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RABIES - INDIA (09): (MAHARASHTRA) CANINE, HUMAN, TREATMENT FAILURE
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Date: Tue 24 Dec 2013
Source: The Times of India [edited]
http://timesofindia.indiatimes.com/city ... 809109.cms


A 27-year-old man succumbed to rabies at the civic-run Naidu Infectious Diseases Hospital [Maharashtra state] [on 13 Dec 2013], taking the toll of deaths due to the infection to 15 in the city so far this year. Civic officials said the man had been bitten by a dog near his right ankle 5 months ago [July 2013] and that he had taken anti-rabies vaccines on scheduled days. However, doctors he was taking treatment from did not administer rabies immunoglobulin that can [inactivate] the virus. "The victim was not from Pune city. As per our medical records, he was a resident of Bhosari [Maharashtra state] and was admitted to Naidu Hospital when his health condition deteriorated," said S T Pardeshi, medical officer of health (MoH), Pune Municipal Corporation (PMC).

The deceased has been identified as a resident of Alandi road in Bhosari. He was walking on the roadside when a stray dog bit him 5 months ago. According to the World Health Organization [prediction], the incubation period for the infection is typically 1-3 months, but may vary from one week to one year. "It was a category III dog bite wound. As per the medical history given to our health staff by the victim's relatives, the victim received anti-rabies vaccination on the scheduled days at some hospital in Pimpri Chinchwad. However, he was not administered rabies immunoglobulin, readymade antibody and is extremely effective in inactivating the virus in category III dog bite injury," said Anjali Sabne, deputy medical officer of health, PMC. The victims are usually injected with a fast-acting readymade antibody, rabies immunoglobulin (RI), near the wound, to inactivate the rabies virus. The readymade antibodies are given to the patient for immediate protection because the vaccine generally takes 14 days to [induce] antibodies. As per WHO guidelines, rabies immunoglobulin (RIG) should be given for all category III exposures, irrespective of the interval between exposure and beginning of treatment.

The victim developed mild fever and breathlessness a few days before he was admitted to PMC-run Naidu Infectious Diseases Hospital on [12 Dec 2013]. "He had developed symptoms of rabies, like hydrophobia (fear of water), and was extremely breathless at the time of admission. He succumbed to rabies infection at 12:30 pm on [13 Dec 2013]," Sabne said. The hospital he initially sought treatment from could not be identified. He was brought to Naidu hospital by his relatives.

An 11-year-old girl from Bibvewadi [Pune, Maharashtra state] died of rabies infection on [4 Dec 2013]. Her parents had alleged that she was administered anti-rabies vaccines but not inoculated with rabies immunoglobulin in and around the wound, which is a prerequisite if the bite wound is serious. However, doctors had refuted the charge.

An average of 1000 dog-bite cases are being reported in the city [Pune] every month, with as many as 12 319 cases recorded from January to November, this year [2013]. A total of 14 people have died of rabies in Pune city in this period, 3 of whom were local residents. Densely populated areas of Gadikhana, Mandai, Shukrawar Peth, Bajirao Road in the heart of the city, Yerawada, Hadapsar, Kothrud and Sahakarnagar have reported the highest number of dog-bite cases this year. According to the Association for Prevention and Control of Rabies in India, greater awareness about rabies and timely treatment, combined with efforts at controlling the stray-dog population, pet-dog licensing and annual anti-rabies vaccination of animals, are necessary to control the infection.

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[This account describes the unfortunate outcome of anti-rabies treatment that varied from the strict protocol advised by the WHO and other medical authorities. While this was clearly a rare event, visitors to India should avoid situations where they may be in contact with free-ranging urban dogs, and if bitten should be aware of the essential treatment response. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1*Oa.]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (21): (UTTAR PRADESH)
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Date: Thu 26 Dec 2013
Source: The Gulf Today, Press Trust of India report [edited]
http://gulftoday.ae/portal/00b7cbf2-552 ... 14d66.aspx


The menace of encephalitis continues unabated in eastern Uttar Pradesh as 3 more children succumbed to the disease at BRD Medical College Hospital, official sources said on Wednesday [25 Dec 2013].

With these deaths, which took place during the last 24 hours, the toll has reached 640 this year [2013].

Sources in the office of Additional Director (Health) said all 3 deaths occurred at BRD Medical College Hospital.

The deceased hailed one each from Gorakhpur, Kushinagar [both in Uttar Pradesh state] and an adjacent area in Bihar [state], they said, adding, the patients were admitted to the medical college hospital during the last 24 hours while 46 patients are undergoing treatment.

Sources said that this year [2013] as many as 3008 encephalitis patients were admitted to different government hospitals of eastern region, of which 640 died.

The disease causes death in 33 per cent of cases, while over 50 per cent of patients suffer from various forms of mental and physical disabilities, they said.

The disease is caused due to mosquito bite [that transmutes Japanese encephalitis virus] or consumption of contaminated water.

Central and state agencies are continuously conducting awareness campaigns on sanitation and safe drinking water.

The official said 3 rounds of vaccination against Japanese encephalitis (JE) for children up to 15 years have also been conducted, adding that the move has [caused JE cases to go down by 15 per cent].

