Re: India: Mystery virus kills 160
UNDIAGNOSED FATAL ILLNESS - INDIA (06): (UTTAR PRADESH)
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A ProMED-mail post
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http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
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In this update:
[1] Further clarification - 2 outbreaks
[2] A state-wide alert in Uttar Pradesh
[3] Rodentborne disease
[4] The AES outbreak in eastern Uttar Pradesh
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[1] Further clarification - 2 outbreaks
Date: Fri 29 Aug 2008
From: Arvind Nath
<
arvindnath@rediffmail.com>
Part (1) of archive no.
20080828.2697 (28 Aug 2008), entitled "Undiagnosed
fatal illness - India (04): (UP)" is not related to the earlier archive on
"Undiagnosed fatal illness - India (03): (UP) RFI
20080826.2666". This is
because the affected locations in the former are "13 districts of eastern
Uttar Pradesh" while the location of the latter is Kanpur Dehat District
which does not belong to eastern Uttar Pradesh.
However, Part (2) of the former conveying Dr Jacob John's comments is most
probably related to the latter.
--
Dr Arvind Nath,
Scientist 'C'
Div. of Epidemiology & Communicable Diseases
Indian Council of Medical Research
New Delhi, INDIA
[Agreed -- see: Undiagnosed fatal illness - India (05): (UP), clarifying
20080829.2709. ProMED-mail thanks Dr Nath for this additional
clarification. To avoid further confusion ProMED-mail will refer to the
outbreak of 'acute encephalitis syndrome (AES) as the eastern outbreak, and
the outbreak of febrile possibly waterborne disease as the south eastern
outbreak.
An interactive map of the states of India that shows the districts in Uttar
Pradesh can be accessed at
<
http://www.mapsofindia.com/maps/india/india-political-map.htm>. - Mod.CP]
******
[2] A state-wide alert in Uttar Pradesh
Date: Fri 29 Aug 2008
Source: Thaindian News, IANS report [edited]
<
http://www.thaindian.com/newsportal/uncategorized/health-alert-in-uttar-pradesh_10090149.html>
Health alert in Uttar Pradesh
-----------------------------
With thousands of people affected by diarrhoea, malaria, gastroenteritis,
and even a mysterious disease that has claimed at least 135 lives, Uttar
Pradesh has sounded a statewide health alert. "Since January [2008], the
state has been grappling with diseases like diarrhoea, gastroenteritis,
measles, malaria and such. Taking this into account, we have sounded the
alert across Uttar Pradesh," I S Srivastava, director general (medical and
health), told Indo-Asian News Service (IANS).
Doctors in the state will now make door-to-door visits in the affected
villages. Fogging and spraying of insecticides will be undertaken on a
war-footing, he added.
The Kanpur division is grappling with a mysterious disease that has claimed
about 135 lives in 4 weeks, officials said Friday [29 Aug 2008]. This
disease has symptoms similar to that of malaria and is accompanied by high
fever.
Since January 2008, diarrhoea has affected more than 7000 people, of whom
94 have died. Likewise, out of the 570 people infected by gastroenteritis,
15 have died, say officials.
In east Uttar Pradesh, acute encephalitis syndrome (AES) has infected more
than 900 people, of whom 160 have died. Cases of jaundice and kala azar
have also been reported, according to health records. The worst affected
districts include Kanpur Dehat (Akbarpur), Muzaffarnagar, Maharajganj,
Siddharthnagar, Mau, Azamgarh, Balrampur and Gorakhpur.
"Directions have been issued to the chief medical officers to disinfect all
sources of drinking water, especially wells and hand pumps," said Srivastava.
