MILZBRAND, HUMAN, LIVESTOCK - KAZAKHSTAN, RUSSIA (02): (SOUTHERN KAZAKHSTAN)
***********************************************
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Date: 31 Jul 2008
Source: RIA Novosti [trans. Mod.NP, edited]
<http://www.rian.ru/incidents/20080731/115294324.html>


A patient death from anthrax was reported on Thursday [31 Jul 2008]
by the press service of the Kazakh Ministry of Emergency Situations.

On Monday [28 Jul 2008], the 38-year-old man was hospitalized in the
Infectious Department of the municipal hospital in the town of Lenkor
in the southern Kazakhstan region. The patient died on Wednesday [30
Jul 2008 in spite of intensive care. According to the Ministry, the
patient contracted anthrax during the slaughter of sick cattle [The
number of cattle involved is unclear. - Mod.MHJ].

Preventive measures are now being carried out in the focus of the infection.

[Byline: Olga Kovalenko]

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

[The early July 2008 report (see below) was of 3 persons affected in
the Qyzylorda [Kyzylorda] oblast in central Kazakhstan. We appear to
be witnessing the usual here-and-there series of outbreaks reported
whenever a human is hospitalized in this country.

For a map of Kazakhstan go to:
<http://www.fallingrain.com/world/KZ/>. - Mod.MHJ]

MILZBRAND HUMAN - KIRGISISTAN (05): OSH, SUSPECTED
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Date: 5 Aug 2008
Source: RIA 24.kg [trans. Mod.NP, edited]
<http://www.24.kg/incidents/2008/08/05/89141.html>


An outbreak of anthrax has been registered in one more district of
Kyrgyzstan, according to the news agency in the Ministry of Emergency
Situations.

According to officers of the Ministry, 3 persons have been
hospitalized in the infectious department of Kara-Kulja district
hospital with suspicion of anthrax. All of them are inhabitants of
the rural formation (district) Kara-Kulja. Three men aged 39, 46, and
50 years old are now under medical supervision and waiting results of
laboratory investigations.

According to specialists at the Center of Quarantine & Especially
Dangerous Infections of the Republic, anthrax was confirmed earlier
in 21 inhabitants of the Osh and Jalalabad regions. One person died.

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

[The Kyrgyz authorities are patently having problems controlling
anthrax in their livestock in these 2 oblasts in SW Kyrgyzstan.
Logically, there will be similar problems over the nearby (open)
border in Uzbekistan.

To see a map of Kyrgyzstan, go to: <http://www.fallingrain.com/world/KG/>.
For Kara-Kulja, go to:
<http://www.fallingrain.com/world/KG/0/KaraKuldzha.html>. - Mod.MHJ]

MILZBRAND HUMAN - KYRGYZSTAN ( 06 ): (JALAL-ABAD)
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Date: Sat 2 Aug 2008
Source: Central Asian News [subscription required; in Russian, trans.
Corr.ATS, edited]
<http://www.ca-news.org/news/33778?from=ya>


The number of people with anthrax in [Ala-Buka] district reaches 6
------------------------------------------------------------------
The Kyrgyzstan Ministry of Emergency Situations reports that 6 people
have been hospitalized in the district hospital with suspicion of
anthrax. The hospital is located in [Ala-Buka] district of
[Jalal-Abad province], which is in the south of the republic. All the
patients are from the same village.

The Ministry of Emergency Situations also reported that 2 out of 7
patients from [Ala-Buka] district have been discharged and 3 other
patients have been discharged from Aravanskaya district hospital.

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

[The epidemic situation for anthrax in humans and animals has
worsened in Kyrgyzstan over the last years. There were 17 human cases
in 2006, 23 in 2007, and [so far] 21 this year (2008). Since 1918
more than 1000 cases of animal anthrax have been registered in
Kyrgyzstan. There is a problem in proper surveillance of anthrax in
Kyrgyzstan; the places of animal burial were not registered, instead
local people were trying to remember infected areas. - Corr.BA

To date they have now had outbreaks in the following districts of
Jalal-Abad: Ala-Buka, Aravan, Nooken, and Suzak.

For maps of Kyrgyzstan, go to
<http://www.fallingrain.com/world/KG/> and
<http://healthmap.org/promed?v=41.5,74.6,5>
and for Ala-Buka district go to
<http://www.fallingrain.com/world/KG/0/AlaBuka.html>. - Mod.MHJ]

UNDIAGNOSED PULMONARY DISEASE - INDIA: REQUEST FOR INFORMATION
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Date: Tue 5 Aug 2008
Source: Yahoo India News [edited]
<http://in.news.yahoo.com/32/20080805/10 ... and_1.html>


Uttarakhand's health department is alarmed after the death of a girl
due to high fever and severe lung infection. Another girl has
reported similar symptoms.

The officials are suspecting the spread of the deadly hantavirus and
these to be the 1st cases of the disease in India. Authorities at
Mahant Indresh Hospital here said 2 girls, one from Dehradun and
another from Tehri, were admitted some days ago with very high fever
and severe infection in their lungs, both symptoms of hantavirus
pulmonary syndrome (HPS).

The patients were later shifted to Himalayan Institute Hospital at
Jollygrant for better treatment after they complained of stomach
problems and difficulty in breathing. One of the girls later died,
and the other is still battling for her life.

Dr Ved Prakash, director of Mahant Indresh Hospital, told media
persons that symptoms in both the girls indicated hantavirus
infection, a deadly disease that spreads through rats and lizards and
could lead to bubonic plague [sic., see Mod. comment below]. Taking
note of the death, the health department sent a team of doctors to
Mahant Indresh Hospital and the Himalayan Institute Hospital on
Sunday [3 Aug 2008] to investigate and take blood samples from the
surviving patient.

