major problem.

However, making any conclusions about what is causing AES outbreaks in Uttar Pradesh is hampered by poor patient record systems. A study from Kushinagar in 2011-2012 found that record keeping, test results and vaccination history were so poor that “inferences about the epidemiology and etiology of AES could not be made”.(13)

One of the conclusions that can be drawn from the various studies in Uttar Pradesh is that the cause of AES outbreaks can vary from location to location. This is also true for the country at large. For example while outbreaks in Assam have consistently tested >35% positive for JE since 2008, Chandipura Virus has been implicated in outbreaks in Gujarat. West Nile Virus (WNV), as in Kerala in 2011, may also be playing a part.(14)

But some outbreaks remain a mystery. One intriguing outbreak has drawn much attention. The State of Bihar has seen periodic outbreaks for over twenty years. Recent recurrent outbreaks centered on Muzaffarpur appear unusual. One such outbreak of unknown aetiology occurred in 2012. Rather than peaking in September as is usual for JE, on this occasion the peak happened in June. None of the 334 patients tested positive for JE and at least 118 (35.3%) of them died.(15)

This year (2014), the outbreak lasted through June and early July and resulted in around 200 deaths. None tested positive for JE, Chandipura, Nipah or WNV. The victims were mostly children, mostly poor, mostly malnourished.

The outbreak coincided with the litchi (lychee) picking season. One hypothesis is that a toxin in unripe litchis leads to hypoglycaemic syndrome in under nourished children causing symptoms that are being diagnosed as AES. (16) Others suggest that the outbreak is really a form of encephalopathy brought about by heatstroke. (17) In parallel with Uttar Pradesh, most cases got their drinking water from shallow hand pumps, but I am not aware of any enteroviruses being identified.(18)

Investigations over the past two years have resulted in local treatment recommendations such as rapid assessment for and correction of hypoglycaemia. Preliminary study suggests that this may have reduced the mortality rate in Muzaffarpur this year down to 26%.

October 01, 2014 at 07:20 AM

[MHSC]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Great Job Ronan!!

[Pathfinder]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

You worked very hard on this subject Ronan and you deserve appreciation!

His thread on FT:
http://www.flutrackers.com/forum/sho...d.php?t=215606

Congratulations!

[JJackson]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Very nice Ronan. You somehow managed to make a subject in which the data is as clear as mud into a into a readable coherent post - no mean feat - Bravo.
For those unfamiliar with this thread India Encephalitis 2014 - 1,297 fatalities - which I dip into from time to time but have never been able to understand what is going on - Ronan has been plugging away at the very unrewarding task of imposing order on chaos.
Thank you for your perseverance.

[Ronan Kelly]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Thank you all very much
You are a truly inspiring group to work with.

[Emily]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Excellent work, Ronan!

[Ronan Kelly]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Some graphs to help visualize the numbers; Data is from the National Vector Borne Disease Control Programme. There is some evidence that these figures underestimate the actual incidence of AES. *Data for 2014 are to November 6th.

[Ronan Kelly]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Some questions - What happened in 2005 in UP and did it cause the tripling of cases in that state thereafter?

What is causing the big jump in cases in Assam, Bihar & WB since 2011?

[Ronan Kelly]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Assam & West Bengal - When AES cases rise, so too do confirmed Japanese Encephalitis cases, suggesting that JE is causing the increase in those states.

[Ronan Kelly]

Re: Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle. - by me

Uttar Pradesh & Bihar have a JE component, but the situation may be more complex - there seems to be another player.

[Ronan Kelly]

Deadly Japanese encephalitis surges in northeast India
BY AMARJYOTI BORAH
Mon Jan 26, 2015 6:01am EST

GUWAHATI, India (Thomson Reuters Foundation) - Cases of deadly mosquito-borne Japanese encephalitis have risen nearly five-fold in five years in India's northeast Assam state as a result of warming weather and changing rainfall, health experts say.

Between 2010 and 2014, the number of annual cases rose from 154 to 744, with deaths rising from 41 to 160, according to data from the Assam health department. The disease, which in 2009 was recorded in only half of the state’s districts, now is seen in all of them.

Doctors say climate change has played a major role in the spread of the disease, which once appear largely from May to July, but now is seen as late in the year as November, as mosquitoes survive longer in warmer conditions.
...
(Reporting by Amarjyoti Borah; editing by Laurie Goering)
http://www.reuters.com/article/2015/...0KZ10L20150126

[Ronan Kelly]

I hadn't come across this before - a moving, thoughtful piece on the annual tragedy. The article discusses the 2014 Acute Encephalitis outbreak of unknown origin in Muzaffarpur, Bihar.This was written last year, but it could have been any year for the past 40 years. These outbreaks are relentless, predictable and ongoing. Please follow the link to read in full. - Ro

Muzaffarpur diary: Chronicles of deaths
POSTED BY CHINKI SINHA AT 10.59 PM, 20 JUNE 2014
TAGGED UNDER | children | Muzaffarpur | Acute Encephalitis Syndrome |

I try to find drama. For the sake of the story. Because in journalism school, they told me to locate the conflict, and to show and not tell.

But there's too much conflict. So much that I have to walk out on and off to feel better. I step on the chlorine powder sprinkled on the ramps of this hospital, and try to look away when I cross the corridors for it is full of the sick and the dying. There are those that may be categorized as 'mentally challenged' that lurk everywhere. I am here to report on the Acute Encephalitis Syndrome that kills hundreds of poor children in Bihar's Muzaffarpur district every year.

I have never covered an epidemic. To me, this is one. They won’t declare it. But children are dying in the temporary ICUs and are then loaded on to the mortuary vans and taken home.

On Sunday morning, I walked into an PICU on the second floor of the Sri Krishna Memorial College Hospital in Muzaffarpur, and they didn’t stop me. They let me sit there.

For three days, I recorded the deaths of a three-year-old, and a seven-year-old, and others. I sit determinedly. I don't let the facts get blurry.

I just sit, and I write.

"They are temporary people. This is suffering that comes from indifference to it. Dejection is a permanent feature of this place. This is a temporary place."

I write exactly like how an objective reporter is not supposed to write. My mother had accompanied me. She is afraid to let me travel in my own state on my own. She is outside. She tells me to leave. She is worried that I won’t be able to handle this.

They say the epidemic will go when the rains come. But the sky looks and feels like a blasted furnace. White and blue, shimmering, and merciless. Relentless, too.

But I am not going to be ‘soft’. I sit, and watch the nine cardiac monitors that show the pulse rate and the arterial pressure. I don’t know what these digits mean. The doctors tell me everything is dismal.

What can a poor man do? Ram Bharose knows his curse. His wife isn't here. His three-year-old daughter is dying.
...
http://www.openthemagazine.com/blogp...cles-of-deaths