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[As noted in previous comments, reports of viral encephalitis in Uttar Pradesh state provide no indication of the proportion of these cases due to Japanese encephalitis virus infections or to other, undetermined causes. In previous reports, some have been diagnosed as due to Japanese encephalitis virus (JEV) infections and others associated with contaminated water, suggesting enterovirus infections. The massive Japanese encephalitis virus vaccination campaigns in Uttar Pradesh and Bihar states has resulted in a significant reduction in cases due to infection with that virus.

The cause of the majority of the AES (acute encephalitis syndrome) cases remains undiagnosed. A study of encephalitis in Udorn, Thailand indicated that the histopathologic features from autopsies conducted on 40 children were characterized by those findings associated with acute Reye syndrome. The latter report also details the evidence pointing to acute aflatoxin poisoning as the etiology of the condition in Udorn (see ProMED-mail archive no. 20131011.1995836). No autopsy results have been reported for the above cases of acute encephalitis syndrome.

One hopes that the scientists involved in attempting to determine the etiologies of these undiagnosed cases will continue to attempt to find out what is going on, so that scientifically sound preventive measures may be devised and implemented. As mentioned previously, although JEV outbreaks may continue to be prevented through vaccination, preventing enterovirus infections, in the absence of vaccines, requires improvement of sanitation infrastructure to assure adequate human waste disposal and uncontaminated potable water supplies, a very costly effort.

A HealthMap/ProMED-mail map of India showing the location of Uttar Pradesh and Bihar states can be accessed at http://healthmap.org/r/1-k3. - Mod.TY]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (70): ASIA
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Cholera - India (Karnataka)
Date: Wed 18 Dec 2013
Source: The Hindu [edited]
http://www.thehindu.com/todays-paper/tp ... 472462.ece


Deputy Commissioner and District Magistrate N. Jayaram on Tue 17 Dec 2013 declared Sultanpur village -- under the Noginahal Primary Health Centre (PHC) of Hukkeri taluk [a taluk is an administrative region. - Mod.LL] -- as cholera-affected. He directed officials of the Health Department to take up measures to prevent the spread of the disease to adjoining areas.

Mr. Jayaram said that 36 cases were reported from the village. All patients were being treated at the PHC and other private health centres. He told the Health Department officials to set up teams of doctors to provide treatment. He urged the residents of Sultanpur and adjoining areas to maintain cleanliness and to drink boiled water.

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[An interactive ProMED HealthMap of the state can be found at: http://healthmap.org/r/1-eG.]

ZIKA VIRUS - GERMANY ex THAILAND
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Date: Fri 27 Dec 2013
From: Jonas Schmidt-Chanasit <jonassi@gmx.de> [edited]


A previously healthy 53-year-old man consulted at the Saarland University Medical Center on 22 Nov 2013 after returning from travel to Thailand. During his 3-week round trip (31 Oct-20 Nov 2013), including visits to Phuket, Krabi, Kho Jum, and Ko Lanta, he developed joint pain and swelling on his left ankle and foot on 12 Nov 2013 after several mosquito bites, followed by a maculopapular rash on his rear and front trunk that spread to the face and the upper as well as lower extremities over the next 4 days before fading. Accompanying symptoms were malaise, fever, and shivering, of which the latter 2 appeared only for one day. He and his travel partner, who never had any comparable symptoms, were using insect repellent during travel. Upon presenting in Germany, which was intended as a check for tropical diseases and included taking blood samples, no clinical signs could be found, and the only subjective complaint was continuing tiredness.

Initially, the 1st serum sample collected 10 days after disease onset gave a positive result in the dengue IgM antibody tests (IFA and rapid test), although tests for dengue IgG antibody (IFA and rapid test) and dengue NS 1 antigen (ELISA and rapid test) were negative. However, the isolated positive result for dengue IgM antibodies prompted us to investigate a probable flavivirus etiology through a serological approach. Serological tests for Japanese encephalitis virus, West Nile virus, yellow fever virus, tick-borne encephalitis virus, and Zika virus were performed by the WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research (WHOCC), Hamburg, Germany. IFAs gave positive results for Zika virus IgG and IgM antibodies, demonstrating an acute or recent Zika virus [ZIKV] infection of the patient. In contrast, IFAs gave negative results for the other flaviviruses tested as well as for chikungunya virus. Real-Time RT-PCR for ZIKV RNA (in-house) was negative. The presence of ZIKV-specific neutralizing antibodies was confirmed by a virus neutralization assay, and an IgM titer decrease in IFA was demonstrated in the 2nd serum sample collected 31 days after disease onset.

This is the 1st laboratory confirmed case of ZIKV reported in Germany and Europe and the 2nd case reported from Thailand. Thus, differential diagnosis in febrile returning travelers from the south of Thailand (Phuket, Krabi, Ko Jum, and Ko Lanta) should include Zika virus infection.

--
Jonas Schmidt-Chanasit, Petra Emmerich, Dennis Tappe, Martin Gabriel, Stephan Gunther: Bernhard Nocht Institute for Tropical Medicine, WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research, National Reference Centre for Tropical Infectious Diseases, Hamburg, Germany.
Jorgen Rissland, Gerhard Held, Sigrun Smola: Saarland University Medical Center, Homburg/Saar, Germany
<jonassi@gmx.de>

[ProMED thanks Jonas Schmidt-Chanasit and colleagues for sending in this interesting, firsthand report.

