MANAGEMENT OF ZOONOTIC DISEASES

IN HUMANS DURING OUT-BREAK

DR S J GANDHIDEPUTY DIRECTOR

EPIDEMICGUJARAT

Zoonoses- General Aspects• In 1959, WHO defined Zoonosis (plural Zoonoses) as

"Those diseases and infections which are naturally transmitted between vertebrate animals and man"

• Zoonosis are among the most frequent and dreaded risks to which mankind is exposed

• They are no longer solely a national problem.• For effective control of zoonoses, global surveillance is necessary.• Resulting from ecological changes such as urbanization, industrialization

and diminishing proportion of persons working in the so called primary sector.

• Most frequent infections of man that have been discovered in the last 20 years are shared with lower animals and a number of other diseases previously thought to be limited to man have found to be zoonoses.

• Important diseases are anthrax, plague, brucellosis, bovine tuberculosis, leptospirosis, salmonellosis, spotted fever caused by Rickettsiae, rabies, several common arthropod borne viral infections (aboviral infection), certain parasitic diseases especially cysticercosis, Hydatid disease, trypanosomiasis and toxoplasmosis.

Cases Deaths Cases Death Cases Death Cases Death Cases Death Cases Death

1 Dog bite 36768 3 45777 2 53826 0 62042 6 62048 0 44298 0

2 Hydrophobia (Rabies) 8 6 11 9 14 4 23 15 38 14 29 6

3 Snake bite 661 6 1185 21 1548 19 2061 18 2079 20 1490 29

4 Anthrax 0 0 0 0 9 0 0 0 0 0 6 0

5 Hydatid diseases 0 0 1 0 0 0 0 0 0 0 0 0

6 Leptospirosis 4 0 37 6 373 40 630 92 392 81 657 124

7 Japanese encephelitis 0 0 0 0 0 0 0 0 0 0 0 0

8 Food borne disease 1284 23 1109 19 1450 20 1046 6 1585 11 524 0

9 Plague 0 0 0 0 0 0 0 0 0 0 0 0

10 K. F. D. 0 0 0 0 0 0 0 0 0 0 0 0

11 Leishmaniasis 0 0 0 0 0 0 0 0 0 0 2 0

12 Recketsiasis 0 0 0 0 0 0 0 0 0 0 0 0

13 Dangue fever 88 0 45 0 278 9 120 4 454 11 545 5

14 Toxoplasmosis 0 0 0 0 0 0 0 0 0 0 0 0

15 Scorpion bite 1743 1 1635 0 1532 1 1434 0 1434 4 1087 0

40408 36 49800 57 59030 93 67356 141 68030 141 48638 164

2003 2004

Total

YEAR WISE STATUS OF ZOONOTIC DISEASES IN HUMAN IN GUJARAT FROM 2001 to 2007

2005 2006Sr. No. Name of Diseases

2001 2002

Year wise Status Report of Zoonotic Disease in Animals in Gujarat State

Name of Disease 2003-04 2004-05 2005-06 2006-07 2007-08Foot Mouth Disease

71 35 25 13 9

Anthrax 1 2 6 0 1Rabies 4 2 1 2 3Cow Pox/ Buffalo Pox

0 1 11 1 3

Trypanosomiasis 2 2 3 2 1Collibacillosis 0 1 0 0 0Fascioliasis 3 0 1 0 0Salmonellosis 1 0 0 0 0Brucellosis 0 0 0 0 1Mycoplasmosis 0 0 0 4 2Bird Flu 0 0 1 0 0Foot Root Disease

0 0 0 7 0

Courtesy: Directorate of Animal Husbandry Department Gandhinagar, Gujarat

Factors influencing prevalence of Zoonoses• Ecological Changes in Man's environment :

Man is forced to exploit virgin territories and natural resourcesEntering of humans in the unaccustomed ecosystemLarge scale expansion of agricultural and engineering resources, construction of dams, irrigation schemes, clearing of forests leads to change us the biting habits of blood sucking vectors.

• Handling animal by-products and wastes :Anthrax in carpet weaversLeptospirosis in rice field workersBovine tuberculosis in farmers

• Increased movements of Man :Land development, engineering project work, pilgrimages, tourism etc expose the people to contaminated food and water

• Increased trade in animal products like hide, wool, bone, meal, meat etc

• Increased density of animal population• Transportation of virus infected mosquitoes• Cultural anthropological norms.

Zoonoses as a public health problem

• In India, Zoonotic diseases assume great public health significance due to

80% of population lives in rural areas in close contact with large domestic animal population.

Abundance of vectors due to suitable climate, low socio-economic conditions and lack of proper medical care.

Inadequate diagnostic facilities.

Unfamiliarity of physicians with these diseases &

Lack of coordination amongst physicians, veterinarians and epidemiologists.

Rabies• Incubation Period

The average incubation period is between 30-90 days. Factors which may influence the length of incubation period include the site of bite, the amount of virus in the saliva of biting animal, the virus strain and the age & immune status of the victim.

• Clinical Features in Man:Pain and tingling in the affected limb especially around the site of

bite in 35 to 65 % cases.

Hydrophobia is pathognomonic for rabies.

Post-exposure treatment in humans :• Due to long incubation period in most of the cases of human

rabies, it is possible to institute prophylactic post- exposure treatment.

• Decision to Treat:In rabies endemic country like India, where every animal bite ispotentially suspected as a rabid animal bite the treatment should be started immediately.The risk of dog being infected with rabies is greatly reduced when it appears healthy and there is confirmed history of vaccination with minimum of two immunization with potent rabies vaccine in last two years.Bat rabies has not been conclusively proved in India, hence exposure does not warrant treatment.

