Recent -( 2014 ) J E out Break in West Bengal, India, Need for JE vaccination programme in West Bengal that must cover the target children and young adults up to 20 years adequately( 700 MILLIONS) nationwide who are at risk of JE & there is need for investigation on the circulating strains of JE cases, in state of West Bengal .
Authors By Professor Pranab kumar Bhttacharya MD(Cal.Univ.( FIC path(India) Professor and Head Department of Pathology [in charge, of DCP course of WBUHS & DLT course, Member of Board of studies for Pathology(UG/PG/ Doctoral) & Member Secretary( For DCP) of Board of studies of West Bengal university of Health sciences(WBUHS) , DD36 sector-1, Salt lake, Kolkata, W.B, India; In-charge of DLT of STM, Kolkata, W.B Indiia ] Dept. of Pathology, 2nd floor; Room No 10 CCalcutta School of Tropical Medicine108 C.R. Avenue, Kolkata-700073; West Bengal; India E mail profpkb@yahoo.co.in Telephone no- 91 9231510535
2] Professor Sougata Ghosh MD( Cal.Univ) Professor and Head Department of Microbiology; Medical College Kolkata
Fever with altered sensorium and/or seizure is known as acute encephalitis syndrome(AES). Encephalitis may be caused by several viruses , bacterial and fungal infections parasites, spirochetes. More than 100 different pathogens are recognized as causative agents of AES are JEV, MVEV , West Nile virus, St. Louis encephalitis virus, Ebola Virus, herpes simplex, varicella-zoster, Epstein barr virus, mumps, measles, enteroviruses, influenza, adeno virus, echo virus, mycoplasma pneumonia the frequent pathogens. Bacterial, fungal, parasitic (like cerebral malaria) and some viral encephalitides (like Herpes simplex, Varicella- zoster) have however specific treatment. The majority of cases of viral AES (~90%) have no specific treatment (AESn). Japanese encephalitis(JE), is an encephalitis, caused by JEV- a mosquito-borne flavivirus infection , is prevalent in the regions like West Bengal; Manipur, Assam and in other south Indian states than other forms of Encephalities . JE occurring with an estimated 30,000 to 50,000 of cases and 15,000 deaths annually [3-5]. About 20% to 30% of JE cases lead to death, and 30-50% result in permanent neuropsychiatric squeal [5, 6]. Malnourished, poor economic class children and young adults are main victims of the disease [7, ] though adults in west Bengal states are also affected in 2014 . In India, nearly all states reported JE cases except that of Jammu & Kashmir, Himachal Pradesh, and Uttaranchal [8 ]. . In West Bengal, the first major outbreaks of JE occurred in the districts of Bankura and Burdwan in 1973[9], where about 700 cases and 300 deaths occurred. From 1978 to 2007, 103 389 cases and 33 729 deaths due to JEV infection were recorded from various parts of India[9]. Every year, 1 500-4 000 cases are reported from this country. JE - is major public health problems world wide and is thus low endemic areas with seasonal distribution in China( higher Incidence Stratum is 3.3 at risk are 1026 millions populations in all age groups) , the Russian Federation's south-east, Australia and South and South-East Asia like India, Pakistan, Bangladesh, and Singapore( Lower incidence Stratum is .003 in all age groups at risk covering 89.5 millions populations ) . In India alone, 375 million population now at risk of developing AES. 70% to 75% of disease burden are in Uttar Pradesh of India.