"The blood samples would be sent to the National Institute of
Virology, Pune and the National Institute for Communicable Diseases
in New Delhi for confirmation. We can say whether the death was due
to HPS only after we get the reports," said Dr G.C. Baunthiyal, CMO, Dehradun.

Appealing to the public not to panic, health department officials
have asked them to refrain from coming in close contact with rodents
like rats and lizards [sic., see below] in their homes and work
places as a safety measure. Health Minister Ramesh Pokhriyal Nishank
stated that the department is keeping a close watch on the situation
and has directed chief medical officers in all districts to keep
track of any similar symptoms in their areas and notify the higher
authorities immediately.

According to doctors, HPS is a rare but serious and often deadly lung
infection caused by a type of virus called a hantavirus that is
carried by rodents like rats and lizards [sic.]. To date, there has
been no known case of the disease in India.

People get HPS when they breathe in dust contaminated with saliva,
urine, or droppings from infected rodents. No anti-virus drug is
effective against HPS, and there is no vaccine.

To prevent it one, should avoid contact with rodents and avoid
inhaling contaminated dust.

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

[The symptoms reported for these 2 cases are too general to suggest
agents that might be responsible for the illnesses. The hantaviruses
that cause HPS have never been found in South or Southeast Asia. The
hantaviruses found in these regions cause hemorrhagic fevers with
renal complications. That does not rule out the possibility that
HPS-causing hantaviruses are present in northern India, but it is
unlikely based on current information. It is likely that the health
authorities were misquoted by the reporter of this article. Lizards
are not rodents, and no hantaviruses have been associated with
lizards to date. Similarly, hantavirus infections do not turn into
bubonic plague. There are several possible etiological agents that
might be involved in these cases. ProMED requests further information
as the laboratory results become available. - Mod.TY]

[As Mod. TY states above, a symptom complex of fever and lower
respiratory infection is too non-specific to narrow down the possible
differential diagnosis of the etiology. In India, there was an
outbreak of pneumonic plague with 16 cases and 4 deaths attributable
to the disease in 2002 in Himachal Pradesh, a bordering state to
Uttarakhand (see prior ProMED mail postings referenced below). In
1994 there was a large multistate outbreak of plague, both bubonic
and pneumonic in India (Maharashtra {488 cases}, Gujarat {77 cases},
Karnataka {46 cases}, Uttar Pradesh {10 cases}, and Madhya Pradesh {4
cases) and from the federal district of New Delhi (68 cases) (see
reference below). Other possibilities would include bacterial
pneumonia or a primary viral pneumonia. It would be helpful if there
was information on the veterinary health situation in the areas where
these girls lived. It is also quite possible that these are simply 2
case reports of complicated lower respiratory infection without any
common denominators to suspect there is something more sinister to be
concerned about. ProMED-mail would greatly appreciate receiving more
information from knowledgeable sources.

Uttarakhand (also known as Uttar Anchal) is located in the north of
India sharing a border with China to the north, with Nepal to the
east, Uttar Pradesh to the south, and Himachal Pradesh to the west. A
map of India can be found at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
- Mod.MPP]

UNDIAGNOSED PULMONARY DISEASE - INDIA (02): HANTAVIRUS NEPHROPATHY
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Date: Fri 8 Aug 2008
From: Jan Clement and Piet Maes, Hantavirus Reference Centre, Leuven, Belgium
<Jan.Clement@uz.kuleuven.ac.be>


Hantaviruses in India
---------------------
Even if the Uttarakhand cases were serologically to be confirmed in
Pune and/or New Delhi as recent hantavirus infections, and
consequently could be presented eventually as "Hantavirus Pulmonary
Syndrome (HPS)" cases, they would not be, as stated by the local
health authorities, the 1st to be reported so in India. We briefly
reported already in 2000 2 fatal hantavirus cases in South India:
see, Clement J., Muthusethupathi M., Nainan G.,Van Ranst M. "First
fatal cases of hantavirus nephropathy in India". Clin Inf Dis 2000; 31: 315.

As discussed in a subsequent 2006 publication, one of these acute
Indian fatalities had all the clinical characteristics of severe HPS,
also complicated however with renal involvement: see, Clement J, Maes
P, Muthusethupathi M, Nainan G, Van Ranst M. "First evidence of fatal
hantavirus nephropathy in India, mimicking leptospirosis." Nephrol
Dial Transpl 2006; 21: 826-7:
<http://ndt.oxfordjournals.org/cgi/conte ... 3/826?etoc>.

Since until recently no clinical hantavirus infections had been
documented in India, we screened acute Indian cases from Chennai and
Cochin (South India), suspected for leptospirosis, by means of
recombinant nucleoprotein ELISA for Puumala virus (PUUV) and SIA
(strip immunoblot assay) with recombinant PUUV and Seoul virus (SEOV)
antigens. Leptospirosis was used as clinical screening symptom,
because fever, myalgiae and acute renal failure (ARF) in
leptospirosis are indistinguishable from the clinical symptoms of
"Hemorrhagic Fever with Renal Syndrome"(HFRS) in the Old World
hantavirus infections. More importantly, cases in both diseases often
mention previous rodent contacts. PUUV was chosen as screening agent
because it is the most important hantavirus in Europe and Russia.
SEOV was added because it is spread by wild rats (_Rattus rattus_ and
_R. norvegicus_), the only known so far rodent reservoir of
hantavirus with a documented presence in India.