• Post-exposure treatment is a three pronged approach1. Management of wound2. Passive immunization3. Active immunization

(A) Management of animal bite wound

1. Wound toilet:To remove as much saliva, and there by the virus from the wound.Since the rabies virus can persist and even multiply at the site of bite for a long time, wound toilet must be performed even if patient reports late.Should be done by prompt and gentle thorough washing with soap or detergent and flushing the wound with running water for 10 minutes.Anti rabies clinics should have wound washing facilities.Should not involve additional trauma.Avoid direct touching of wounds with bare hands.Never apply soil, chilies, oil etc which are unnecessary & damaging.Suturing of wound should be avoided as far as possible & if unavoidable, minimum loose sutures can be applied after adequatelocal treatment along with proper infiltration of anti-rabies serum.Injection tetanus toxoid should be given to the unimmunized individual.A suitable course of an antibiotic may be recommended for the prevention of wound sepsis.

Management of animal bite wound (contd)

2. Application of Antiseptic.Available any of chemical agents like Savlon (in appropriate recommended dilution), Dettol, Povidone iodine, alcohol should be applied as an antiseptic after thorough washing and drying of the wound.

3. Local infiltration of rabies immunoglobulin :In category III bites rabies immunoglobulins should be infiltrated in the depth and around the wound to inactivate the locally present virus.

(B) Passive immunization by rabies immunoglobulin.

• Human Rabies Immunoglobulins (HRIG):HRIG are free from the side effects encountered in a serum of heterologus origin, and because of their longer half life, are given in half the dose of equine antirabies serum.

• Dose :The dose of HRIG is 20 i.u. per kg body weight (maximum 1500 i.u.).HRIG does not required any prior sensitivity testing.HRIG preparation is available in concentration of 150 i.u. per ml.

• Tolerance & side effects :HRIG must never be given intravenously as it can produce symptoms of shockIf immunoglobulin was not administered when vaccination was begun, it can be administered up to the seventh day after the administration of the first dose of vaccine.Immunoglobulin should never be administered in the same syringe or at the same anatomical site as vaccine.

(C) Active immunization- Anti-rabies• Tissue Culture Vaccine (TCV):

As recommended by the WHO Expert Committee on Rabies (1992), thecourse for post-exposure prophylaxis should consist of five injections(Day 0,3,7,14 & 28) and the sixth injection (Day 90) as an optional (for old age,& immunologically deficient individuals).The dose of the the vaccine per injection is 1 ml for HDCV and PCECvaccines and 0.5 ml for PVRV, irrespective of age and weight of vaccinee.

• Indications:All cases of animal bites, irrespective of severity of exposure, require the same number of injections and dose per injection.The category III require administration of rabies immunoglobulins.

• Site of inoculation : Deltoid region is ideal• Storage & transportation: at a temperature range of 2-8* C.• Adverse Effects are sore arm, headache, malaise, nausea, fever

and localized edema at the site of injection.• Intra-dermal Regimen for TCV however has not yet been cleared

by drug controller General of India.

Other Important Issues• Post exposure therapy for previously vaccinated persons:

If re-exposed, persons who have previously received full post-exposure treatment with a potent cell-culture vaccine should be given only two booster doses, intramuscularly on days 0 and 3but no rabies immunoglobulin.

• Approach to a patient requiring rabies immunoglobulins when none is available.

Proper wound toileting followed by Essen schedule of Tissue Culture Vaccine with double dose on day 0 at two different sites.

• Management of animal bite exposure to pregnant women and lactating mothers.

Pregnancy and lactation are not contraindications for rabies vaccinations well as no adverse effect found on the foetus.

• Pre-exposure prophylaxis : 3 full IM dose of TCV given on day 0,7,and 28 OR 0,28 and 56 followed by booster at one year and then a booster every three year. Such individuals,require only two booster inj of TCV on day 0 & 3 without any anti-rabies serum.

Laboratory Diagnosis• Specimen from human being :

Ante mortem specimen to be collected are saliva, corneal smear, skin biopsy, hair follicles, blood & CSF.Post Mortem specimen shall be brain or spinal cord.

• Collection of specimen from suspected rabid animals :Brain & salivary glands

• Preservation:If possible, the samples of brain & salivary glands may be sent in wide mouth leak proof containers preserved on ice.

• Laboratory Tests: Negri Bodies examinationThe intracytoplasmic inclusion bodies called 'Negri Bodies' can be detected by using Seller's stain.

ANTHRAX

Introduction & Epidemiology• Known as Malignant Pustule, Malignant Oedema, Wool sorter's

Disease Or Rag picker's Disease • It is one of the oldest recorded ,primarily a disease of herbivorous

animal caused by Bacillus Anthracis that occasionally affects human.

• First disease of humans and animals in which causative agent wasdefinitely identified.

• Most common in agriculture regions.• B antracis is a gram positive, spore forming bacillus. The virulence

is determined by the capsule and exotoxins; Oedema toxin and lethal toxin.

• Transmission : Animals get infected by ingestion of contaminatedsoil or feed. They shed bacilli during terminal hemorrhage or if blood of dead animal is spilled accidentally. On exposure to air, the vegetative forms sporulate.

• Cutaneous anthrax is the most common anthrax infection.• inhalation of spore particles less than 5 μm in diameter that may

reach the terminal alveoli of the lungs.

Clinical manifestationsIn Animals :• The incubation period in the susceptible herbivore ranges from about

36 to 72 hours.• The first signs of an anthrax outbreak are one or more sudden deaths

in the affected livestock• going off feed, or producing less milk, distressed, difficult breathing and

cease eating and drinking.In Humans :• 95 % Cutaneous Lesions, 5 % Inhalation Lesions, Rarely G.I.T.

involvement • Meningitis may complicate any of the three primary forms, frequently

hemorrhagic.• confirmed by demonstration of the organism in the CSF by microscopy or

culture or both.• Case Fatality Rate :

Inhalation Anthrax is almost always fatalIntestinal Anthrax results death in 25-60%Untreated Cutaneous Anthrax up to 20%

Recommended case definition in humans

• Suspect: A case that is compatible with the clinical description and has an epidemiological link to confirmed or suspected animal cases or contaminated animal products and also if smear from clinical specimen is positive.