In temperate areas of Asian countries , J E V transmitted during warm seasons, when large epidemics occur. In tropics and subtropics, transmission occur year-round but often intensifies during rainy seasons and pre-harvest period in rice-cultivating regions. JE is transmitted to humans through bites from infected mosquitoes of Culex species (mainly Culex tritaeniorhynchus). Humans, once infected, do not develop sufficient viraemia to infect feeding mosquitoes. The virus exists in transmission cycle between mosquitoes, pigs and/or water birds (enzootic cycle). The disease is predominantly found in rural and peri-urban settings, where humans live in closer proximity to these vertebrate hosts. Outbreaks of AES and JE are common every year in India, especially during the monsoon season, and claim hundreds of lives. Indian states that reported AESn cases were Andhra Pradesh, Assam, Bihar, Delhi, Goa, Haryana, Jharkhand, Kerala, Karnataka, Maharashtra, Manipur, Nagaland, Punjab, Tamil Nadu, Uttar Pradesh, Uttarakhand and West Bengal. States of India that did not report AESn were Arunachal Pradesh, Chhattisgarh, Gujarat, Himachal Pradesh, Jammu and Kashmir, Madhya Pradesh, Meghalaya, Mizoram, Odisha, Rajasthan, Sikkim and Tripura. But this year, major outbreaks - usually most prevalent in the northern states of Uttar Pradesh , Bihar(2013 &14) & have spread to regions such as West Bengal and in Assam. JE is not at all a contagious disease and does not spread from man to man unless there is an intermediate hosts like Pigs or water living birds. In West Bengal in 2014 , major outbreak occurred in North Bengal & toll from the disease in north Bengal only rose to 121 up to august 2nd and four new cases have also been reported in the state in August 04th 2014. Taking into account the death of 20 persons from other states in north Bengal due to possibly other Encephalitis, the death toll was 141 since January this year 2014. Death are reported from areas like Malda, Balurghat, Kranti near Maynaguri, North Bengal Medical College and Hospital (NBMCH), Birbhum, Bardwan, Bankra districts
In Assam state more than 100 people died of JE and AES so far, and over 24 districts have been affected by JE. The disease had severely affected Barpeta, Nagaon, Baksa, Darrang, Sonitpur, Nalbari and Bongaigaon where such cases were not many in the previous years. Diagnosis- Individuals who live in or had travelled to a JE-endemic area and experience encephalitis are considered a suspected JE case. Patients with JE present vivid signs of AES. JE cases are found highest amongst the children and young adults (2 -20 years). Children up to 10 years of age are most vulnerable group for JE due to either absence or low protective immunity against the virus in them However, in areas where JEV is recently introduced, adults are also getting the infection . Most common presenting symptoms are moderate to high grade fever , altered sensorium , seizures (82%), headache , and vomitings . Signs of meningeal irritation usually present in 55-60% of cases. Around 50% of JE patients undegoes in Glasgow comma scale (GCS) 3 to 8. All JE patients present to any hospital between 1 to 12 days from the onset of illness. The CSF WBC counts usually ranges from 2.0/mm3 to 520.0/mm3 Elevated levels of WBC (>5/mm3) found in 80% patients and predominantly lymphocyte. The mean CSF protein and glucose level usually 57.0 ? 27?mg/dL and 45.0 ? 12 mg/dL, . Of these 50% shows elevated (>40?mg/dL) level of protein. To confirm JE infection, to rule out other causes of encephalitis requires a laboratory testing of serum or, preferentially CSF by ELISA orby RT PCR. The kits available are Japanese Encephalitis-Dengue IgM Combo ELISA (Panbio Diagnostics, Australia) and JEV-CheX IgM capture ELISA (XCyton Diagnostics Limited, India). or JEV-CheX IgM capture ELISA (XCyton Diagnostics Limited, India). The average duration of illness is usually 5.4 days. Mortality rate from JE is more (49%) in children when admitted less than 7 days from the onset of illness. The mortality was significantly more in patients with GCS between 3 to 8 . Presences of meningeal signs are not found to be associated with fatal outcome. Similarly, no significant association is observed between high cell counts, elevated level of protein in CSF, and children fatality. As there is no specific treatment for Japanese encephalitis, supportive care in a medical facility is important to reduce the risk of death or Post JE neurological disability. The disease is preventable by proven effective vaccines - "Jenvac"(1), - Indian first indigenously developed vaccine for Japanese encephalitis jointly developed in 2013 by scientists at the Indian Council of Medical Research (ICMR), National Institute of Virology (NIV) and Bharat Biotech International Ltd. The Japanese encephalitis vaccine candidate strain (821564 XZ), used for making this Indian vaccine, Jenvac was isolated from the blood sample collected from a patient admitted to a government hospital in Kolar, Karnataka, in 1981.