All studied sera were seronegative for leptospirosis in MAT and
Patoc- IgG and IgM ELISA. Dengue infection was likewise serologically
excluded. However, we found positive (PUUV and/or SEOV) IgG SIA in
10/60 cases. All IgG SIA-positive cases, except 1 SEOV, were also IgM
SIA-positive, and were confirmed by positive IgM ELISA. 2 of the 10
Indian cases were fatal. One Chennai patient with dyspnoea died of
ARF despite peritoneal dialysis. The 2nd fatal case was a Cochin
female patient (64 years old), who presented with fever, myalgiae,
abdominal pain, and severe dyspnoea; i.e., with symptoms similar to
the current Uttarakhand cases. She developed jaundice, very low
platelets (7000/mm [cubed]), disseminated intravascular coagulation
(DIC), and ARF needing dialysis as well. Moreover, an adult
respiratory distress syndrome (ARDS) or a HPS picture with extreme
hypoxia developed, prompting not only dialysis for fluid removal, but
additionally also mechanical ventilation, as indicated in other
severe HPS cases. Despite this intensive care treatment, the patient
died in refractory shock on hospital day 7. SIA IgG and IgM was
clearly positive for PUUV-bands, and PUUV IgM was likewise positive
in ELISA, thus confirming for the 1st time and in 2 different test
formats a recent and fatal hantaviral infection in an Indian patient.

In a 2nd step, we applied RT-PCR on all Indian sera, including the 2
fatal cases, with primers specific for most of hitherto known
hantaviral pathogens, being PUUV, SEOV, Hantaan virus (HTNV), Dobrava
virus (DOBV) and Andes virus (ANDV). All turned out to be negative.
Moreover, we also performed RT-PCR for Thottapalayam virus (TPMV),
which was equally negative. TPMV is the only indigenous hantavirus
known in India, since it was isolated already in 1964 from a house
shrew (_Suncus murinus_) captured in Thottapalayam, near Vellore in
South India. No human TPMV pathogenicity has been demonstrated so
far, and it should be noted that shrews are insectivores, not
rodents. So far, human hantavirus pathogenicity has been linked to
rodents only.

As explained in a Letter to the Indian Journal of Medical Research
(Clement J, Maes P, Van Ranst M. "Which hantaviruses in India?"
Indian J Med Res. 2006; 123: 91-2.), our SEOV-positive results could
be expected, and SEOV-induced ARF might be considered indeed in the
differential diagnosis of leptospirosis in India, as elsewhere in the
world, since the wild rat is the only cosmopolitan hantavirus
reservoir. However, the PUUV-positive results came as a surprise,
particularly in the 2 fatal Indian cases. In Europe and Russia, PUUV
infections are spread by bank voles (_Myodes glareolus_), but this
rodent is absent from India, as are all other related species of the
subfamily _Arvicolinae_. Consequently, PUUV cannot be expected to be
endemic in India. Bearing in mind also our PCR-negative findings,
serological results in India, positive for PUUV (and even more
specific techniques such as SIA), should be interpreted as
cross-reactions with another yet unknown, but PUUV- like hantavirus
strain. Cross-reactions with TPMV are unlikely, since this
insectivore-borne hantavirus is genetically totally different from
all other known rodent-borne hantaviruses. Moreover, we recently
demonstrated a similar PUUV-like IgG and IgM seroreaction in acute
leptospirosis-suspected cases from Sri-Lanka, some of which also
presented with cough or dyspnea (manuscript in preparation, and see
Promed-mail 20080606.1808 "Leptospirosis- Sri Lanka (02): Hantavirus
also suspected").

Sri-Lanka is a country neighbouring India, with a fauna very similar
to it, including the total absence of rodent species of the subfamily
_Arvicolinae_. Interestingly, it should be remembered that Sin Nombre
virus (SNV), and Andes virus (ANDV), the 2 main etiologic factors of
HPS in the New World, are genetically related to PUUV (as are their
rodent reservoirs), thus explaining frequent cross-reactions in
serology. In fact, it was a PUUV-like reaction in ELISA on the sera
of the 1st HPS cases from the Four Corners region in the USA that
ultimately led to the discovery in 1993 of a new highly fatal
pathogen, affecting mainly (but not only) the lungs.

From a purely clinical point of view, it is unlikely that the severe
hospital course as depicted above in the fatal Cochin case could be
attributed to a true PUVV infection, which is mostly rather mild or
even asymptomatic (Clement J, Maes P, Van Ranst M. Acute Kidney
Injury in emerging, non-tropical Infections. Acta Clin Belg
2007;62:387-95). In fact, and as pointed out already in 2006, [the
patient's] course with ARF, DIC, ARDS, and refractory shock leading
to death one week after admission is highly reminiscent of the more
severe American HPS forms. As we now realize, renal participation is
more and more noted together with lung symptoms in HPS, particularly
in South American ANDV-induced forms. Conversely, severe
non-cardiogenic acute lung edema, i.e., a HPS-like complication, has
been reported in Old World HFRS as well, including PUUV infections
(Clement J., Colson P., Mc Kenna P. Hantavirus pulmonary syndrome in
New England and Europe. N.Eng.J.Med. 1994; 331: 545-6.
(see: <http://content.nejm.org/cgi/content/full/331/8/545?
ijkey=0e4b01144fe8ff212d732a17c71e293434a7d8be&keytype2=tf_ipsecsha>
[subscription required]).

For comparison with the current Uttarakhand cases we need more
clinical details indeed, which can be readily available, such as the
presence or absence of initial thrombocytopenia and proteinuria, of
leukocytosis with a left shift, and of immunoblasts.

--
Jan Clement MD and Piet Maes PhD
Hantavirus Reference Centre
Laboratory of Clinical and Epidemiological Virology,
Department of Microbiology and Immunology,
Rega Institute and Universitary Hospitals Leuven,
Kapucijnenvoer 33,
BE-3000 Leuven
BELGIUM
<Jan.Clement@uz.kuleuven.ac.be>

[This contribution is an authoritative statement of some significant
observations that have identified the existence of a novel hantavirus
in India which has been associated with HPS with renal involvement.
The agent resembles the rodent-associated hantaviruses such as the
European/Russian Puumala virus and the more cosmopolitan Seoul virus,
but not with Thottapalayam virus the only hantavirus so far isolated
in India which is transmitted by insectivores and not associated with
human disease.

