1. 17.01.2017 1
Dr. Dharmendra Gahwai
(MD- Community Medicine, DHA, DAE)
DD & State Epidemiologist (IDSP)
Directorate of Health Services
Chhattisgarh
2.
Death of a 3 and half year old female child of was reported
on 20/10/2016 from District Hospital Malkaangiri, Orisa.
She was resident of village-Girlikutti, District-Sukma of
Chhattisgarh.
She was admitted with history of 3 days fever with altered
sensorium (AES)
Her blood investigation for IgM ELISA was positive for
Japanese Encephalitis virus. 2
JE Outbreak in Sukma, Chhattisgarh
October 2016
3.
On 28th Oct 2016 a one more death of a 2 year male child
reported from with district hospital Sukma and was
positive for IgM ELISA for JEV.
Subsequently 3 more cases from village Jhirampal, and
one case from village Bhandarras, district- Sukma were
reported positive for IgM ELISA for JEV.
3
5.
So in two week duration six positive cases of Ig M
ELISA for JEV were registered with 3 deaths.
JE positive cases were clustered in village –
Jhirampal, PHC- Gadiras, Block- Sukma, Disrict-
Sukma.
5
6.
Village-wise distribution of cases positive for IgM ELISA for JEV
0
0.5
1
1.5
2
2.5
3
3.5
4
Girlikutti Jhirampal Bhandaras
1
4
1
8. Line-list Of AES/JE Cases
Date of Report 03/11/2016
Case ID Name & Address Dist. Name Block Name
Sex Age
Date of onest
fever
Seizure
(Y/N)
Type Of
Sample
Date to
Sample
Collection
Lab Result Outcme
2 3 8 10 11 12 13 14
1 K. Bharti / Jhilikuti Sukma Chhindgarh F 3.6 year 19-10-16 Y Blood 20-10-16 + Death 20/10/16
2 Somnath / Jirampal Sukma sukma M 2 Yeat 27-10-2016 Y Blood 20-10-16 + Death 28/10/16
3 Bharti / Jirampal Sukma sukma F 9 Year 29-10-16 No Blood 30-10-16 + Discharged
4 Sanjay / Bhandarras Sukma Chhindgarh M 5 Year 29-10-16 Y Blood 30-10-16 + Death 31/10/16
5 Sukru / Jirampal Sukma sukma M 13 Year 30-10-16 No Blood 31-10-16 + Discharge
6 Surja / Jirampal Sukma sukma F 14 Year 30-10-16 No Blood 31-10-16 + Discharge
9.
Sukma is a tribal dominated district of
Chhattisgarh and its border is directly connected
with two different states of Orissa and Andhra
Pradesh.
Sukma district shares a long border with
Malkaangiri district of Orisa.
10.
Total six positive cases during the two week duration in
Chhattisgarh state which has no history of endemic of JE is an
alarming sign of emerging of new disease in a virgin
population of Chhattisgarh state.
Possible source of transmission of infection may from the
Malkangiri district of Orissa which shares border and trade
culture with the Sukma district of Chhattisgarh.
11.
Malkaangiri district of Orisa had an outbreak of
Japanese Encephalitis since month of September
2016 with 121 confirmed JE cases and 27
deaths till 30/10/2016.
Source- http://nvbdcp.gov.in
13.
Japanese Encephalitis is a viral disease.
It is transmitted by infective bites of female mosquitoes - Culex vishnui group - Culex
tritaeniorhynchus.
JE virus is primarily zoonotic in its natural cycle and man is an accidental host.
JE virus is neurotorpic arbovirus and primarily affects central nervous system
13
Epidemiology
14.
14
Natural Cycle of Disease
Natural hosts of JE virus water birds of
Ardeidae family (mainly pond herons and
cattle egrets)
Pigs play an important role- Amplifier
Host.
Man is a dead-end host - very low
viraemia and no man to man transmission.
15.
JE virus causes at least 50 000 cases of clinical disease each
year(children < 10 years)
Results in 10 000 deaths ,15 000 neuro-psychiatric sequelae.
Outbreaks of JE have occurred in several previously non-
endemic areas.
It is a preventable disease and no specific antiviral
treatment.
15
Public Health Importance
http://www.who.int/biologicals/areas/vaccines/jap_encephalitis/en/
17.
First case was reported in 1955.
Outbreaks have been reported from different parts of
the country.
More than15 states have reported JE incidence.
Annual incidence ranged between 1714 and 6594 and
deaths between 367 and 1665.
17
Extent of problem in India
20.
20
Agent: ARBOVIRUSES
Viruses of vertebrates
transmitted by
hematophagus insect
vectors.
Special characteristic:
Ability to multiply in
arthropods.
More numerous in tropical
than in temperate zones
Flavivirus
21.
Natural reservoir of infection
Amplifier Hosts
Accidental Host Dead end Host
21
Hosts
22.
Irrigated rice fields
Shallow ditches
Pools of water
Primarily outdoor resting in vegetation
Fly range : 1-3 kms
22
Environment
23.