• Probable : Has positive reaction to allergic skin test.

• Confirmed : A suspect case with isolation or demonstration of B.Anthracis from clinical samples (blood, lesions, discharges, CSF, stools) Or Positive serology (ELISA, WB, FAT, Toxin detection, Chromatographic assay).

• Direct demonstration B.anthracis from blood, skin lesion or respiratory secretion by polychrome Methylene blue staining and Gram staining which shows encapsulated as evidenced by clear zones around gram-positive rods in short chain 2 – 4 cells.

Case management• Cutaneous anthrax:1. Ciprofloxacin 500 mg BD orally for 10 days or• Doxycycline 100 mg BD orally for 10 days or• Amoxicillin 500 mg TDS orally for 10 days2. Oral penicillin V 500 mg 6 hourly or• Procaine penicillin 1 million unit 12 to 24 hourly by IM route3. Chloramphenicol, Rifampicin, erythromycin, clindamycin or

clarithromycinmay also be given.• Pulmonary and intestinal anthrax:• Ciprofloxacin 400 mg IV BD till 2 weeks after the clinical

response, or Penicillin G, 2 million units per day by infusion or by slow intravenous injection should be administered until the temperature returns to normal. After that, treatment should be continued in the form of intramuscular procaine penicillin, 1 million units every 12-24 hours. Streptomycin, 1-2 grams per day intramuscularly, may act synergistically with penicillin.

• Supportive care: Oxygen inhalation, Respiratory support, and treatment of shock if present

Prevention and controlThe problem of anthrax continues because of the following:• The custom of butchering and eating roasted meat from sudden

death animals and utilizing their hair, hides, bones etc.• Lack of cooperation• Long delays in diagnosis • Failure to implement policiesControl measures• breaking the cycle of infection. • proper disposal.• disinfection, decontamination and disposal.• vaccination of exposed susceptible animals and humans.

Guidelines for an effective control programmeSurveillance • of all unexplained livestock deaths or suspected human and animals

cases.Reporting• Mandatory reporting of sudden deaths among livestock & all human

cases.Vaccination• to all high risk persons• Annual boosters if exposure continues• Immunise all animals at risk and re-immunise annually.Disposal• a carcass should not be opened• should be disposed of by incineration or rendering. • Necropsy should not be done.Disinfection• Decontaminate soil seeded by carcasses.

Guidelines for an effective control programmeEducation• Educate employees handling potentially contaminated articles about

modes of anthrax transmission, care of skin abrasions and personal cleanliness.

• Control dust and properly ventilate.• Do not use/sell hides of animals exposed to anthrax nor use their

carcasses as food or feed supplements.• Proper treatment of effluents from hazardous industries.Inter-sectoral cooperation• Good communication and cooperation including sharing laboratory

facilities and• knowledge between veterinary, medical and wild life services are

essential to control of anthrax.

Actions to be taken in the event of an outbreak of Anthrax

For Animal• Carcasses of infected cattle are to be either burnt at the site of death• Ashes buried deeply, or wrapped in double thickness plastic bag to

prevent spilling of body fluids and removed to a more suitable site.• The site of dead animal is to be disinfected with 5% formaldehyde.• All other animals in the affected herd are to be vaccinated.• Affected premises are to be quarantined for at least 20 days after

the last case or 6 weeks after vaccination.• All cattle on neighboring premises should also be vaccinated.• A buffer zone, 20-30 Km wide, is to be established around the

infected area within which all cattle and exposed sheep are vaccinated and quarantined.

• Any milk collected from a cow, buffalo or goat showing signs of anthrax is to be destroyed, along with any other milk that may have been mixed with the suspected milk.

Actions to be taken in the event of an outbreak of AnthraxFor Human• People entering infected premises are required to wear protective

clothing and footwear, which are disinfected before leaving the premises.

• Such persons should avoid any contact with other persons or animals.

• • Where there is a risk of aerosolization of spores, further precautions should be considered such as damping down the material, possiblywith 5% formalin, wearing face masks etc.

• Chemoprophylaxis – asymptomatic exposed individuals are put on a four week course of Doxycycline 100 mg twice daily or ciprofloxacin 500 mg twice daily.

• Human vaccine: In China and former USSR live spore vaccines are in use.

• 3 SC injections given 2 weeks apart followed by 3 additional SC injgiven at 6,12 and 18 months & then annual inj for maintaining immunity.Anthrax vaccines intended for use in animals should not be used in humans. Pregnant women should not be vaccinated.

Actions to be taken in the event of an outbreak of Anthrax

Animal vaccine: • Most animal vaccine for anthrax in use around the world utilize the

toxigenic, non-capsulating B.anthracis strain 34F2. • The protection by single dose of strains 34F2 vaccine is said to last

about 1 year, therefore annual boosters are recommended for livestock in endemic areas.

Plague

Introduction• Human Plague again struck the country after a lapse of 28 years

when in August 1994 cases of bubonic plague were reported from Mamla village of Beed district in Maharastra and of pneumonic plague from Surat in Gujarat State in September 1994.

• Total 876 cases & 54 deaths were reported.• In 2002 16 cases & 4 deaths due to pneumonic plague reported in

Himachal Pradesh.Epidemiology:• Plague is an acute, specific communicable disease caused by

Yersinia Pestis and transmitted to man by the bite of infected rat flea.• It is primarily a zoonoses being a disease of rodent and man is

affected incidentally.• It is based on the balance of susceptibility of rodents to plague

bacillus and degree of which man is exposed.• Sylvatic plague is maintained in relatively resistant hosts called

permanent reservoir host.