This is the 2nd ProMED-mail report of a Zika virus infection originating in Thailand. The virus was 1st isolated in 1947 from sentinel rhesus monkey serum in Uganda. Fortunately, the probability of ongoing transmission from this case in Germany is nil.

This is another example of long-distance international travel involving an individual who acquired a tropical arbovirus disease who was seen in a temperate zone clinic halfway around the world. The above case is an excellent example of a thorough laboratory approach to establishing a diagnosis of a disease exotic to Germany. It also underscores the importance of taking a good travel history for these types of cases. It also indicates that Zika virus transmission is active in Thailand and could be confused easily with a dengue virus infection without comprehensive laboratory testing. This report along with the earlier one this year [2013] make one wonder how many Zika virus infections in Thailand and other Southeast Asian countries are mistakenly diagnosed as dengue virus infections.

A HealthMap/ProMED-mail map of Thailand can be accessed at http://healthmap.org/r/1l5W. - Mod.TY]

RABIES - INDIA (10): (TAMIL NADU) CANINE, HUMAN
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Date: Sat 28 Dec 2013
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... tients-grh


A 20-year-old youth from Madurai [Tamil Nadu state], infected with rabies virus transmitted from his pet dog, died in a private cell meant for rabies victims at Government Rajaji Hospital (GRH) on Friday [27 Dec 2013]. His relatives, friends and doctors at GRH watched the youth die.

Doctors say a rabies patient cannot be saved. Preventive medicine alone is available and death is sure if [symptoms of infection develop]. In 2013, 8 people admitted to GRH with rabies infection died in the private cell.

The victim had completed class 12 and was working as an earthmover operator. He was bitten by a puppy while staying at his grandfather's house in Palamedu [Tamil Nadu state] a month ago [November 2013]. The son of a farmer, the youth did not take it seriously and did not even tell his family members that the puppy had bit him. Doctors from the GRH said their enquiry revealed that the puppy died recently, due to rabies. [The victim] developed health complications 3 days ago [25 Dec 2013] and was admitted in a private medical college hospital in Madurai. He was shifted to GRH on Friday [27 Dec 2013], when the doctors learnt that he was infected by rabies. GRH doctors say, on an average, 10 to 12 rabies patients are admitted to the hospital every year and they all die within 24 hours of admission.

Doctors say people who get bitten by a dog must seek vaccination [immediately] irrespective of whether the dog was a stray or a pet. If 3 injections are administered in the 1st month, the person will be rabies free. In case of a pet dog, it should also be vaccinated, they say. Ironically, when doctors say there is no treatment for rabies victims who have reached a terminal stage, a professor at Madurai Kamaraj University had claimed that she has invented a cure. The ethical clearance committee at GRH needs to clear her medicine.

T Anitha Sironmani, head and chairperson of department of genetic engineering, MKU, obtained permission from Tamil Nadu government to apply her nanotechnology medicine on rabies patients a while ago. She was allowed to test the medicine with the permission of the patient and after clearance from the ethical clearance committee at GRH. "I approached the ethical clearance committee several times. They would allow the victims to die but would not let me try out the medicine. I have tested my technology on a rabies-infected cow and it worked," Sironmani told TOI [Times of India].

Dr N Mohan, dean, GRH and Madurai Medical College, said the independent (ethical clearance) committee consists of 2 retired professors, senior doctors and a legal expert with me as coordinator. "There are certain procedures to be followed. If she fulfils the requirements, she would be allowed to do the experiment on patients," he said.

[Byline: V Devanathan]

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[Unfortunately, the victim's delay in seeking post-exposure treatment made the outcome of this incident inevitable. Under these circumstances it is unfortunate the nanotechnology expert was not given permission to treat the patient with her nanotechnology-based therapy. It could hardly have worsened the patient's condition.

Madurai is the administrative headquarters of Madurai District in the southern Indian state of Tamil Nadu. It is the 3rd largest city in Tamil Nadu. Located on the banks of River Vaigai, it has been a major settlement for 2000 years and is one of the oldest continuously inhabited cities in the world (http://en.wikipedia.org/wiki/Madurai). A HealthMap/ProMED-mail interactive map is available at http://healthmap.org/r/2kP3. - Mod.CP]

DENGUE/DHF UPDATE (106): ASIA
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Pakistan (Sindh province). 27 Dec 2013. Dengue 5500 cases; Deaths 32.
http://tribune.com.pk/story/651012/bewa ... -in-sindh/

[In this report, the Director of the National Institute of Blood Diseases indicated that the number of dengue cases is significantly underreported and that there are at least 15 000 cases.

