Japanese Encephalitis

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17.01.2017

Japanese Encephalitis Inter-sectoral Coordination for Outbreak

containment

Dr. Dharmendra Gahwai(MD- Community Medicine, DHA, DAE)

DD & State Epidemiologist (IDSP)Directorate of Health Services

Chhattisgarh

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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.

JE Outbreak in Sukma, ChhattisgarhOctober 2016

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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.

20-10-16 21-10-16 22-10-16 23-10-16 24-10-16 25-10-16 26-10-16 27-10-16 28-10-16 29-10-16 30-10-16 31-10-16 01-11-16

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2 2JE POSITIVE CASES

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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.

Village-wise distribution of cases positive for IgM ELISA for JEV

Girlikutti Jhirampal Bhandaras0

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Line-list Of AES/JE CasesDate of Report 03/11/2016

Case ID Name & Address Dist. Name Block NameSex Age Date of onest

feverSeizure (Y/N)

Type Of Sample

Date to Sample

CollectionLab 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

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.

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.

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

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Epidemiology

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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

Epidemiology

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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.

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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.

Public Health Importance

http://www.who.int/biologicals/areas/vaccines/jap_encephalitis/en/

Global Scenario

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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.

Extent of problem in India

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Endemic areas in

India

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Epidemiological Triad

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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

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Natural reservoir of infection

Amplifier Hosts

Accidental Host Dead end Host

Hosts

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Irrigated rice fields Shallow ditches Pools of water Primarily outdoor resting in vegetation Fly range : 1-3 kms

Environment

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Vector Transmission

Most common type of Mosquito:Culex vishnui group - Culex tritaeniorhynchus Culex vishnui Culex pseudovishnui

Culex

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Pathogenesis

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Susceptible population. High density of Culex mosquitoes. Presence of amplifying hosts such as pigs,

water birds etc. Paddy cultivation.

Factors favouring outbreak

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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

Clinical Features

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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.

Treatment

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07-08-2014

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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.

Preventive and control measures

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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.

Challenges in Outbreak Management

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Sukma-District

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1. Surveillance 2. Personal and Specific Protection 3. Vector control 4. Segregation of Reservoir 5. Monitoring and Supervision

07-08-2014

Epidemic Management

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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.

Continuous Disease Surveillance

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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

Personal and Specific Protection

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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

Vector control

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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.

Segregation of Reservoir

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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.

Monitoring & Supervision

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History of JE. Endemic areas. Epidemiological factors. Role of Govt of Chhattisgarh JE vaccine.

Lessons learnt