The putative Indian hantavirus previously implicated in 2 fatal cases
of HPS-like disease in India may or may not be the agent responsible
for the outbreak in Uttarakhan. However, at the very least hantavirus
infection should be considered in the differential diagnosis of
leptospirosis and pulmonary syndromes with renal involvement in India
and elsewhere in Asia.

Uttarakhand (also known as Uttar Anchal) is located in the north of
India sharing a border with China to the north, with Nepal to the
east, Uttar Pradesh to the south, and Himachal Pradesh to the west. A
map of India showing the locations of Uttarakhan, Chennai and Cochin,
can be found at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
- Mod.CP]

Japanische Enzephalitis in Indien - Impfung empfohlen
05.08.2008 - Ärztezeitung

DÜSSELDORF (mut). In Nordindien gibt es derzeit einen Ausbruch der Japanischen Enzephalitis. Wer in den betroffenen Gebieten umherreist, sollte sich gegen das Virus impfen lassen, rät das Zentrum für Reisemedizin in Düsseldorf. Mindestens 449 Menschen sind bisher bereits an der Virusinfektion, die zu schweren Hirn- und Hirnhautentzündungen führen kann, erkrankt und 95 verstorben. Am meisten betroffen ist der Bundesstaat Uttar Pradesh, indem auch das von vielen Touristen besuchte Taj Mahal stehtsowie die Stadt Varanasi am Ganges ... mehr

ANTHRAX, HUMAN - KYRGYZSTAN (07)
********************************
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Date: 14 Aug 2008
Source: IRIN News [edited]
<http://www.irinnews.org/Report.aspx?ReportId=79812>


Anthrax in animals has long been endemic in southern Kyrgyzstan, but
since 2006, an increasing number of human cases have been registered.
41 cases of anthrax in humans were registered in Kyrgyzstan in 2005;
15 in 2006; and 23 in 2007, according to Jalalidin Gaibulin, head of
the National Centre for Quarantine and Especially Dangerous
Infections (NCQEDI). As of 14 Aug 2008, the number of confirmed human
cases since May 2008 was 27, Gaibulin told IRIN in the capital,
Bishkek [As of 2 Aug 2008, there were 21 cases; see 20080807.2426. -
Mod.MHJ]. All patients had received treatment.

"If strict measures are not taken, there is a danger of mass
disease," said a senior official at the Agency for the Protection of
the Environment and Forestry, Kubanychbek Noruzbaev.

Prime Minister Igor Chudinov has ordered the establishment of a
special commission to design a programme to combat the spread of the
disease.

Anthrax spores are to be found in the soil in many areas, and these
spores are frequently ingested by animals, which then catch the
disease and can pass on the infection to humans. Factors identified
by specialists as promoting the spread of the disease include: late
or non-vaccination of cattle in the poorest regions; poor hygiene
standards and lack of veterinary supervision at local markets;
inadequate veterinary services; insufficient data on animals and
anthrax hotspots; and the failure of animal owners to register
newly-purchased cattle.

Nurlan Duisheev, deputy director-general of the Department of
Veterinary Medicine, said that "535 [historic] sites have been
documented, covered with concrete and fenced off," but that track had
been lost of many hotspots since World War II.

Duisheev said his department could not vaccinate all animals and
pointed out that currently the number of animals in Kyrgyzstan was
twice the number registered by the National Statistical Committee.
"We allocate vaccines according to National Statistical Committee
data and cannot give out additional drugs." He also said his
department faced a serious shortage of veterinarians: He only had 30
percent of the necessary 4000 veterinarians. Lack of funds was to
blame for his department's inability to fight the outbreak
successfully, he said. "We were able to buy only 2 000 650 doses of
anthrax vaccine [for animals] with the money allocated in the budget.
That is only 30 percent of the required amount. We requested 126
million soms [about USD 3.7 million] for the department's work, but
so far we have received less than half of the requested amount,"
Duisheev said.

Experts from the International Epizootic Bureau who conducted an
evaluation of the Kyrgyz veterinary service gave it a low score: 1-2
points out of a possible 5. Duisheev interpreted this as meaning
veterinary services in Kyrgyzstan were at a very low level.

"To implement all planned tasks [for 2008-2012] we need USD 42
million. During talks with representatives of the EU, the
International Epizootic Bureau, the World Bank, the Asian Development
Bank, and a number of European states and members of international
community, verbal agreement to provide funds was given," said
Duisheev.

"We are very scared about anthrax among cattle and people. One person
has died," said Syrgak Kurmanbaev, 50, a resident of Nooken village,
Jalalabad Province. "There have been outbreaks of anthrax over several
years. We keep cattle, and we buy drugs and treat animals if there is
any sign of an infection. We try not to buy meat at the market," he
said.