There is another vaccine developed in China .The vaccine, manufactured in China, the attenuated SA 14-14-2 Japanese Encephalitis vaccine, needs to be given in one dose, can be used for infants, and is less expensive than other Japanese encephalitis vaccines. The imported Chinese vaccine costs around Rs.20 per dose while Jenvac is likely to be priced around Rs.70 per dose. In India, the Universal Immunization Programme targets 27 million infants and 30 million pregnant women every year against six vaccine-preventable diseases - tuberculosis, diphtheria, tetanus, pertussis, polio and measles - and the vaccination of pregnant women against tetanus. In some states, vaccines against hepatitis B and Japanese encephalitis are also included in the programme. However Indian Association of Paediatric Does not r outinely Recommend JE Vaccine(2) Factors which might have decreased JE 1] Improved environmental sanitation, proper health education and availability of more Infectious Disease doctors & Pathologists specialists might have resulted in early diagnosis and prevention of spread of AESn, JE & Dengue. 2] Improved communication and transport systems, methods of detection of treatable aetiologies and availability of multimedia teaching facilities might have supplemented the diagnostic efficiency of medical and nursing personnel resulting in early specific treatable diagnosis. 3] Although utmost care to be taken to report every case, there might be possibility that many cases of AESn might have died before being seen by any doctor, thereby reducing the number of cases of AESn. Part of the low IR might have been due to lack of staff or timely diagnostic facilities for making a diagnosis before the death of patient or lack of awareness among doctors that they have to report AESn cases. 4] JE vaccination with live attenuated china vaccine (SA-14-14-2) (genotype III) must be included in routine immunization programme as per National Immunization Schedule (NIS). vaccination programme must cover the target children adequately 700 MILLION children nationwide are at risk ; . Due to the widespread use of JE vaccine, JE cases has been declined in China, Korea, and Japan. The targeted age group for this vaccination should be below 20 years age. However there remains possibilities of the change in genotype of the circulating strains and that to be excluded in West Bengal. 5] dedicated hospital beds for encephalitis patients in affected districts. 6] investigation on the circulating strains are essentially required to find out the reasons of increasing tendency of JE cases in this state.
References-: 1]http://www.livemint.com/Industry/NVyjUE8DUW3phpiHFmIA2H/India-launches- first-indigenous-vaccineforJapanese-encepha.html?utm_source=copy 2] http://www.iapindia.org/IMM%20Schedule.pdf
3] R. Potula, S. Badrinath, and S. Srinivasan, "Japanese encephalitis in and around Pondicherry, south India: a clinical appraisal and prognostic indicators for the outcome," Journal of Tropical Pediatrics, vol. 49, no. 1, pp. 48-53, 2003. View at Publisher * View at Google Scholar * View at Scopus
4] Center for Disease Control and Prevention (CDC), "Question and answer about Japanese Encephalitis," March 2013, http://www.cdc.gov/japaneseencephalitis/qa/index.html.
5] World Health Organization (WHO), "Immunization, vaccines and biological," March 2013,http://www.who.int/immunization/topics/japanese_encephalitis/en/index.html.
6] World Health Organization, "Japanese encephalitis vaccines," The Weekly Epidemiological Record, vol. 81, pp. 331-340, 2006. 7] D. W. Vaughn and C. H. Hoke Jr., "The epidemiology of Japanese encephalitis: prospects for prevention," Epidemiologic Reviews, vol. 14, pp. 197-221, 1992. View at Scopus
8] A. Henderson, C. J. Leake, and D. S. Burke, "Japanese encephalitis in Nepal," The Lancet, vol. 2, no. 8363, pp. 1359-1360, 1983. View at Scopus
9] Banerjee K, Sengupta SN, Dandawate CN, Tongaonkar SS, Gupta NP. Virological and serological investigations of an epidemic of encephalitis which occurred at Bankura district, West Bengal. Indian J Med Res 1976; 64: 121-130.
[10] D utta K, Rangarajan PN, Vrati S, Basu A. Japanese encephalitis: pathogenesis, prophylactics and therapeutics. Curr Sci 2010; 98 (3): 326- 334
Acknowledgement-: Miss Upasana Bhattacharya Student Daughter of Professor Pranab kumar Bhattacharya; Mr Rupak Bhattacharya, Mr Ritwik Bhattacharya; Miss Rupsa Bhattacharya of 7/51 Purbapalli; Po-Sodepur Dist 24 Pargnas(north) West Bengal, Kolkata-700110, India; Miss Oindrila Mukherjee, Mrs Dalia Mukherjee and Mr Debasis Mukherjee of Swamiji Nagar; South Habra , North 24 Pargnas West Bengal India
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Conflict of Interest:
None declared
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