23
Vector Transmission
Most common type of Mosquito:
Culex vishnui group -
Culex tritaeniorhynchus
Culex vishnui
Culex pseudovishnui
Culex
25.
Susceptible population.
High density of Culex mosquitoes.
Presence of amplifying hosts such as pigs, water
birds etc.
Paddy cultivation.
25
Factors favouring outbreak
26.
Incubation Period - 5 to 15 days
Only 1 in 300 infections develop into encephalitis.
Prodromal stage: Fever, headache and malaise.
Acute encephalitic stage: Fever, focal CNS, signs,
convulsion altered sensorium progressing to coma.
Late stage and sequelae: Temperature & ESR, normal
level, neurological signs become stationary
26
Clinical Features
27.
There is no specific treatment against the JE .
Managed symptomatically.
In the acute phase maintaining fluid and electrolyte
balance and control of convulsions, if present.
Maintenance of airway is crucial.
27
Treatment
29.
Reducing the vector density.
personal protection against mosquito.
Reduction in mosquito breeding sites.
Piggeries and cattle may be kept away (4-5 kms)
from human dwellings.
Vaccination of all children in endemic areas.
29
Preventive and control measures
30.
Outdoor habit of the vector.
Scattered distribution of cases spread over relatively large
areas.
Role of different reservoir hosts.
Specific vectors for different geographical and ecological areas.
Immune status of various population groups is not known
making it difficult to delineate vulnerable population groups.
30
Challenges in Outbreak Management
32.
1. Surveillance
2. Personal and Specific Protection
3. Vector control
4. Segregation of Reservoir
5. Monitoring and Supervision
07-08-2014 32
Epidemic Management
33. 1. IDSP-Surveillance system collects the information
on epidemiologic, clinical & laboratory from the
identified sites on a regular basis.
2. Continuous monitoring of all factors influencing
transmission and effective control of JE by team of
District Surveillance Unit and reporting to
concerned authority.
3. Early recognition of impending outbreaks or
epidemics.
4. Sentinel surveillance sites are designated to monitor
the trend of disease.
33
Continuous Disease Surveillance
34.
Promotion of mosquito net use for personal protection is
recommended.
Vaccination of susceptible children against JEV especially
among the rural children as they are potential victim of
Japanese Encephalitis infection as favorable
environmental conditions.
IEC/BCC activities are recommended regarding the
prevention of Japanese Encephalitis among the rural
population using electronic and print media and
community visits.
07-08-2014 34
Personal and Specific Protection
35.
Vector control using ULV (ultra low volume-
Malathion) fogging is the only recommended
method of vector control and periodic repetition of
ULV fogging every 10-12 days.
However insecticide susceptibility of Culex
mosquito is recommended for effective vector
control.
07-08-2014 35
Vector control
36.
Segregation of pigs are recommended at least 3
kilometers away from human residence which
prevent transmission of infectious agent from Pigs to
human being by vectors i.e. Culex mosquito.
36
Segregation of Reservoir
37.
A successful implementation of any disease control
porgramme largely depends upon a robust
supervision and monitoring mechanism.
It is importance to generate clear basic data which
when filled up appropriately can be analysis
efficiently for providing quick feed back to the
concerned health authorities.
37
Monitoring & Supervision
38.
History of JE.
Endemic areas.
Epidemiological factors.
Role of Govt of Chhattisgarh
JE vaccine.
38
Lessons learnt
Editor's Notes
In North bengal, Last week of july 2014 , 22.7.14
There are 15 states that show cases of JE every yr, but these 5 states are considered under highly endemic area coz they account for total 80% cases all over India
Group B arbo virus, Flavi virus, the glycoprotein envelope of the virus contains specific as well as cross reactive neutralizing epitopes
Birds : Pond herons, cattle egrets, poultry birds, appear to be involved in natural transmission of JE virus.
The vector mosquito species prefer cattle blood as compared to that of human beings.
The pigs are “amplifier hosts” for the virus.
Migratory birds may be involved in the transfer of virus one region to another
Cattle :It is believed that prevalence of an enormously large population of cattle in India may act as deterrent to the spread of JE infection.
Pigs : Infected pigs do not manifest many overt symptoms of the disease but allow multiplication and circulation of the virus in their blood. They are capable of infecting a large number of vector mosquito species, which in turn may transmit the virus to man after the completion of extrinsic incubation period of 9-12 days.
Culex vishnui subgroup is very common, widespread and breed in water with luxuriant vegetation mainly in paddy fields and the abundance is related to rice cultivation, shallow ditches and pools.
These vectors are primarily outdoor resting in vegetation and other shaded places but in summer may also rest in indoors.
They are in principally cattle feeders, though human and pig feeding are also recorded in some areas
Prodromal stage: Fever, headache and malaise. Duration- 1 to 6 days.
b} Acute encephalitic stage: Fever, 38 to 40.7°C,
nuchal rigidity, focal CNS signs, convulsion altered
sensorium progressing in many cases to coma.
c} Late stage and sequelae: Temperature & ESR
touch normal level, neurological signs become
stationary