Maps of Pakistan can be accessed at http://www.ezilon.com/maps/images/asia/ ... kistan.gif and http://healthmap.org/r/2NT8. - Mod.TY]

Malaysia. 28 Dec 2013. Dengue as of 21 Dec 2013, 41 226 cases; Deaths 88; Municipalities most affected: Kuala Lumpur 24 deaths, Johor 21 deaths.
http://blogs.wsj.com/searealtime/2013/1 ... -malaysia/

[Maps of Malaysia can be seen at http://www.ezilon.com/maps/images/asia/ ... al-map.gif and http://healthmap.org/r/1yAq. - Mod.TY]

RABIES - INDIA (11): (TAMIL NADU) CANINE, HUMAN, COMMENT
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Date: Mon 30 Dec 2013
From: Henry Wilde <henrywilde27@gmail.com> [edited]


Comment: Rabies - India (10): (TN) canine, human 20131230.2143331
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The death of patients from rabies in Tamil Nadu, India, is another tragedy that could have been prevented by early post-exposure prophylaxis. The total number of such cases in India is unknown but likely in the thousands. The number of worldwide human rabies quoted by WHO is around 55 000 every year, but widely considered under reported. Most of these human deaths occur in smaller communities and remote areas where post-exposure prophylactic treatment is simply not available at all and not likely to be available soon. Victims do not have the means to travel to a distant treatment center. During the last few years, there has been an increase in hope that rabies might be treatable, initiated by the recovery of several patients who underwent intensive care in tertiary medical centers. Very isolated such cases have been reported in past decades and a voluminous literature dealing with this subject can be found in PubMed database. The current view among experts in this field is that they are very rare and mostly due to a vigorous natural immune response that kills the virus before it does irreparable damage. Such patients have evidence of an active antibody titre in serum and CNS fluid on admission, or very soon thereafter, and had expert intensive life support treatment as well. Nevertheless, further work, dealing with active therapy for rabies, is most desirable and must be supported. To do this, there are ample small animal models that have been explored by experienced virologists and immunologists in years past. This is where Anitha Sironman needs to start. I note that she has published 2 peer review papers not dealing with rabies viruses or indeed infection. There may, however, be something in the "not indexed" Indian literature; if yes, it needs to be expanded and published. She will find that it will be much easier for her to convince skeptical ethics committee members to allow human efforts when some of her experimental work appears in print. In the meantime, it is imperative for all of us seeing human rabies patients, to try and provide good ICU care (not banishment to a rabies cell) for such unfortunates who might well be a very rare, true, natural recovery case if properly supported. Rabies is not a highly transmittable disease like flu or measles. Normal preventive hospital measures will render a rabies patient safe if cared for in a fully equipped and staffed ICU where experimental therapies can be carried out.

--
Henry Wilde
Professor of Medicine
WHO-CC for Research and Training on Zoonoses
Chulalongkorn University
Bangkok 10330
Thailand
<henrywilde27@gmail.com>

[ProMED-mail thanks Professor Wilde for these comments on the provision of treatment for rabies virus infection, and the need for further research support. - Mod.CP]

JAPANESE ENCEPHALITIS AND OTHER - INDIA (22): (BIHAR)
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Date: Mon 30 Dec 2013
Source: Two Circles [edited]
http://twocircles.net/2013dec30/one_mor ... eight.html


A 5-year-old child suspected to have encephalitis, a condition that causes inflammation of the brain, died in Bihar's Araria district Monday [30 Dec 2013], taking the toll from this disease to 8 in the last 10 days, officials said.

Araria civil surgeon B.K. Thakur said that while one child died Monday [30 Dec 2013], there were others admitted to hospital with similar symptoms and who were in critical condition.

Last week [23-29 Dec 2013], 2 children, a 4-year-old and a 6-year-old, died of the disease at Belwa panchayat near Araria town, officials said, and 5 children were earlier reported to have died in the district.

Araria district magistrate Ajay Kumar Choudhury said preventive measures have been taken on a war footing since last week, after 5 children succumbed to encephalitis.

A team of health experts from Patna [Bihar state] visited the affected village in Araria 3 days ago [27 Dec 2013], on a directive from Chief Minister Nitish Kumar, to oversee measures to check the spread of the disease.

Encephalitis is an acute inflammation of the brain resulting either from a viral infection or when the body's own immune system mistakenly attacks brain tissue. Children and elderly people, whose immunity is low, are especially prone to fall prey to the disease.

Till now, over 3 dozen children have died of encephalitis in the state this year [2013].

Last year [2012], the disease killed nearly 240 children in Muzaffarpur and Gaya districts of Bihar.

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[As in previous reports of encephalitis (often termed locally as acute encephalitis syndrome), the etiology of these cases is unknown. Each year, there are hundreds of encephalitis cases in the area of Uttar Pradesh and neighboring Bihar state. In past reports, the disease has been associated with Japanese encephalitis virus infections and with consumption of contaminated water, suggesting enterovirus infections. Reye syndrome and heat stroke have been suggested as possible causes of encephalitis in the children. However, massive Japanese encephalitis virus vaccination campaigns in Uttar Pradesh and Bihar states have resulted in a significant reduction in cases due to infection with that virus. One hopes that the scientists involved in attempting to determine the etiologies of these undiagnosed cases will continue to attempt to find out what is going on, so that effective, scientifically sound preventive measures may be devised and implemented.