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

[In 2007, they had, according to OIE, 1 168 026 cattle and vaccinated
1 028 500; sheep & goats: 4 251 813 (2 408 000 vaccinated); equids
around 360 000 (202 400); and vaccinated 17 000 of 74 918 pigs. With
the higher cost of gasoline/petrol, even with Russian subsidies, that
will eat into the ability of vaccinating teams to get out and do
their job. If they can persuade their Uzbek neighbours to mount an
effective vaccination programme, it would be logical to hit the
southwest in the oblasts adjoining Uzbekistan, where the disease is
common and the border porous. Similarly in the northern oblasts
adjoining Kazakhstan, it would be wise to move when the Kazakhs have
effective control programmes in their southern neighbouring oblasts.
The countries have to move together for any cost-effective livestock
control programme. It is not a simple problem. - Mod.MHJ

Location map of Kyrgyzstan:
<http://aboutkazakhstan.com/images/kazak ... icture.jpg>
Regional map showing neighboring countries:
<http://www.pickatrail.com/jupiter/map/kyrgyzstan.gif>
- Mod.JW]

Pakistan - Dengue
15.08.2008

Aus Karachi wird ein Dengue-Ausbruch gemeldet. Seit Mitte Juli erkrankten mindestens 94 Patienten mit Dengue-Symptomen, bei 38 konnte die Diagnose labortechnisch bestätigt werden. Schutz vor tagaktiven Stechmücken beachten. / Quelle: crm

KRIM-KONGO-HÄMMORHAGISCHES FIEBER - TÜRKEI (15)
*********************************************
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Date: Wed 20 Aug 2008
Source: Today's Zaman Istanbul [edited]
<http://www.todayszaman.com/tz-web/detay ... &bolum=100>


Farmer falls victim to Crimean-Congo hemorrhagic fever
------------------------------------------------------
A patient with Crimean-Congo hemorrhagic fever (CCHF) from northern
Tokat province succumbed to the disease at the Sivas hospital where
he was being treated.

According to the Anatolia news agency, a tick bit the 37-year-old
farmer while he was working in a field in a village in Tokat. He went
to a hospital in Tokat and hospital staff removed the tick. After
being released from the hospital he fell ill and went back to the
hospital. He was transferred to Sivas Cumhuriyet University Research
and Training Hospital, where he died despite medical attention.
Reports say the farmer, a father of 3, was buried in his village
yesterday [19 Aug 2008].

Mostly infecting animals, CCHF is a viral disease transmitted by
ticks. The virus can infect sheep and cattle in addition to humans
and is fatal if not detected and treated early. It has been
responsible for the deaths of more and more people in Turkey each
year since its first recorded incidence in Turkey in 2002.

--
Communicated by:
ProMED-mail Rapporteur A-Lan Banks

[Between 2002 and 2007, a total of 1820 confirmed cases, including 92
deaths, were reported, showing an increasing trend over the years.
The majority of cases (95 percent) were reported from middle and
eastern Anatolia, particularly from Tokat, Sivas, Yozgat, Corum, and
Erzurum. Most of the cases were diagnosed between March and October,
with peak levels in June and July, which correspond with the tick
season. The average case fatality rate between 2002 and 2007 was 5
percent. 70 percent of the cases had a history of tick contact, while
most of the remaining 30 percent had a history of contact with
livestock, and 3 cases were attributed to nosocomial transmission
[see ProMED-mail Crimean-Congo hem. fever - Turkey (14): background
20080814.2530].

The 1st CCHF case in 2008 was detected and notified on 24 Mar 2008.
As of 30 Jun 2008, 688 confirmed cases have been reported. Of these,
41 patients have died due to CCHF, corresponding to a case fatality
rate of 5.96 percent. As in previous years, most of the cases were
from Middle and Eastern Anatolia (91 percent).

The unfortunate death described in the current report indicates that
transmission of CCHF from ticks is still occurring in rural areas of
the central Anatolian region.

A map of the provinces of Turkey showing the central location of
Tokat can be accessed at
<http://en.wikipedia.org/wiki/Provinces_of_Turkey>. - Mod.CP]

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2008 (33)
**********************************************
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In this update:
Asia
[1] Cholera - India (Delhi)
[2] Gastroenteritis - Pakistan (Punjab)

******

[1] Cholera - India (Delhi)
Date: Mon 25 Aug 2008
Source: Sindh Today, Indo-Asian News Service (IANS) report [edited]
<http://www.sindhtoday.net/south-asia/15118.htm>


Delhi has reported 450 cases of cholera in 2008, the civic
authorities said [Mon 25 Aug 2008] and felt that the situation may
worsen in the wake of the recent floods in Yamuna.

"Cholera has been a constant problem in the city. We have so far
reported over 450 cases," said VK Monga, head of the health committee
of Municipal Corporation of Delhi (MCD).

"As the water in the Yamuna river has receded, people living along
the river bank, especially the slum dwellers, need to be extra
careful. They need to be careful about their water intake to prevent
the spread of cholera and other gastroenterological problems. The
stagnant water would also assist in spread of dengue," he added.

Monga said MCD has already launched a campaign to spread awareness
about cholera across the city.

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[A map of India showing New Delhi, in the north, can be found at
<http://www.nationsonline.org/bilder/map_of_india50.jpg> - Mod.LL]

******
[2] Gastroenteritis - Pakistan (Punjab)
Date: Sat 16 Aug 2008
Source: The Post [edited]
<http://www.thepost.com.pk/Arc_NatNews.a ... &fcatid=14>


A gastroenteritis outbreak killed 3 minors in Kohlan Hatthar Village,
including 2 brothers aged 4 and 2 who died of the disease here [in
Kasur] on Saturday [16 Aug 2008]. Another 3-year-old child also died
with the same disease in another area of Kasur. Dozens of others
suffering from gastroenteritis were admitted at Chuniyan hospital.
Doctors said that majority of the patients were children, adding that
more than 60 patients suffering from the disease were being brought
to DHQ Hospital alone.

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

[Kasur is in eastern Punjab province, which can be seen on the map at
<http://www.un.org/Depts/Cartographic/ma ... kistan.pdf>.