Vectors of Plague

• 132 species of fleas in world

• In India XenopsyllaCheopis, Xastia and X. brasiliensis.

PLAUGUE SUEVEILLANCE ACTIVITY : GUJARAT

KUTCHH1998[Cyclone]

2001[Earthquake]

SURAT*

ACTIVITY: MET of RDD SURAT:RURAL

SMC: URBAN SURAT* KNOWN FOCI

1997[Flood]

2001[Earthquake

]

Plague Surveillance in Gujarat

• Regular Surveillance in Surat Urban• Regular Surveillance in Surat Rural• Special surveillance in natural calamity

affected areas:• 1996- Floods in Mehsana district• 1996- Cyclone in Kandla in Kutch District• 2001- Earthquake affected area• 2002 – Earthquake affected area – team,

headed by NICD-PSU, Banglore, visited. • 2003 to 2007 – Earthquake affected area of

Dist. Bhuj twice in a year.

Incidence of Plague and other Rodent borne diseases.

Plague in Gujarat :• An out break of Pneumonic Plague reported in Surat in September-October

1994.• 453 confirmed cases with 41 deaths.Other rodent borne disease :• Followed by Plague outbreak in South Gujarat, cases of Leptospirosis

appeared during monsoon season in 1994.• High incidence 657 cases in year 1997, and confirmed 135 deaths due to

Leptospirosis were reported in the year 2007.• Significant reduction in morbidity and mortality of Leptospirosis was

achieved by following short term and long term measures initiated by GOG.

– Effective and timely anti rodent activity undertaken by inter-sectoral coordination of Health and Agricultural department including other sectors.

– Enhanced EDPT as well as awareness in community played vital roll to bring down the morbidity and mortality.

Surveillance in Rodents : 2007

Sr.No. Month

No. ofTrapslaid

Traps +Ve for

Rats

No. of Ratscollected

No. of Rat organ

sample (HLLS)

collected

No. of Rat sera

sample collected

1 January 132 23 71 46 602 February 80 14 36 9 93 March 120 11 29 9 94 April 141 17 57 25 255 May 60 10 22 14 146 June 170 32 78 15 157 July 100 29 108 67 678 August 210 54 215 157 157

9 September 60 11 42 9 9

10 October 250 24 72 26 2611 November 125 21 124 40 4012 December 100 16 31 0 0

Impact of Spray of Malathion 5% in Impact of Spray of Malathion 5% in Villages with Flea Index above 1Villages with Flea Index above 1

Before Spray After SprayDate of Spray & MLN 5%

used

Veluk 3/2/06 2.42 23/2/06 28/2/06 0.6

Village

Date Flea Index

Date Flea Index

Bhatha 21/9/05 1.5 4/1/06 29/1/06 0.76

Bhatpor 21/9/05 1.6 5/1/06 29/1/06 0.31

Bhesan 31/1/06 3.75 3/2/06 23/2/06 1.0

Anti Flea Measures : 2007 (Surat Rural) Anti Flea Measures : 2007 (Surat Rural) FinalFinal

Before Spray After SprayDate of Spray & MLN 5%

used

Veluk 23/1/07 1.88 9/2/07 35.0 kg.

21/2/07 0.0

Kamrej 5/8/07 1.8 17/9/07 75K.g.

27/9/07 0.36

Laskana 6/8/07 1.38 14/9/07 50K.g.

27/9/07 0.01

Village

Date Flea Index

Date Flea Index

Month wise-Reporting /Year : 2007

A. Serological and Bacteriological Studies

Rodent/Dog Sera Samples Rodent Organs and Organs Smears

Ti Bb Rr Other

Total

Dog Sera

Ti Bb Rr Other Total

January-2007 0 0 39 0 39 7 0 0 53 0 53

February-2007 0 0 23 0 23 8 0 0 36 0 36

March-2007 0 0 17 0 17 3 0 0 29 0 29

April-2007 0 0 20 0 20 5 0 0 57 0 57

May-2007 0 0 9 0 9 7 0 0 22 0 22

June-2007 0 0 43 0 43 12 0 0 78 0 78

July-2007 0 0 57 0 65 4 0 0 99 0 99

August-2007 0 0 111 0 111 0 0 0 189 0 189

September-2007 0 0 13 0 13 4 0 0 37 0 37

October-20067 0 0 35 0 35 4 0 0 65 0 65

November-2007 0 0 47 0 47 2 0 0 90 0 90

December-2007 0 0 20 0 20 3 0 0 31 0 31

MET Surat

Plague Control Sub-Unit

Date

Plague Surveillance : (Urban)Flea Index Monitoring 1996 to Oct. 2007

Surat Municipal CorporationYear # of

Traps# of

Rodent Collected

General Flea

Index

Specific Flea

Index

#of Rat Burrows

Treated with Malathion5%

Consumption of

Malathion 5% (Kg)

1995 22627 6056 0.1 0.07 54401 25063

1996 17828 2860 0.97 0.86 74757 23708

1997 17723 3999 0.73 0.63 94514 28664

1998 17577 4022 0.81 0.77 83183 21021

1999 18218 4068 0.99 0.95 127662 32729

2000 15682 2702 1.09 1.08 120969 29467

2001 30307 8860 0.86 0.81 187345 60963

2002 40915 9061 0.94 0.7 112153 34205

2003 45051 11618 0.96 0.68 110638 304802004 48012 14025 1.04 0.76 1,32,620 67942

2006 37251 1406 0.64 0.49 98103 62287

Up to Oct.2007

29030 10994 0.66 0.47 63705 37648

2005 39428 12643 0.98 0.66 100546 49366

SURVEILLANCE IN RODENT – SURAT RURAL.

