Re: India Encephalitis 2013; 318 fatalities
Re: India Encephalitis 2013; 318 fatalities
This is about as damning a report on Indian epidemiological surveillance and healthcare as I have seen. Year after year, these outbreaks affect Uttar Pradesh, but still - shoddy case reporting continues, test results disappear into limbo and vaccination levels appear to be vanishingly small. - Ro
Volume 19, Number 9?September 2013
Perspective
Acute Encephalitis Syndrome Surveillance, Kushinagar District, Uttar Pradesh, India, 2011?2012
Manish KakkarComments to Author , Elizabeth T. Rogawski, Syed Shahid Abbas, Sanjay Chaturvedi, Tapan N. Dhole, Shaikh Shah Hossain, and Sampath K. Krishnan
Author affiliations: Public Health Foundation of India, New Delhi, India (M. Kakkar, E.T. Rogawski, S.S. Abbas); University College of Medical Sciences, New Delhi (S. Chaturvedi); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (T.N. Dhole); Centers for Disease Control and Prevention, New Delhi (S.S. Hossain); Office of the World Health Organization Representative to India, New Delhi (S.K. Krishnan)
Abstract
In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011?June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23% had illogical entries. AES incidence was highest among boys <6 years of age, and cases peaked during monsoon season. Records for laboratory results (available for Japanese encephalitis but not AES) and vaccination history were largely incomplete, so inferences about the epidemiology and etiology of AES could not be made. The low-quality AES/Japanese encephalitis surveillance data in this area provide little evidence to support development of prevention and control measures, estimate the effect of interventions, and avoid the waste of public health resources.
full paper available at;
http://wwwnc.cdc.gov/eid/article/19/9/12-1855_article.htm
extracts;
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AES Epidemiology
In 2011, a total of 721 AES cases from Kushinagar District were identified through BRD Medical College; in 2012 (January?June), 91 cases were identified. Using the cleaned line lists, we determined the weekly number of AES cases reported during January 2011?June 2012 (Figure 1). Cases peaked during August?October 2011; >150 cases were identified in each of these 3 months. This seasonal trend corresponds with an expected increase in cases during the monsoon season, when transmission of both waterborne and vector-borne diseases increases (vector density is at its maximum).
In 2011 and 2012, most case-patients were male (57.4% and 59.3%, respectively) (Table 1). In 2011, almost half of the AES cases were in children <5 years of age (44.7%); the distribution of cases by age group was not substantially different in 2012.
The case-fatality rate was 18.0% in 2011 and 19.8% in 2012.
Using 2011 population data (20), we estimated that there were 20.2 AES cases/100,000 population in Kushinagar District in 2011 (Table 2). The incidence was higher among male residents than female residents (incidence rate ratio 1.29, 95% CI 1.11?1.49), and it was highest among children 0?6 years of age. The crude incidence rate ratio, comparing case-patients 0?6 years of age with those >6 years of age, was 7.97 (95% CI 6.87?9.25). Boys 0?6 years of age were at highest risk for AES. The incidence among 0- to 6-year-old boys was almost 50% greater than that among girls of the same age.
The weekly numbers of AES cases, classified by JE IgM laboratory result (positive, negative, awaiting determination), is shown in Figure 2.
Only 3 (4.2%) cases of JEV infection were identified in 2011: two cases were in 55-year-old men, 1 of whom died, and 1 case was in a 14-year-old girl.
Vaccination status was reported for 119 case-patients, of whom 3 (2.6%) had been vaccinated. The case-patients who had received vaccine were boys 6, 7, and 8 years of age; they began experiencing symptoms in July 2011 and were discharged within 3 weeks of hospital admission. None of the 3 JE case-patients had been vaccinated.
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Current surveillance data provide little credible information to guide program planning and policy making for AES/JE in Kushinagar District. We could not determine if JE is etiologically responsible for AES in this area because reporting for JE laboratory testing was vague and incomplete. In addition, it is likely that only serum samples were collected to determine if AES was caused by JEV infection because the sampling procedure for serum is simpler than that for CSF. However, serum is a suboptimal sample for determining the cause of AES. Many JE infections are asymptomatic, so AES may be caused by an agent other than JEV even if JEV?specific IgM is present in the serum (2,3). In addition, a live, attenuated JEV vaccine is used in India, so the presence of JEV IgM in serum may be the effect of previous vaccination. CSF is preferred over serum samples for JEV testing because the presence of JE antibody in CSF provides a definitive diagnosis of JEV infection. A record of the type of sample collected is also essential for assessing the diagnostic yield of the sample and determining whether the sample was collected at the appropriate time after symptom onset (2). This need for a complex diagnostic process may have contributed to the incompleteness of laboratory results.
Regardless of the type of sample collected, the recording of JEV laboratory test results was inconsistent during the latter half of 2011 and nonexistent during 2012, despite collection of clinical samples soon after hospital admission. It is unknown whether the delays were caused by laboratory constraints or miscommunication in reporting the results. However, lack of timeliness in reporting surveillance data hinders its utility for guiding interventions and responding to outbreaks. JEV laboratory test results were available only during the low-transmission period, thus excluding any analysis for peak-transmission periods. JEV vaccination has been variously reported at 52% (22) to >95% (district health authorities, pers. comm.). We could not use the current surveillance data to estimate or validate the reported coverage figures because most vaccination histories were unknown.
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