--
communicated by:
ProMED-mil
<
promed@promedmail.org>
[This state-wide alert includes the outbreak of AES in eastern Uttar
Pradesh, the outbreak of febrile possibly waterborne disease in the Kanpur
Dehat district in south eastern Uttar Pradesh, and some other outbreaks not
previously reported. - Mod.CP]
******
[3] Rodentborne disease
Date: Fri 29 Aug 2008
From: Dr Jan Clement
<
jan.clement.dr@telenet.be>
Rodentborne disease: leptospirosis and hantavirus infection
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We fully agree with Dr T Jacob John, when he says that immediate
serological testing for leptospirosis is warranted. With the scarce
clinical and epidemiological information we have already, the presumptive
diagnosis of a Japanese encephalitis (JE) outbreak seems rather improbable.
Sudden epidemics of a "viral disease" in warm and moist regions with poor
sanitation should always evoke the possible diagnosis of leptospirosis,
particularly if they occur after floods.
The wild rat is here the prime suspect, being the main (but not the only)
reservoir for leptospirosis. However, the wild rat is also the worldwide
reservoir of at least one known serotype of hantavirus, being Seoul virus
(SEOV). Double infections by both leptospirosis and SEOV have already been
described. In previous ProMED-mail posts, we have already pointed out to
the distinct possibility of a novel hantavirus in India, discovered but not
isolated yet in patients presenting with symptoms suggestive for
leptospirosis. It should be remembered that in similar episodes in Orissa
and Mumba, the serodiagnosis of leptospirosis was worked out indeed, but
not a potential concomitant infection by a hantavirus. It is striking that
in most reports of leptospirosis outbreaks in South East Asia (and even in
South America), the number of seroconfirmed cases surpasses rarely 50 per
cent.
Moreover, the main clinical characteristics of what we know from the
current outbreak in Uttar Pradesh are fever and CNS involvement. Both can
occur also in leptospirosis, as well as in hantavirus infections. Aseptic
meningitis is, together with renal involvement, the most common
complication of leptospirosis, but encephalitis may also occur. The same,
perhaps to a minor degree is true for hantavirus and dengue (Clement J,
Colson P, Van Ranst M. Dengue versus hantavirus CNS infections. Lancet
2000; 355: 2163-4). Leptospirosis and hantavirus infections, although
resulting from totally different pathogens, have not only most clinical
symptoms, but also most laboratory anomalies in common. Both are announced
by thrombocytopenia, the severity of which is an indicator of the clinical
complications to come (Clement J, Maes P, Van Ranst M. Acute kidney injury
in emerging, non-tropical infections. Acta Clin Belg 2007; 62: 387-95).
Thrombocytopenia is not a consistent sign for JE. Early, marked, but
transient proteinuria is the most consistent sign however in both early
leptospirosis and hantavirus infections.
Even in the New World hantavirus infections, which are (wrongly) supposed
to target only the lungs, early proteinuria is found in > 90 per cent of
cases. With the restriction in mind for a minimal degree of proteinuria in
high fever cases (probably even more in infants), a detection of + to +++
degree of proteinuria is without doubt the quickest, simplest, and by far
the cheapest bedside test for a first tentative diagnosis of leptospirosis
and/or hantavirus infections. When urine dipsticks are not available or too
expensive, even the good old urine boiling test might be considered. The
fact that only (?) infants seem affected is the only serious argument
against the tentative diagnosis of both these rodent-borne infections, and
would point rather to a dengue hypothesis.
For reasons still ill understood, hantavirus cases under the age of 15 are
definitely rare in most series. But then, IF there is really a novel
hantavirus roaming around in India, it could as well be a form having the
brain in youngsters as main target organ. Let us not forget that nobody
expected to see emerging in the USA in 1993 a "new disease," affecting
mainly the lungs in healthy young adults, and later called "hantavirus
pulmonary syndrome." Health authorities in Pune tried virus culture to
track the elusive cause of the current outbreak, and expected "results
within 2 or 3 days of collection of the samples."