Year #of Rodent Collect.

Species # of Rodent Organs Process

ed

# of Rodent

Sera Collecte

d

Result of

Investiga-tion

# of Dog Sera

Collected

Result of

Investigation

Remark

2001 539 R.r 539 306 -ve - - By MET

2006 518 R.R 502 285 -ve 69 -Ve-

By MET

2007 751 R.R 996 367 -ve 59 -Ve By MET

2002 633 R.r. 633 276 -ve - - By MET

2003 681 R.r. 659 423 -ve - - By MET

2004 662 R.r. 609 381 -Ve - - By MET

2005 735 R.r. 619 450 -Ve 11 -Ve By MET

Plague Surveillance Activities – Bhuj 2001-2007

Month/Year # of Rodent Collected

# of Flea Collected

General Flea Index

# of RodentDissected

# of Blood SeraCollected

Rodent VisceraHLLS

Feb 01 24 0 0.0 24 11 24

April 01 29 8 0.27 29 14 29

April 03 95 23 0.24 95 63 95

Nov 03 92 45 0.48 92 60 92

Jun 04 135 13 0.09 135 61 135

Dec 04 75 58 0.77 75 45 75

May 05 48 2 0.04 48 21 48

Nov 05 71 13 0.18 71 50 71

April 06 41 6 0.14 41 20 41

Jun 07 53 53 0.21 53 29 53

Dec 07 31 0 0 31 20 31

Plague Surveillance Activity (Rural)Flea Index Monitoring 1996 to 2007

Year # of Rodent

Collected

# of Flea Collected

Species Flea Index

Insecticide used

Frequency of Spraying

1996 49 47 X. cheopis X. astia 0.9 - -1997 243 147 X. cheopis X. astia 0.6 - -1998 343 369 X. cheopis X. astia 1.0 - -1999 339 537 X. cheopis X. astia 1.5 MLN 25% As & When

Required

2000 489 676 X. cheopis X. astia 1.38 MLN 25% Do2001 539 408 X. cheopis X. astia 0.76 MLN 25% Do2002 633 350 X. cheopis X. astia 0.55 MLN 25% Do2003 681 573 X. cheopis X. astia 0.84 MLN 25% Do2004 662 669 X. cheopis X. astia 1.01 MLN 25% Do

2005 735 679 X. cheopis X. astia 0.92 MLN25% Do

2006 1237 617 X. cheopis X. astia 0.5 MLN 5% Do

2007 885 471 X. cheopis X. astia 0.53 MLN5% Do

TREATMENT, PREVENTION & CONTROL

TREATMENT

Chemotherapy:• Streptomycin is the drug of choice for advance bubonic, and patients

with pneumonia or septicemia.• Chloramphenicol for patients with meningitis or endopthalmitis• Tetracycline for simple & uncomplicated bubonic plague.• All above antimicrobial therapy should continue for 10 days or for 3

to 4 days after clinical recovery.Chemoprophylaxis:• Tetracycline or Trimethoprim+Sulpamethoxazole may be used

for persons with known or strongly suspected exposure.

PREVENTION & CONTROL• Management of Patients:

Strict isolation of suspected or diagnosed pt for 48 hrs after initiation of therapy to prevent person to person transmission.

• Management of Contacts:Casual contacts of plague pt and those have similar exposure should be placed under surveillance for 6 to 10 days, & generally do not require antibiotic prophylaxis.If contact develops fever or other symptoms, do medical evaluation & give Tetracycline SOS.Close family members & intimate close contacts with pt & with signs of pneumonia should immediately be placed on chemotherapy with close monitoring.

PREVENTION & CONTROL• Vaccination

Recommended for all persons with occupation require repeated contact with agent (Lab workers) or the host and/or vectors in endemic areas.

Not recommended for the public at large or for those with only casual potential exposure.

• Environmental Control Measures:If the identified Zoonotic source of infection is considered to pose a significant threat to the public health, (e.g. involves areas of high human use like residents or recreational areas), rodent and vector control measures with effective approved pesticides should be implemented with prior or concomitant Ectoparasite control.

Aggressive & ongoing rodent population management is the best plague prevention programme.

Antirodent Activities:- Surat District:-

YearTaluka Covered

Village covered

Rodenticide Used

No. of Rats killed

Name of Rodenticide

Lepto. Case

Death

2000 9 330 5436 Kg. 446621 78 10

2001 11 330 7431 Kg. 244515 0 0

2002 14 1062 9149 Kg. 389955 23 2

2003 14 1043 9756 Kg. 321689 154 22

2004 0 0 0 0 0 285 34

2005 14 4118 kg 133783 185 43

2006 14 905 4305 kg 138338 119 42

2007 No Anti-Rodent Activities Carried Out 238 55

Bromadiolin 0.005

Bromadiolin 0.005

Antirodent Activities:- Navsari District:-

YearTaluka Covered

Village covered

Rodenticide Used

No. of Rats killed

Name of Rodenticide

Lepto. Case

Death

2000 5 388 705008 Tab.2115kg

524619 56% 50 2

2001 5 387 882388 Tab.8823Kg

615268 Brmadiolin0.005

2 0

2002 5 387 1618700 Tab.6214 kg

290686 Brmadiolin0.005

25 1

2003 5 384 7352 kg 488741 Brmadiolin0.005

154 27

2004 246 43

2005 2 146 4122 kg 288600 Brmadiolin0.005

114 26

2006 5 385 4100 Kg. 137330 Brmadiolin0.005

109 29

Antirodent Activities:- Valsad District:-

YearTaluka Covered

Village covered

Rodenticide Used

No. of Rats killed

Name of Rodenticide

Lepto. Case

Death

2000 5 465 484380 Tab. 286419 Bromadiolin 0.005 28 4

2001 5 465 484326 Tab.8073 Kg.