A HealthMap/ProMED-mail map of India showing the location of Uttar Pradesh and Bihar states can be accessed at http://healthmap.org/r/1*O9. - Mod.TY]

DENGUE/DHF UPDATE (02): ASIA
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Malaysia. Fri 3 Jan 2013. Dengue as of 14 Dec 2013, 39 222 cases; Deaths 87.
http://www.themalaymailonline.com/malay ... more-lives

[Maps of Malaysia can be seen at http://www.ezilon.com/maps/images/asia/ ... al-map.gif and http://healthmap.org/r/1yAq. - Mod.TY]

HEPATITIS C - INDIA: (JAMMU AND KASHMIR)
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Date: Thu 9 Jan 2014
Source: Greater Kashmir [edited]
http://www.greaterkashmir.com/news/2014 ... ing-38.asp


The state and central governments have failed to provide any treatment to patients diagnosed with hepatitis C in Kokernag villages of [the south Kashmir district of Anantnag] even as the "silent killer" continues to consume precious lives. At least 10 patients have died in the past 2 months because of hepatitis C in these villages while few others are battling for life in various Kashmir hospitals, reports said.

The lives of hundreds of patients in Takia Magam, Sonabarie, and some adjacent villages [in Anantnag district] are at risk, with governments failing to provide them any medicine or monetary assistance.

The hepatitis C was detected in Takia Magam and Sonabarie villages and some adjacent areas in February last year [2013]. After the collection of samples, almost 60 per cent of the population from the twin villages was diagnosed with hepatitis C. Some isolated cases were detected in other villages of Kokernag as well.

The state government later sent a proposal to the Centre for providing costly medicine to the patients. The proposal, however, has not been approved even as health experts declared a large-scale epidemic in the area. They also warned of further spread of the infection in case precautionary measures were not taken.

A man, 48, of Magam village -- who was diagnosed with hepatitis C last year [2013] -- died in November after he was admitted to SK Institute of Medical Sciences [SKIMS, in Nohata, Srinagar, Jammu and Kashmir]. "The doctors at SKIMS told us that he was suffering from hepatitis C infection from many years," said his family members. They said due to their poor financial condition, they could not afford to treat him outside.

Another man, 55, of the same village reportedly died last month [December 2013] after he was battling for his life at a hospital. "He was complaining of severe abdominal pain for 8 months and after conducting investigations doctors found his liver completely damaged," said his family members.

Reports said many other people from the same village, who were infected with hepatitis C, lost their lives this month [January 2014]. These include a man, 65; and another man, 50. Among the dead was also a 35 year old married woman. Another middle-aged man from adjacent Drawai village, according to reports, was taken to PGI [Post Graduate Institute] Chandigarh following his deteriorating health condition at SKIMS and his liver was found to be completely damaged.

Many other patients from Takia Magam, Sonabarie, and some other villages, according to reports, are undergoing treatment at various hospitals in Kashmir and the condition of few of them is slated to be critical.

"A woman is undergoing treatment at SMHS hospital [in Srinagar] for the past one week," sources said. Her family members say doctors have termed her condition as "critical". Another woman, 45, is battling for her life in the hospital even as her husband and 3 children have also been diagnosed with hepatitis C.

"There is grave fear in Magam and Sonabarie villages as a result of outbreak of the disease and the consequent deaths," says a villager. He said hepatitis C patients are now directly referred to SKIMS or SMHS from district hospital Anantnag (Islamabad).

"Last year [2013] when media reported the infection, ministers and health department officials made beelines to the affected areas and promised free treatment. But now patients have been left at the mercy of God. Nobody is coming forward to help them," he rued.

Another resident said since many villagers are not financially sound, they are unable to get themselves treated or even examined. "Few families have sold their land for treatment of their patients," he said.

Noted gastroenterologist Dr MS Khuroo had declared the infection as epidemic. He had warned that if the authorities did not wake up, the situation could worsen in years to come.

Health experts had also declared the infection as decades old transmitted by some specific source. "The mode of transmission is same as HIV [unlike HIV, hepatitis C virus is rarely transmitted sexually. - Mod.TY] and as such, besides necessary treatment of the already infected, educating and creating awareness among the people is equally important to prevent the further spread of this silent disease," said a medico, wishing anonymity.

Director of Health Services Kashmir, Dr Saleem-U-Rehman, said, "Till now we have not received any assistance from the Union Health Ministry for the treatment of the hepatitis C patients." However, official sources said the proposal of the state government was rejected by the centre. "The central government does not have any specific program for the treatment of the disease which is prevalent in Punjab and Haryana too. Also, it will need crores [1 crore = 10 million] of rupees for treatment of the affected people. So the central government has been reluctant to approve the proposal," said an official.

Director of SKIMS Dr Showkat Zargar also said they have not received any assistance from the Union Health Ministry for treatment of the affected villagers.

However, about the reports of deaths, Dr Zargar said, "Deaths can occur in advanced stage [of disease] only. The infection is decades old, may be even 30 years. So the infection might have lead to some deaths." He, however, said attributing every death to the infection cannot be right as the infection is not fatal in initial stages, which may go even up to 20 years.

[byline: Khalid Gul]

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[Hepatitis C virus infections are not uncommon in India. High incidence of hepatitis C was reported in Kalala village, Barnala district, Punjab state, in July 2013.