However, during JE outbreaks, virus isolation is rarely successful, because
the viraemic phase is probably over when CNS symptoms start to appear. The
same goes for hantavirus infections, at least for the milder (Puumala
virus-induced) forms in Europe and Russia. Moreover, hantavirus isolation
is always a tricky affair, needing several time-consuming passages on VERO
E 6 cells in labs with a BSL of at least 3. Finally, since hantaviruses do
not induce a CPE in culture, they can only be detected by selective
techniques such as IFA with specific antisera, or PCR with specific
primers. For a putative novel hantavirus, both are lacking.
--
Jan Clement MD and Piet Maes PhD
Hantavirus Reference Centre
Laboratory of Clinical and Epidemiological Virology and Rega Institute for
Medical Research
University of Leuven
U.Z. Gasthuisberg, Herestraat, 49
B-300 Leuven
Belgium
<
jan.clement@uzleuven.be>
[Drs Clement and Maes have made a constructive contribution to assessment
of the etiology of the outbreak of febrile, possibly waterborne, disease in
south eastern Uttar Pradesh. Their assessment of the role of hantaviruses
in such situations is persuasive and worthy of further intensive
investigation. - Mod.CP]
******
[4] The AES outbreak in eastern Uttar Pradesh
Date: Thu 28 Aug 2008
Source: Thaindian News, ANI report [edited]
<
http://www.thaindian.com/newsportal/health/doctors-team-visit-encephalitis-hit-gorakhpur_10089818.html>
Doctors team visit encephalitis-hit Gorakhpur
---------------------------------------------
A team of doctors deputed by the Union Government, including 2 from the
United States, visited Gorakhpur district of Uttar Pradesh today to examine
patients suffering from encephalitis. The team, along with the 2 doctors of
the US Centers for Disease Control and Prevention, Atlanta (CDC), visited
Gorakhpur to examine patients and study the virus that causes the disease.
The fatal vectorborne disease spreads through viral infection and has
already claimed 171 lives during this season. "From 1 Jan 2008, records
shows that 851 people were admitted out of which 171 people have died,"
said Lalit Mohan, a doctor at the local BRD hospital to reporters. Most of
the patients fall in the age group of 6 months to 12 years. The death toll
due to disease is rising and experts have expressed serious concern.
The disease causes inflammation of the brain. The initial symptoms of the
disease are recurring fever and vomiting. Experts feel that parents as well
as the local doctors have failed to understand the seriousness of this mild
fever, which can prove to be fatal.
The disease is endemic to the region and experts say that immediate
measures are required to contain the virus from spreading.
--
communicated by:
ProMED-mail
<
promed@promedmail.org>
[This report refers to the outbreak of undiagnosed fatal disease in eastern
Uttar Pradesh. The etiology of the disease remains unclear.
A map of the Indian state of Uttar Pradesh showing Gorakhpur in the far
east of the state and Kanpur in the central/south-eastern region of the
state is available at
<
http://mapsofindia.com/maps/uttarpradesh/uttar-pradesh-district.htm>. - Mod.CP
The AES outbreak report does not indicate why this is not thought to be
Japanese encephalitis (JE). Is this a region where JE vaccine has been
routinely included in the children's vaccine series for years, and where
that coverage has been good, suggesting that most children should be
protected? ProMED-mail would appreciate information on that aspect. - Mod.JW]
[see also:
Undiagnosed fatal illness - India (05): (UP), clarifying
20080829.2709
Undiagnosed fatal illness - India (04): (UP)
20080828.2697
Undiagnosed fatal illness - India (03): (UP) RFI
20080826.2666
Undiagnosed fatal illness - India (02): (UP) RFI
20080811.2478
Undiagnosed fatal illness - India (Uttar Pradesh): RFI
20080331.1194
2007
---
Japanese encephalitis - India (02) (Uttar Pradesh)
20071026.3486
Undiagnosed viral disease - India (02): (Uttar Pradesh)
20071026.3485
Undiagnosed viral disease - India: (Uttar Pradesh)
20071022.3440
Japanese encephalitis - India (Uttar Pradesh)
20070930.3233]
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