The outbreaks discussed in this update can also be found on the
HealthMap/ProMED-mail interactive map at
<http://www.healthmap.org/promed>. - Mod.LL]

DENGUE/DHF UPDATE 2008 (37)
***************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
[1] Pakistan (Karachi)
[2] India (Delhi)
[3] India (Haryana)

******
[1] Pakistan (Karachi)
Date: Wed 20 Aug 2008
Source: Daily Times [edited]
<http://dailytimes.com.pk/default.asp?pa ... 08_pg12_10>


The total number of dengue patients in the city this year [2008] has
risen to 287, as 5 new patients were admitted in different hospitals
in the last 24 hours.

Dengue Surveillance Cell Dr Shakeel Malik said on Tuesday [19 Aug
2008] that one patient was sent home after complete recovery. In the
city, 36 patients with dengue symptoms were admitted in different
hospitals, while 2 of these were confirmed as dengue patients.

He said that so far, 4 dengue patients have died this year [2008] in the city.

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

A map of Pakistan can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... l_2002.jpg>.
An interactive HealthMap/ProMED-mail map of Pakistan can be accessed at
<http://healthmap.org/promed?v=30,69.4,5>. - Mod.TY]

******
[2] India (Delhi)
Date: Wed 20 Aug 2008
Source: Times of India [edited]
<http://timesofindia.indiatimes.com/Delh ... 382847.cms>


The number of dengue cases reported so far this year [2008] is 3
times more than those reported during the same period last year
[2007], said MCD officials on Tuesday.

Until 19 Aug 2007, only 10 cases of dengue were reported. Even during
the 2006 dengue outbreak, MCD reported just 24 cases and in 2005, 22
cases were reported in August.

A total of 35 cases were reported up until Tuesday [19 Aug 2008], of
which 32 are from MCD area, 2 from NDMC [New Delhi Municipal Council],
and one from Delhi Cantt [Cantonment]. "In the last 4 years, this is
the 1st time we have so many cases in the month of August," said a
senior MCD official.

The civic agency said that this year [2008], due to early monsoon and
infrequent rains, the number of cases has risen. "People have stopped
using air-coolers, but have not got them cleaned or have kept them
so that rainwater can collect in them. We are taking all measures
to keep breeding under check. But this year [2008] the number of cases
are more than those reported during the last few years," said Dr N.K.
Yadav, MHO [municipal health officer], MCD.

--
Communicated by:
ProMED-mail Rapporteur A-Lan Banks

[It is unfortunate that the help of the public in eliminating _Aedes_
mosquito breeding sites has not been successful, and an earlier report
suggests that penalties are being considered. It would be interesting
to know what public education initiatives have been taken, and an
assessment of why they have not succeeded.

A map of India showing the location of Delhi can be accessed at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
An interactive HealthMap/ProMED-mail map of India can be accessed at
<http://healthmap.org/promed?v=22.9,79.6,5>. - Mod. TY]

******
[3] India (Haryana)
Date: Thu 21 Aug 2008
Source: Express India [edited]
<http://www.expressindia.com/latest-news ... on/351715/>


With 2 dead out of the 150 confirmed dengue cases reported at Gurgaon
hospitals, an alarmed district administration is taking immediate
steps to arrange special facilities at its civil hospital.

The local civil hospital has started a separate ward for dengue
patients. According to sources, 278 suspected dengue patients came to
light in the district, but [only] 150 tested positive and the rest
were diagnosed with viral fever. He said out of the patients suffering
from dengue, 2 had died. The rest of the patients are out of danger
and the majority of them have been discharged after being cured. He
said most of the dengue patients are from Gurgaon city and adjoining
areas.

The administration has advised the people to clean their desert
coolers at least once a week and keep their overhead water tanks
properly covered as the standing water is the breeding ground for the
female mosquitoes responsible for spreading dengue [virus].

He also advised people to wear full-sleeved clothes while sleeping and
check for accumulation of water near their houses. If waterlogging is
unavoidable then they should spray kerosene, diesel, or black oil [on
standing water]. [Kerosene, diesel, or black oil should *not* be used
in storage containers for drinking or washing water; they should be
covered with a lid or a cloth. - Mod.TY/JW]

--
Communicated by:
ProMED-mail Rapporteur A-Lan Banks

[One wonders if the reported non-dengue viral fevers might be
chikungunya virus infections.

Gurgaon is the southern-most district of Haryana state in the Punjab
region of northern India. The state can be located on the map at
<http://www.lib.utexas.edu/maps/middle_e ... _pol01.jpg>.
Gurgaon is one of Delhi's 4 major satellite cities. It can be located
via the interactive HealthMap/ProMED-mail map of India at
<http://healthmap.org/promed?v=22.9,79.6,5>. - CopyEd.MJ]

UNDIAGNOSED FATAL ILLNESS - INDIA (03): (UTTAR PRADESH), 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>

Date: Mon 25 Aug 2008
Source: Hindustan Times [edited]
<http://www.hindustantimes.com/StoryPage ... 95ff5d1cd7>


*****
[This is not a continuation of the outbreak in March 2008,
reported in ProMED ref. 20080331.1194 below. This is another episode
whicb only began this month, August 2008 -- see ProMED
ref.20080811.2478 below. - Mod.JW]*****

Rural Kanpur is fighting its most frightening scourge -- a mystery
disease that has left a long line of bodies in its trail and doesn't
seem anywhere near finished.

What started from one village 2 weeks ago [week of 9 Aug 2008] has
now spread to 350 and has so far claimed 160 lives. Thousands more
are bed-ridden. On an average, 15 to 20 people have been dying every
day; Saturday [23 Aug 2008) saw the highest toll in a day: 24.

The district's health department is somewhat confused about the
nature of the disease that has struck. At the beginning, the
diagnosis was viral fever. Then doctors concluded that it was
falciparum malaria. But after 2 weeks, they have ruled out both, but
still don't have an exact answer.