Mod.CP provided an excellent summary of hepatitis C and its virus (see ProMED-mail archive no 20130724.1843447): "Hepatitis C is found worldwide, with some countries having chronic infection rates as high as 5 per cent and above. The main mode of transmission in these countries is attributed to unsafe injections using contaminated equipment. Hepatitis C is not a waterborne infection as believed by the Kalala villagers. Hepatitis C virus is most commonly transmitted through exposure to infectious blood. This can occur through receipt of contaminated blood transfusions, blood products, and organ transplants; injections given with contaminated syringes and needlestick injuries in health care settings; injection drug use; or by being born to a hepatitis C infected mother. Hepatitis C may be transmitted through sex with an infected person or sharing personal items contaminated with infectious blood, but these are less common. Hepatitis C is not spread through breast milk, food, or water, or by casual contact with an infected person.

About 75-85 per cent of newly infected persons develop chronic infection and 60-70 per cent of chronically infected people develop chronic liver disease; 5-20 per cent develop cirrhosis and 1-5 per cent die from cirrhosis or liver cancer. In 25 per cent of liver cancer patients, the underlying cause is hepatitis C.

Combination antiviral therapy with interferon and ribavirin has been the mainstay of hepatitis C treatment. Unfortunately, interferon is not widely available globally, it is not always well tolerated, some virus genotypes respond better to interferon than others, and many people who take interferon do not finish their treatment. This means that while hepatitis C is generally considered to be a curable disease, for many people this is not a reality.

Scientific advances have led to the development of new antiviral drugs for hepatitis C, which may be more effective and better tolerated than existing therapies (involving combined use of interferon and ribavirin). However, these drugs are too expensive for widespread use. - Mod.CP"

Maps of India can be accessed at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/9MyZ. A map of Jammu and Kashmir can be seen at http://www.mapsofworld.com/india/jammu- ... ashmir.jpg. - Mod.TY]

DENGUE/DHF UPDATE (05): ASIA
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Pakistan. (Sindh province) 12 Jan 2014. Dengue 43 cases; Increasing.
http://www.thenews.com.pk/Todays-News-4 ... ith-dengue

[Maps of Pakistan can be accessed at http://www.ezilon.com/maps/images/asia/ ... kistan.gif and http://healthmap.org/r/2NT8. - Mod.TY]

HEPATITIS C - INDIA (02): (JAMMU-KASHMIR) COMMENT
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Date: Tue 14 Jan 2014
From: G Caspari http://www.ladr.de [edited]


[This comment came in response to the ProMED-mail post "Hepatitis C - India: (JK) RFI 20130128.1518620" on hepatitis C virus infections in Kashmir. In that report, the mode of virus transmission was unclear. The following comment offers an indication of the probable common means of transmission. Mod.TY]

The most frequent reason for hepatitis C virus transmission in resource-poor countries is indeed reuse of needles for injection. During my time in Dakar/Senegal in the 1980s, needles were cooked for 3 minutes before reuse, but colleagues from other countries told me injection needles were simply flushed with water before reuse. Another important source is blood transfusion, again with reuse of equipment and "commercial" blood donors, where one infected donor may infect dozens of blood recipients.

Interferon therapy is not suitable and not licensed for end-stage liver disease. A very important side effect is depression, which may lead to interruption of therapy or even suicide. It requires regular injections which in turn require sterile equipment and possibly a cold chain (freezer for transport and storage). Ribavirin treatment at least requires exclusion of pregnancy and regular control of hemoglobin concentration. Treatment with newer protease inhibitors is far more complex and requires more sophisticated laboratory control.

The most important step might be to identify asymptomatic patients. In these patients, treatment might make sense if resources for treatment are available. These patients should avoid all additional liver damage (above all, alcohol) and be vaccinated against all hepatotropic infections if not already having been infected in the past.

--
Dr G Caspari
Priv.-Doz. Dr. med. habil. Gregor Caspari
Facharzt fur Laboratoriumsmedizin
Facharzt fur Mikrobiologie, Virologie und Infektionsepidemiologie
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Medizinisches Versorgungszentrum
Arztliche Leitung: Priv.-Doz. Dr. med. habil. G. Caspari
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[ProMED-mail thanks Dr Caspari and colleagues for these helpful comments.

It is clear that prevention and treatment of hepatitis C virus infected individuals is difficult in countries of limited resources, but it is essential to carry out monitoring to detect virus infections early when treatment is more likely to be effective.

Maps of India can be accessed at http://www.mapsofindia.com/maps/india/i ... al-map.htm and http://healthmap.org/r/9MyZ. A map of Jammu and Kashmir can be seen at http://www.mapsofworld.com/india/jammu- ... ashmir.jpg. - Mod.TY]

LEISHMANIASIS - IRAN
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Date: Tue 14 Jan 2014
Source: Tehran Times [edited]
http://tehrantimes.com/science/113447-2 ... -in-a-year


The chancellor of Tehran University of Medical Sciences announced on Monday [13 Jan 2014] that every year 20 000 cases of leishmaniasis are diagnosed as other types of skin disease. Ali Akbar Sari alluded to the fact that there may be more people than the reported number affected by the disease, the IRNA news agency reported.

For treatment of the skin disease, proper steps should be taken within limited time to reduce patients' complications, he added. He encouraged physicians to keep themselves constantly updated on all skin diseases, otherwise they may misdiagnose rare or outdated diseases.

