H5N1

Uttar Pradesh: NCDC in Firozabad to probe ‘viral’ deaths, WHO says ‘dengue haemorrhagic fever’

Via the Times of India: UP: NCDC in Firozabad to probe ‘viral’ deaths, WHO says ‘dengue haemorrhagic fever’. Excerpt:

AGRA/NOIDA: A five-member team of the National Centre for Disease Control (NCDC) sent by the Union health ministry is in Firozabad to investigate deaths of children after prolonged fever, dropping platelets, severe dehydration and bleeding of gums. 

The Firozabad DM and UP DG (health) said dengue haemorrhagic fever could be the cause while the UP medical education principal secretary said these are cases of dengue, leptospirosis and scrub typhus.  

With six more cases, the death toll in Firozabad, the epicentre of the viral disease, touched 71. Of them, 52 were children, local sources said. “The WHO has suggested dengue haemorrhagic fever (DHF) could be causing deaths,” Firozabad DM Chandra Vijay Singh told TOI.  

UP DG (health) Dr Ved Vrat Singh said, “The Centre has asked the NCDC team to investigate deaths due to viral fever and dengue-like symptoms in Firozabad. The team will also study the nature of vector-borne diseases spreading there.” He added, “Local authorities have been alerted about the spread of dengue haemorrhagic fever. It is a severe form of the disease.”

During a visit by UP chief secretary Rajendra Kumar Tiwari to Noida, officials said some samples had been tested. “We can say for sure that there are known causes and there is no mystery. We had sent samples to KGMU (King George’s Medical University), Lucknow that have confirmed dengue in several cases. It was a small outbreak of dengue and leptospirosis,” Alok Kumar, principal secretary of UP medical education, told TOI. Officials said 185 samples had been tested by the Indian Council for Medical Research (ICMR), of which 73 were positive for dengue, 47 for leptospirosis, 28 for scrub typhus and one for Japanese encephalitis.

At a meeting in Lucknow, CM Yogi Adityanath had asked Kumar to position himself in Firozabad and monitor the situation. Senior IAS officer Sudhir M Bobde has been appointed nodal officer for Firozabad district. Sources in Firozabad told TOI that an estimated 5,000 people in the district are bedridden with fever, at home and in hospitals.

India: Rare triple disease combination shocks docs

Via The Times of India: Rare triple disease combination shocks docs. Excerpt:

Jaipur: An uncommon combination of triple diseases — dengue, chikungunya and scrub typhus — has shocked SMS hospital doctors. Two such cases have already been reported in 11 days. 

When a 63-year-old Kiran, was rushed to Sawai Man Singh Hospital from Kotputli of Jaipur district, she had double pneumonia, breathing problems, low platelet count and abnormal functioning of liver and kidneys. 

She was brought to SMS hospital on August 19 and died on August 23 while undergoing treatment. When the doctors conducted diagnostic tests, they found that she tested positive for dengue, chikungunya and scrub typhus. 

The rare combination of the triple diseases — dengue, chikungunya and scrub typhus, has shocked the SMS hospital doctors. 

Two days before Kiran was rushed to SMS Hospital, a patient Mukesh (23), from Baswa of Dausa district, was brought to the hospital on August 17. The doctors immediately admitted him and began with the treatment. He has recovered and was discharged from the hospital on Monday. 

Mukesh was brought to the hospital with high-grade fever and altered sensorium. The doctors provided him with treatment and he responded to the treatment well. 

“Both the patients were brought to the hospital with a more or less similar condition — having double pneumonia, breathing problems, low platelet count and abnormal functioning of liver and kidneys. These complications can be found in a patient suffering from dengue, or chikungunya or scrub typhus. But when we conducted tests, we found that they (both patients) have a triple combination of these diseases. So it is quite necessary for doctors not to rule out other diseases, if a patient is tested positive for one disease,” said Dr C L Nawal, senior professor (medicine), SMS Hospital. 

The cases of scrub typhus, which was termed as a ‘mysterious disease’, were reported first from Alwar district, almost 10 years ago. But the disease, which is caused by the bite of a mite, has started affecting other districts such as Dausa, Karauli, Dholpur, Bharatpur and also rural areas of Jaipur. 

Now, it has started targeting its victims in combination with other vector-borne diseases. 