"We really don't know what exactly it is; we are depending on the
finding of a team of specialists from New Delhi," said Dr RC Agarwal,
the district's new chief medical officer.

Specialists from the Infectious Disease and Surveillance Programme,
New Delhi, have collected the blood samples of a few patients. The
team will make its findings known in a few days.

But the fear of the unknown has resulted in a mass exodus of
villagers. Pulandar and Dhar villages under Malasa block are the
worst affected. About 1000 people in these 2 villages alone are
battling the disease. Dhar has taken the maximum number of
casualties. The village has lost about 30 people but only one doctor
has visited it so far. That was 15 days ago.

Dhar still remains a perfect picture of neglect and apathy. Heaps of
garbage continue to be littered all over. Houses are surrounded by
stinking filth and roads are waterlogged -- perfect breeding grounds
for diseases like malaria. The village's secondary school has been
shut down for an indefinite period. Children would wade through
knee-deep water to reach the school.

[Byline: Pawan Dixit]

--
Communicated by:
Ryan McGinnis
<digicana@gmail.com>

[This outbreak of undiagnosed disease has spread dramatically since
the initial report dated 11 Aug 2008 (see: Undiagnosed fatal illness
- India (02): (UP) RFI 20080811.2478). The disease has now spread to
affect some 350 villages in the Kanpur district of Uttar Pradesh,
affecting thousands of people with the death toll now at 160. There
appears to have been no progress in identification of the cause of the
outbreak, other than that malaria and unspecified viral fevers have
been excluded. There is no description of the signs and symptoms of
the disease, but the suspicion of water-borne infection remains in
view of the reported neglected state of the villages and persisting
flooding and lack of adequate drainage.

The results of the analysis of diagnostic materials collected from
villagers are awaited with some impatience. The lack of medical
support for the villagers is alarming.

The Indian state of Uttar Pradesh can be located using the
HealthMap/ProMED-mail interactive map of India at
<http://healthmap.org/promed?v=22.9,79.6,5>,
and the location of Kanpur district can be found at
<http://content.answers.com/main/content ... ic_map.jpg>.
- Mod.CP]

CRIMEAN-CONGO HEMORRHAGIC FEVER - AFGHANISTAN: (HERAT)
******************************************************
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: Wed 27 Aug 2008\Source:
Source: PakTribune on line [edited]
<http://paktribune.com/news/index.shtml?204993>


Outbreak of rare disease kills two
----------------------------------
An outbreak of a rare disease that causes its victims to bleed and can kill
within 2 weeks has infected 3 people and killed 2 others in the western
province of Herat. The disease called Crimean-Congo hemorrhagic fever
(CCHF), has never been recorded in Afghanistan, according to the World
Health Organization's (WHO) website. Doctors in Herat warned that the
disease, which is transmitted from animals to humans through ticks, will
spread to other parts of the country unless preventative steps are taken
immediately.

Victims have a 30 per cent chance of dying within the second week of the
disease once infected, WHO says. Sudden fever, aching muscles, dizziness,
neck pain, backache, headache, sore eyes, and photophobia (sensitivity to
light) are early symptoms of CCHF. These are followed by a fast heart rate,
a rash that causes the skin to bleed, bleeding from the upper bowel, blood
in the urine, nosebleeds, and gum bleeding.

Head of the regional hospital in Herat said nine potential victims of the
disease had come into hospital for treatment, but only 5 of them had tested
positive for CCHF so far. Two of the 5 infected with the disease have died.

Infection can be prevented by using repellents on the skin and clothing and
by wearing gloves or other protective clothing to prevent skin contact with
infected tissue or blood. Doctors in Herat sent blood samples to the UN's
medical centre in Egypt to find out if the patients had the disease - 5
tested positive. The results of 4 other potential victims are still pending.

Butchers, shepherds, and others who have daily contact with animals are
more likely to be infected with the disease. The disease is endemic in many
countries in Africa, Europe, and Asia. The disease was first described in
the Crimea in 1944.

--
communicated by:
ProMED-mail rapporteur A-Lan Banks

[Although this report states that these are the first reported cases of
CCHF in Afghanistan, ProMED-mail posted a report in 2002 (see:
Crimean-Congo hem. fever - Iran ex Afghanistan 20020607.4430) that 5
residents of Afghanistan were treated for suspected CCHF in a hospital in
Iran close to the Afghan border. Three of the patients died. CCHD is
endemic in countries bordering Afghanistan, Iran, and Pakistan in
particular, therefore it would seem unlikely that Afghanistan is a
CCHD-free country.

For further information on CCHF a WHO fact-file is available at
<http://www.who.int/mediacentre/factsheets/fs208/en/>.

A map of the provinces of Afghanistan, showing Herat province in the west,
is available at <http://www.afghana.com/GetLocal/Afghanistan/
Provinces.htm>. - Mod.CP]

UNDIAGNOSED FATAL ILLNESS - INDIA (04): (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>

[1]
Date: Tue 26 Aug 2008
Source: The Hindustan Times, online [edited]
<http://www.hindustantimes.com/StoryPage ... trParentID>


The mystery virus striking children dead in eastern Uttar Pradesh (UP) has
been diagnosed as "acute encephalitis syndrome" by Union Health Ministry
experts. Simply put, they do not know what is causing the acute brain fever.

Within weeks, about 800 cases and 150 deaths were reported from 13
districts in UP, and experts predict that the numbers could rise.

"Less than 5 per cent blood and serum samples have tested positive for
Japanese encephalitis (JE), which has seen major outbreaks in the region
each year," said Dr Shiv Lal, director of the National Institute of
Communicable Diseases.