81576 Bromadiolin 0.005 0 0

2002 5 465 484344 Tab.8073 kg

115858 Bromadiolin 0.005 12 0

2003 5 90 1360652268 kg

30355 Bromadiolin 0.005 72 9

2004 5 106 140734 Tab.2352 kg

15332 Bromadiolin 0.005 98 15

2005 5 107 158820 Tab.2347 kg

26057 Bromadiolin 0.005 88 11

2006 5 106 175248 Tab.2920 kg

127664 Bromadiolin 0.005 40 7

2007 5 131 175041 Tab.2917.35 Kg

57897 Bromadiolin 0.005 102 26

Avian Influenza

List of Wetland Area of GujaratSr.No. Name of Place District

1 Pariaj Talav Anand

2 Kaneval Talav Anand

3 Lambhvel Khodiar Talav Anand

4 Vadhavana Talav Vadodara

5 TB Vadodara

6 Thol Talav Ahmedabad

7 Nal-Srovar Ahmedabad

8 NaniKamkarad ane Antavibha Navsari

9 Savda, Taranagar, Kodadha, Little Desert of Kutchh Kutchh, Surendranagar, Patan, Banaskantha.

10 Dholavira Kutchh

11 Janan Kutchh

12 Great Desert of Kutchh Kutchh

13 Subapur Patan

14 Dharoi Dem Mahesana

15 Nana Vada chikhaldi Junagadh

16 Khijadiya Senctury Porbandar

17 Amipur Porbandar

18 Meghakhadi Porbandar

19 Kuchhadi Porbandar

20 Patangadi Dahod

21 Khera Patva Amreli

22 R.P.L. to G.S.F.C. Coastal Area Jamnagar

23 Charkhala Salt Jamnagar

24 Hathmati Dem Sabarkantha

High-risk Villages in Uchhchhal taluka

Initial Actions• A fact sheet on Avian Influenza released by WHO

on 15th January 2004 was circulated to medical colleges, district hospitals, regional deputy directors, chief district health officers, chief district medical officers and municipal corporations.

• Updated informations of Avian Influenza released by WHO was put on website www.gujhealth.gov.inby Govt. of Gujarat for awareness and alertness amongst the health functionaries.

Influenza VirusTypes A, B, and C

Type A Type B Type C

Causes significant disease

Causes significant disease

Does not cause significant disease

Infects humans and other species !

Limited to humans Limited to humans

HumanHumanvirusvirus

ReassortantReassortantvirusvirus

NonNon--humanhumanvirusvirus

Re-assortment and Direct Transmission

DIRECTDIRECT

Epidemiology Terms

• Epidemic– When the cases of a disease exceed what is normally

expected • Pandemic

– An epidemic that occurs over a large geographic area, or across the whole world

Seasonal Influenza– A public health problem each

year

– Usually some immunity built up from previous exposures to the same subtype

– Infants and elderly most at risk

– Result of Antigenic Drift

Influenza Pandemics– Appear in the human population

rarely and unpredictably

– Human population lacks any immunity. Virulence and mortality not entirely linked to immunity.

– All age groups, including healthy young adults, may be at increased risk for serious complications

– Result of Antigenic Shift

Seasonal Epidemics vs. Pandemics

1918-19 Spanish Flu (H1N1)– ~ 40 million deaths worldwide

1957-58 Asian Flu (H2N2)– 1 - 2 million deaths worldwide

1968-69 Hong Kong Flu (H3N2)–– ~ 700,000 deaths worldwide

Mortality Impact of Past Pandemics

U.S. Life Expectancy 1900-1960

35

40

45

50

557060

65

1900 1918 1960Date

Age

• 1918 pandemic influenza virus (H1N1) was likely of avian origin without reassortment

• Total deaths in 1918-1919 estimated to be 20-50 million worldwide. U.S. Deaths = 550,000-675,000

• U.S. Military deaths to flu = 43,000 (out of ~100,000 U.S. Troop casualties in W.W.I.)

1918 was the Worst

Human Life ExpectancyGraph in U.S.

WHO Phases of a Pandemic

Inter-pandemic Period

Phase 1: No new Influenza virus subtypes in humans

Phase 2: No new virus subtypes in humans; animal subtype poses a risk of human disease

Pandemic Alert Period

Phase 3: Human infection with novel virus; no instances of human-to-human spread

Phase 4: Small, localized clusters of human-to-human spread

Phase 5: Larger clusters, still localized; virus adapting to humans

WHO Phases of a Pandemic

Pandemic Period

Phase 6: Increased and sustained transmission in the general population.

Post Pandemic PeriodRecovery phase

WHO Phases of a Pandemic

Key Characteristics

Influenza: a disease caused by human influenza virus that predominantly, but not

exclusively, infect cells of the upper respiratory tract.

Transmission– Highly contagious– Primarily through contact with respiratory droplets – Transmission from objects possible

Key Characteristics

Communicability– Transmission 1 day

before to 4 - 5 days after onset of symptoms

– Peak viral shedding occurs on day 1 of symptoms

– Infants, children and immunocompromised people may shed the virus longer

Incubation period– Time from exposure to onset of symptoms– 1 to 4 days (average = 2 days)

Seasonality– In temperate zones, sharp peaks in winter

months – In tropical zones, circulates year-round with

seasonal increases (???)