Leishmaniasis is a disease caused by protozoan parasites and transmitted by the bite of an infected female sand fly. Symptoms of the disease appear in weeks to months after the bite of the sand fly. Less commonly, symptoms arise only years later when a person's immune system becomes suppressed. The 5 classic symptoms of more severe disease are: weight loss, which may be severe; low blood counts; enlargement of the liver and spleen; fever, which is usually intermittent; high levels of immune globulin in the blood. The skin may turn dark. Some people who recover will have a persistent rash or pigment changes in the skin. The kidney is also affected, which may lead to renal failure. Other organs, including the bowel and the lung, may be affected. The infected person should seek proper medical care immediately.

--
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[The epidemiology of leishmaniasis has recently been reviewed (Alvar J, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS ONE 7(5): e35671. doi:10.1371/journal.pone.0035671). The country specific profiles can be found here: http://www.plosone.org/article/info%3Ad ... 35671.s036.

Cutaneous leishmaniasis (CL) is an increasing public health problem with several new foci identified in recent years.

Anthroponotic CL caused by _Leishmania tropica_ is found in Tehran as well as in some other large or medium-sized cities and their outskirts. Outbreaks are related to population increase, unplanned urban development and an increase in sandfly population [1]. In the city of Bam, there was an 8-fold increase in the number of cases over the 5 years after the 2003 earthquake. Recent outbreaks in Bam caused 2884 cases in 2007, 3442 in 2008 and 1372 in 2009, with a high rate of recidivant leishmaniasis [2].

CL caused by _L. major_ is endemic and very common in many rural areas, especially in the plains of the north east, near the Russian border, and in the north of the Esfahan province, in the centre of the country, but has recently spread to its southern parts and to Fars province, in southwest Iran. About 70 per cent of CL in Iran is caused by _L. major_.

The endemicity is so high that almost 80 per cent of the rural population contracts the disease before the age of 10 and non-immune newcomers practically all become infected. This area may be the most important focus. However, a recent epidemiological survey in 3 villages in Shiraz province, where underreporting was suspected, found a prevalence of scars of 16.2 per cent and of infection (identified by PCR) of 23 per cent [3].

Visceral leishmaniasis (VL) is caused by _L. infantum_ and is less common [4,5]. The main endemic areas are the province of Fars, in the south, and the districts of Meshkin-Shahr in the north west. It is thought to be underreported. HIV-leishmania co-infection has been reported recently [6].

References:
1. Yaghoobi-Ershadi MR, et al. A new focus of cutaneous leishmaniasis caused by _Leishmania tropica_. Saudi Med J. 2002; 23(3):291-4.
2. Sharifi I, et al. Leishmaniasis recidivans among school children in Bam, South-east Iran, 1994-2006. Int J Dermatol. 2010; 49(5):557-61.
3. Razmjou S, et al. A new focus of zoonotic cutaneous leishmaniasis in Shiraz, Iran. Trans R Soc Trop Med Hyg. 2009; 103(7):727-30.
4. Nadim A, et al. Present status of kala-azar in Iran. Am J Trop Med Hyg. 1978; 27(1 Pt 1):25-8.
5. Rahim KM, Ashkan MM. Epidemiological, clinical and therapeutic features of pediatric kala-azar. Southeast Asian J Trop Med Public Health. 2007; 38(4):626-30.
6. Jafari S, et al. Disseminated leishmaniasis caused by Leishmania tropica in HIV-positive patients in the Islamic Republic of Iran. East Mediterr Health J. 2010; 16(3):340-3.
- Mod.EP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1Cfu.]

UNDIAGNOSED FEBRILE RESPIRATORY ILLNESS - INDIA: (JAMMU AND KASHMIR) REQUEST FOR INFORMATION
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Date: Sun 26 Jan 2014
Source: Greater Kashmir Srinagar [edited]
http://www.greaterkashmir.com/news/2014 ... ase-43.asp


A viral disease is believed to have hit snow-bound Doben, Taryan, Sharanth, Grathnard and Bhatnard villages in the Lolab area some 35 kilometers [about 21.7 miles] from Kupwara [Jammu and Kashmir state]. Reports said that more than 250 people, most of them children, have fallen sick during the past 4 days [around 22-25 Jan 2014], while locals said 2 newborns have died due to the disease. "These patients had been diagnosed with upper and lower respiratory tract infection (RTI) with complaints of fever, cough and influenza, with redness in eyes. The symptoms seem [to be] of a cold-related viral disease," said a doctor who visited the area after the outbreak of the disease.

"Immediately after the reports of disease, we dispatched a medical team comprising a medical officer and paramedical staff to the area with necessary medicines. As there is no health centre in Doben village, our team treated more than 250 patients at Sharanth and provided free medicines to the patients and also did the immunization of children," said Dr Muhammad Tahir, Block Medical Officer [BMO] Sogam.

"The outbreak of the disease has caused panic in the area, as Doben and its adjoining villages are inaccessible due to snow, and there is no health centre around. For medicines, the locals have to walk 4 km [about 2.5 miles] up to Sharanth," said the local Sarpanch [village leader]. "There is no need to panic. We are monitoring the situation. If need arises we shall again send our teams to the area, though it is inaccessible due to snow," the BMO said.

