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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
1 1
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
0.5
1
1.5
2
2.5
3
3.5
4
1
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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
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