Key Characteristics

Chief Signs and SymptomsRapid onset of symptoms– Fever / Chills– Body aches and headaches– Sore throat– Non-productive cough

Range of symptoms differs by age– Vomiting and diarrhea in children and elderly– Fever alone in infants– May be atypical in the elderly

Serious complications can occur among high-risk groups– May be the cause of exacerbations of underlying chronic

illnesses

Symptoms• High Fever(>38

0C) and an influenza like illness

• Lower respiratory tract symptoms like cough and shortness of breath are the usual initial presenting features

• Muscle pains, Malaise, Sore Throat

• Watery diarrhoea without blood or inflammatory changes• Although uncommon, may be more common than in classic

influenza A and may precede respiratory symptoms with up to one week

• Other less common initial symptoms include:

• Vomiting, abdominal pain, pleuritic pain, bleeding from nose andgums and encephalopathy

Groups at Risk for Serious Complications

Complications– Pneumonia, worsening of chronic lung and

heart problems, and death

High Risk Groups– Persons 65 years and older– Persons with chronic diseases – Infants between 6 months and 2 years– Pregnant women– Nursing home residents– Children on long-term aspirin therapy

Vaccination

• Influenza vaccine is the best prevention

• Inactivated viruses in the vaccine developed from circulating strains

• In temperate zones, vaccination is recommended for all high risk persons > 6 months old

• Limited supply of intranasal vaccine is available

Summary

• Influenza is a serious health concern each year

• Influenza virus strains evolve rapidly and can develop into a novel virus with pandemic potential

• Influenza pandemics have caused high morbidity and mortality in the past

Summary• H5N1 Avian Influenza is currently spreading

through birds with occasional outbreaks among humans

• While there is evidence of rare human to human transmission, sustained transmission has notoccurred

• If H5N1 virus obtains the ability to easily transmit from person to person, a pandemic may result

Unanswered Questions

• When will the next pandemic occur?– Unpredictable. Unknown what events might have

preceded previous pandemics.• What will be the type of virus in the next

Pandemic?– H5 best candidate currently but could come

unexpectedly from another source.• Will it be as virulent as 1918?

– Factors that caused the high mortality of 1918 virus are unknown.

Incubation period of 2 - 8 days

• Initial signs and symptoms• High fever (>38 C)• Respiratory symptoms (e.g., cough, sore throat, runny nose) • Muscle aches, headache• More rare: frequent watery diarrhea, abdominal pain, vomiting

• Laboratory findings:• Admission:

• Leucopenia, lymphopenia• Moderate thrombocytopenia

. 2005):1374-85.

H5N1 Clinical Features

Clinical course• Shortness of breath (Dyspnea)

• Clinical pneumonia with variable x-ray findings

• Acute Respiratory Distress Syndrome (ARDS)

• Case Fatality Rate (53%)

H5N1 Clinical Features

Source: The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5. Avian Influenza A (H5N1) infection in humans. N Engl J Med. 2005 Sep 29;353(13):1374-85.

The Zoonotic Potential of Avian Influenza

What conditions favor AI spread?

Agricultural husbandry and marketing practices

• Inadequate biosecurity on farms, use of untreated ground water

• International agribusiness with facilities in multiple countries

• Farm animals raised in close proximity to human habitation

• Multiple bird species sold in “wet” markets• Wet markets that allow birds to be purchased live

Contributors to the Spread of AIOther Factors• Consumption of raw/undercooked meat • Illegal animal trade and smuggling of poultry or

poultry products• Role of migratory birds?• Limited coordination between human health and

agriculture sectors• Delays in diagnosis and reporting of avian

influenza

Identified Risk Factors for Human Infection by HPAI H5N1

• Close contact (especially in enclosed areas) or handling of infected poultry, poultry products, bodily fluids (blood), or poultry excrement

• Slaughter and preparation of infected poultry• Consumption of infected poultry products that are

improperly prepared• Higher incidence of infection in the young and

females, probably relating to traditional roles as caretakers of poultry and predisposition to exposure (children)

Family Cluster Outbreaks• Lateral (human to human) H5N1infection• Limited to “blood” relatives

- the occurrences to date have been limited to genetically related family members, e.g. a mother and her siblings and children, but not the father; and conversely a father and his siblings or children, but not his wife

• Presumption of an underlying biological risk factor in these cases, which has not yet been elucidated

Summary• HPAI H5N1 is an avian virus• HPAI H5N1 prefers to attach to cells with galactose

linked in an α 2, 3 orientation• Humans possess some receptors with the α 2, 3

orientation in their respiratory and gastrointestinal tract

• HPAI H5N1 currently infects humans with great difficulty

Summary

• Infected poultry (chickens and waterfowl) or poultry products is the only currently known source of spread to humans of the disease except for lateral transmission in rare family cluster outbreaks

• Certain risk behaviors will predispose individuals to infection

Surveillance for AI in poultry:A key element of prevention strategy

Control Operations-Major Phases

I. Culling of birdsII. Disposal of birds and infected materialsIII. Clean-upIV. Dis-infectionV. Issue of Sanitization CertificateVI. Post Operation SurveillanceVII.Disease freedom

Operations: major activities up to sealing

1. Mobilisation of teams; Control room operations, movement plan

8. Disposal of culled birds

2. Briefing on use of PPE’s/Tamiflu 9. Disposal of infected materials egeggs, egg trays, feed, feed material, sacks, PPE etc.

3. Demarcation: infected & surveillance zones

10. Deployment of machinery/labor

4. Material procurement and stocking

11. Clean-up

5. Mobilization of vehicles etc. 12. Disinfection/ sanitisation6. Culling of birds: Strategies 13. Vaccination, if considered

7. Quarantine: enforcement 14. Sealing

Phase II: Disposal

BirdsEggsFeed/feed materialsOther infected materialsPPE

Disposal of other infected materials

Eggs-traysSacks Manure

• Digging & re-closing of pits where dead birds were stated to have been buried.