--
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[It seems likely that the mysterious (i.e., undiagnosed) viral respiratory disease is one of the ubiquitous acute respiratory diseases common in infancy, exacerbated by climatic and social conditions. Acute respiratory infections (ARIs) are classified as upper respiratory tract infections (URIs) or lower respiratory tract infections (LRIs). The upper respiratory tract consists of the airways from the nostrils to the vocal cords in the larynx, including the paranasal sinuses and the middle ear. The lower respiratory tract covers the continuation of the airways from the trachea and bronchi to the bronchioles and the alveoli. ARIs are not confined to the respiratory tract, however, and have systemic effects because of possible extension of infection or microbial toxins, inflammation, and reduced lung function. Diphtheria, pertussis, and measles are vaccine-preventable diseases that may have a respiratory tract component but also affect other systems.

Except during the neonatal period, ARIs are the most common causes of both illness and mortality in children under 5, who average 3 to 6 episodes of ARIs annually regardless of where they live or what their economic situation. However, the proportion of mild to severe disease varies between high- and low-income countries, and because of differences in specific etiologies and risk factors, the severity of LRIs in children under 5 is worse in developing countries, resulting in a higher case-fatality rate. Although medical care can to some extent mitigate both severity and fatality, many severe LRIs do not respond to therapy, largely because of the lack of highly effective antiviral drugs.

It is likely that the outbreak of disease in the Lolab area is a consequence of one of the common lower or upper respiratory tract infections and not some more exotic pathogen characteristic of this particular area; nonetheless, further information would be appreciated.

According to Wikipedia, Kupwara is a town and a notified area committee in Kupwara District in the Indian state of Jammu and Kashmir. Among the many tourist places in Kupwara, Lolab Valley has special significance. Sogam is a tehsil and a really beautiful place to visit for its meadows, mountains, gushing waters, and fresh air. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1_IS.]

HANTAVIRUS UPDATE - ASIA: INDIA (KERALA), SUSPECTED
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Date: Fri 31 Jan 2014
Source: The Hindu [edited]
http://www.thehindu.com/news/national/k ... 638360.ece


The 3 probable cases of infection due to [a] hantavirus, including a death, have been reported in the district from Kallara, Nedumangad area [Kerala state], giving rise to fears that this could be another emerging virus that the State's public health system is ill-equipped to handle.

All 3 cases have tested positive for scrub typhus too. This is not the 1st time that suspected hantavirus cases are being reported in Kerala, the earliest one being reported in 2002 from Ernakulam. Despite serological evidence from the population in many parts of the country, there is yet to be any confirmatory evidence because reliable test kits are not available here, microbiologists say.

The 3 blood samples which tested positive for both hantavirus and scrub typhus were part of the bunch of samples referred to the Rajiv Gandhi Centre for Biotechnology (RGCB) from the Medical College Hospital to test for scrub typhus between December 2013 and early January this year [2014].

"We found some 272 blood samples to be positive for scrub typhus. We tested these samples for hantavirus also as rodents or bandicoots are a common host for both these pathogens. Once we found the 3 samples IgM positive for hanta[virus antibodies], we asked for a 2nd sample from the patients, to be collected after 7-20 days, which showed that antibody levels were going up. We can only say that this is a probable hantavirus infection, because PCR testing and gene sequencing alone will confirm the diagnosis," Head of Laboratory Medicine, RGCB, R. Radhakrishnan, says.

RGCB has already placed orders for the specific reagents and primers needed for polymerase chain reaction (PCR) testing for hantaviruses, he says. From the clinician's point of view, all the patients had severe pulmonary and renal infection, pointing to classical symptoms of [a] hantavirus infection. Additional Director of Public Health A.S. Pradeepkumar says these symptoms are the same for scrub typhus and leptospirosis also.

--
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[The investigators are quite correct that if a hantavirus is involved in the hemorrhagic fever with renal syndrome (HFRS) described, virus isolation, or demonstration of hantavirus sequences by PCR, will be necessary to establish the cause of the infections. In Asia, there are 5 recognized hantaviruses with their main rodent reservoir species including: Hantaan virus (_Apodemus agrarius_), Amur virus (_A. peninsulae_), Thailand virus (_Bandicota indica_), Seoul virus (widely distributed worldwide in _Rattus norvegicus_), and Muju virus (_Myodes regulus_). One hopes that follow-up studies are done to better define the incidence of HFRS cases and identify the rodents that are the source of the infection.

The most recent cases of suspected hantavirus infections occurred in October 2011, when there were 3 cases of a suspected hantavirus infection in Nellore, Andhra Pradesh state. The specific hantavirus involved in these cases was not stated.

In a 4 Feb 2010 ProMED-mail post (archive no. 20100205.0385), it was reported that Dr J. Clement and colleagues of the National Reference Laboratory for Hantavirus Infections, University Hospital Gasthuisberg, Leuven, Belgium, found evidence in India of the murine Seoul virus (SEOV) infection, and also of the arvicoline Puumala virus (PUUV) infection, the latter in 2 fatal cases (from the Cochin, respectively Chennai region) with acute respiratory syndrome -- symptoms similar to those in the more recently described Nellore cases in 2011 (see ProMED-mail archive no. 20111026.3187) as well as in the case described above.

A map showing the location of Kallara, Nedumangad area can be accessed at http://isithackday.com/geoplanet-explor ... d=29132121 and Kerala state at http://healthmap.org/r/28JB. - Mod.TY]