"Usually, at least 15-20 per cent samples test positive for JE during an
outbreak, but the low positivity is causing confusion this year [2008].
With 4 crore [40 million] children in 27 districts in UP being vaccinated
against JE this year, experts wonder why the fever refuses to go away.
There is no problem with the Chinese vaccine SA 14-14-2," said a health
ministry official. The virus, approved by World Health Organization,
protects against JE. "We suspect some children could have missed the
vaccination drive." All the hospitalised children have reported symptoms of
acute encephalitis.

"Since less than 5 per cent have tested positive for JE, we are
investigating whether the outbreak is a combination of JE and water-borne
enterovirus that caused the disease in 2006," said Dr Lal. The Centre is
sending a 4-member team comprising a microbiologist, a pediatrician, an
entomologist, and an epidemiologist to Lucknow and Gorakhpur to track the
outbreak and collect blood and serum samples from hospitalisd children for
viral culture.

"Apart from rapid tests for JE done using kits developed by Pune's National
Institute of Virology, we will do virus culture to track the elusive cause
of the current outbreak," said Dr Lal, adding that the result could be
expected within 2 or 3 days of collection of the samples.

[byline: Sanchita Sharm]

--
communicated by:
ProMED-mail rapporteur Mary Marshall

******
[2]
Date: Wed 27 Aug 2008
From: T Jacob John <vlr_tjjohn@sancharnet.in>


Although the details are skimpy, age distribution and clinical description
lacking, yet the available information can be used to propose a provisional
diagnosis to be investigated. Heavy rainfall and flooding, febrile illness
resembling malaria, and relatively large numbers of death does remind one
of leptospirosis. Immediate serological testing for this disease is warranted.

Similar episodes in Orissa and Mumbai a few years ago (all the 3 features
above fitted) turned out to be leptospirosis. In Orissa it was for the
first time (at least recognized), while in Mumbai the presence of
leptospirosis was already known. To add, there is no shortcut to detailed
clinical description and elementary epidemiological investigation of cases
based on specific diagnostic criteria of the outbreak disease, and
exploration of risk factors (to look for transmission pathways). Instead of
doing what one can do locally, the complete dependence on experts from
elsewhere is not good.

--
Dr T Jacob John
Christian Medical College
Vellore
India
<vlr_tjjohn@sancharnet.in>

[Japanese encephalitis virus infection is an unlikely explanation, but
still under investigation. - Mod.CP

ProMED-mail thanks Dr John for his comments and looks forward to more
information about this outbreak. - Mod.LL]

UNDIAGNOSED FATAL ILLNESS - INDIA (05): (UTTAR PRADESH), CLARIFYING
*******************************************************************
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 29 Aug 2008
From: T Jacob John, Christian Medical College, Vellore, India.
<vlr_tjjohn@sancharnet.in>


[ProMED-mail is indebted to Professor T Jacob John for the following
clarification, which is necessitated by our reporting of 2 separate
outbreaks of undiagnosed fatal illness in Uttar Pradesh within the same
thread.]

A clarification
---------------
I wish to alert you to a clarification. 2 distinct outbreaks are mixed up
in the most recent ProMED-mail post: Undiagnosed fatal illness - India
(04): (UP) 20080828.2697.

Part [1] of this report concerns an encephalitis-like syndrome, (almost)
exclusively in children. Clinically it is a CNS disease, commonly called by
the "non-specific" term acute encephalitis syndrome (AES). Some Japanese
encephalitis and other undiagnosed CNS diseases are involved.

My comment in part [2] of the report does not pertain to the AES outbreak,
but a different one (see: Undiagnosed fatal illness - India (03): (UP) RFI
20080826.2666), predominantly rural, not confined to children, clinically a
febrile illness "resembling malaria", and associated with flooding. The
very first report (see: Undiagnosed fatal illness - India (02): (UP) RFI
20080811.2478) of this outbreak emphasised involvement of children,
jaundice, link to flooding, but no mention of AES like nature. The only
commonalities between the 2 are that children are affected and death is
common. The news in 20080826.2666 does not say predominantly children but
such details are not given in it.

In summary, there are 2 major outbreaks, one in East UP [Uttar Pradesh],
resembling Japanese encephalitis (JE) and the other in South-East UP,
resembling leptospirosis with fever, jaundice and no particular brain
involvement. Children are often affected in leptospirosis outbreaks.

Both seem to have fairly high case fatality. The latter is eminently
treatable, only if diagnosis is suspected in the beginning. The CNS
disease, whether JE or another viral disease is not that effectively
treatable, but supportive care minimises mortality. The reason to propose
leptospirosis is that it fits the picture, infection is widespread in
India, outbreaks involving children and young adults occur after heavy
rains and flooding (waterlogging in one description), diagnosis (and
antimicrobial therapy) is often life-saving and specific lab tests are
available in a network of national labs. If government health officers read
ProMED-mail, they could immediately take action.

I hope my description of 2 outbreaks make sense. [ProMED-mail agrees]

--
T Jacob John
Christian Medical College
Vellore
India

[ProMED-mail regrets the confusion and is in complete agreement with
Professor T Jacob John's analysis. In fact the 1st 2 posts describing the
2nd outbreak in Uttar Pradesh in August contained a introductory statement
indicating that it was not known to be connected with an earlier outbreak
of undiagnosed fatal illness in Uttar Pradesh in April. In retrospect it
was inadvisable to combine the reports of the 2 outbreaks in the same thread.

The Hindustan Times report of 26 Aug 2008 was incorrectly included with
Professor T Jacob John's diagnosis of leptospirosis because it was assumed
incorrectly that that the press report did not refer to the outbreak of
encephalitis-like illness reported in Uttar Pradesh in April 2008.

To avoid further confusion any information about the 2 outbreaks will
continue to be included in a common thread until there is final resolution
of the underlying causation.

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/i ... al-map.htm>. - Mod.CP]