• Flaming of upper cages• Flaming of lower cages• Cleaning of cage systems with waterier and feeders• Fumigation in cages• Dis-infection of water supply system in cages• Dis-infection of farm equipment• Wet litter removal (Litres)• Dry litter removal (in M.M.T.)• Fogging operations• Spraying sheds• Disinfection process• Sealing

Clean up/disinfection: more difficult and rigorous than culling in Navapur

Phase VI: Post Operation Surveillance

All birds killed in 10 km. radius

Surveillance;Physical Surveillance of 10 km. zone. No poultry

to be re-stocked in area for a 3 month period

Surveillance of adjoining area for 3 months over a further 5 km zone: clinical, seriological, virological

Fumigation and dis-infection procedures once a fortnight

Effective Co-ordination• Multi-departmental: AH, Health, Forests, Home,

PWD, Local bodies, Panchayati Raj• Core departments are AH and Health-every

step co-ordination:– Rush supplies and RRT’s– Briefing– Tamiflu– Operations– Quarantine of operational forces

Availability of manpower

Manpower availability with AH and HealthTrained manpower for operationsCapacity to lead and supervise

Effective deployment of manpowerRelief after specified phase and quarantineShortage of labor for clean-up-----poultry owners made responsible under governmental supervision

PPE

No entry into farm without PPESingle use itemDisposal on exit from farm/premisesPPE to be burned or buried after useProvided for RRT’s of Health and AH and

all labor engaged in operationsReviewed after operations

Tamiflu

• Mandatory for those having direct exposure• Supply by MOHFW thru State Health

Department• Administration under supervision of Health

RRT• Briefing in use of Tamiflu: Side effects

Human Health SurveillancePhase I- Surveillance in 3 Km zone: 100% population

Phase II- Surveillance in 3-10 Km zone: 100% population

Focus groups: Working in affected/unaffected premise

Exposed to dead /dying backyard poultry

Personnel engaged in operations

All persons coming to OPD of health care facilities in the affected areas

More than 82 Medical Teams deployed for surveillance in Navapur-Uchchhal alone

No Human case

Persons with history of exposure with symptoms were hospitalized

No human sample found positive for H5N1 in India

Non-pharmaceutical Interventions

Potential Tools in Our ToolboxVaccine – best countermeasure will probably be unavailable during first wave of pandemic

Antiviral treatment may improve outcomes but will have only modest effects on transmission

Antiviral prophylaxis may have more substantial effects on reducing transmission

Non-pharmaceutical interventions may reduce and delay transmission, giving time to prepare

Non-pharmaceutical Interventions

1. Delay disease transmission and outbreak peak2. Reduce peak burden on healthcare infrastructure3. Diminish overall cases and health impacts

DailyCases

#1

#2

#3

Days since First Case

Pandemic outbreak:No intervention

Pandemic outbreak:With intervention

Non-Pharmaceutical Interventions

Individual level

IsolationQuarantineInfection control

Hand washingRespiratory etiquettes

Non-Pharmaceutical Interventions

Community level

Quarantine of groups/sitesCommunity wide quarantine-Cordon SanitaireMeasures to increase social distance

School closuresBusiness and market closureCancellation of eventsMovement restrictions

Infection control

Non-Pharmaceutical Interventions

National/ International level

Non essential travel deferred

Provide information to travelers

Self recognition of illness and self reporting

Entry screening

Exit Screening

Maritime/ Airport Quarantine

Ban of flights/ ships originating from affected area (?)

Non-Pharmaceutical Interventions

Isolation

Separation and restricted movement of illpersons with contagious diseaseOften in a hospital settingPrimarily individual levelcan be voluntary or legally mandated

Non-Pharmaceutical Interventions

Quarantinerefers to separation and restriction of movement or activities Persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious.Often at home, may be designated residential facility or hospital Individual or community levelCan be voluntary or legally mandated

Non-Pharmaceutical Interventions

Community wide quarantine-Cordon SanitaireClosing of community with barriers, real/ virtual around a geographic area.Prohibition of travel in and out of the area.Helpful in close settings (Military Barracks, University campuses etc)May be impractical in most settings

Non-Pharmaceutical Interventions

Principles of Quarantine

Used when resources are available to implement and maintain essential services and care for those in quarantineUsed in combination with other interventions

Surveillance, diagnosis, treatment, and preventive interventions

Used only as long as necessaryDoes not have to be absolute to be effective

Non-Pharmaceutical Interventions

Factors influencing level and type of NPI

Pandemic Alert Period- Isolation of suspected cases and Quarantine of contacts.Pandemic Phase-Social distancing measures Geographic area small enough that containment would be logistically possiblePresence of clusters in defined area over short period of timeResources available to implement and maintain essential services and care for those in quarantine

Non-Pharmaceutical Interventions

Risk Communication

• Communicate the risk in clear consistent messages

• Wide spread dissemination through media• One source for official information• Prevention of incorrect information• Allays psychological fear

Summary

• NPI likely useful in delaying and reducing disease transmission, and may decrease health and human impact

• NPI should be used in coordination with other interventions, and early implementation is crucial

• All measures should be implemented within context of local situation

Cause of concern with AI• Once inside human body H5N1 virus is capable of

giving rise to a novel virus that may cause pandemic

• The virus is crossing territorial barrier to affect birds across the globe.

• It has also infected humans in certain countries.

• There had been 3 Influenza A Pandemics in 1918, 1957 and 1968 with massive human/ economic loss

ManagementObjectives:

– Early implementation of infection control mechanism to minimize nasopharyngeal spread of disease

– Proper treatment to prevent severe illness & death

– Early identification and follow up of persons at risk

Current Stock of Tab.Temiflu & PPE Kits

Tab.Temiflu 2486 Tabs. at the Head Office ( Epidemic Branch)

139 Head Office ( Epidemic Branch) PPE Kits

Temiflu Syrup Current Stock at the Head Office ( Epidemic Branch)

500 with Veterinary Officer Uchchhal

Total No.of PPE Kits 600 in No.