A private hospital’s consultant physician Dr Adil Aziz said, “It is quite uncommon that we find a patient suffering from the three diseases — scrub typhus, chikungunya and dengue. We report combinations of diseases such as malaria plasmodium falciparum and malaria vivax, or malaria and dengue, but patients with scrub typhus, chikungunya and dengue at the same time, are very uncommon.” 

The reason for cases of triple diseases being reported, could be a spurt in cases of scrub typhus. In SMS Hospital, 411 cases of scrub typhus have already been reported this year, and 415 cases of dengue were reported. However, chikungunya cases were only 11 in 2018 so far.

India: Hospitals brace for encephalitis season in CM Yogi Adityanath’s constituency Gorakhpur

Via The Indian Express: Hospitals brace for encephalitis season in CM Yogi Adityanath’s constituency Gorakhpur. 

Chief Minister Yogi Adityanath’s Lok Sabha constituency of Gorakhpur has witnessed at least 114 deaths due to Acute Encephalitis Syndrome (AES) this year. AES is an umbrella classification under which come the diseases Japanese Encephalitis (JE), water-borne encephalitis and scrub typhus, among others. As a Member of Parliament, Adityanath had actively raised the issue. 

In the last two days, 16 new cases of AES and three deaths were reported from Baba Raghav Das (BRD) Medical College, the largest in the district. However, the hospital and district health officials are claiming that the situation is much better than the previous years. 

According to Ravindra Kumar, Chief Medical Officer (CMO) Gorakhpur, the Case Fatality Rate (CFR) is reducing with each passing year. “The CFR last year was more than 20 percent and this year we have reduced it to 16 percent. In 2015, the CFR was somewhere near 30 percent,” CMO said, adding that the threat of JE has nearly ended although it has, like last year, claimed three deaths this year.  

“In the months of August to October, people are more prone to acquiring some form of AES. Therefore we are trying to make people aware of the importance of cleanliness, drink clean and boiled water, and should rush to hospital if there is fever,” said the CMO. “We have prepared separate wards and the tests and treatment for AES and JE are free of cost,” CMO added.  

According to Dr. R N Singh, social activist and a campaigner in the Encephalitis Eradication Movement, there hasn’t been a significant decrease in the number of cases and deaths. “It is just the start of August. Though we hope that the figures doesn’t match the earlier ones,” Singh said, adding that the government soon needs to implement the National Encephalitis Eradication Program (NEEP), which is ready and focuses mainly on prevention, which according to him is “surely possible if exercised timely”.

India: Disease sleuths unmask deadly encephalitis culprit

Via Science: Disease sleuths unmask deadly encephalitis culprit. The summary and then a comment:

Soon after the monsoon rains arrive in June, the northern city of Gorakhpur transforms into the "encephalitis capital of India." Hundreds of children from across the surrounding Uttar Pradesh state arrive at Baba Raghav Das Medical College with the brain inflammation that causes delirium, seizures, and—in about 20% of those patients—death. 

For decades, the recurring spates of cases and high mortality rate stumped experts. Now, medical detectives think they have solved the mystery: A major cause of the seasonal encephalitis outbreaks is scrub typhus, a bacterial malady transmitted by a microscopic mite. The culprit was first unmasked 3 years ago—but most researchers didn't believe it then. The new evidence, described this month in Emerging Infectious Diseases, indicates the responsible bacterium is far more dangerous than realized.

I posted an item about scrub typhus and encephalitis in October 2015.

Delhi: 33 test positive for scrub typhus, symptoms similar to chikungunya

Via the Hindustan Times: Delhi: 33 test positive for scrub typhus, symptoms similar to chikungunya. Excerpt:

Of the 150 tested for scrub typhus, a bacterial infection that causes symptoms very similar to chikungunya, 33 tested positive in the last two months at All India Institute of Medical Sciences (AIIMS). 

“As the symptoms of the disease are similar to that of chikungunya, which is circulating in the city this year, doctors do not suspect scrub typhus or any of the other rickettsial diseases (diseases caused by a group of microorganisms called rickettsiae) in fever patients,” said Dr Rama Chaudhary, professor of microbiology at AIIMS. 

Chikungunya, a mosquito borne viral illness, has affected more than 2,600 in Delhi, according to official figures. 

The symptoms of scrub typhus begin with high fever, skin rashes, respiratory problems, red eyes and unconsciousness. Some of the patients also develop joint pains, which is characteristic of chikungunya. 

These symptoms may progress on to respiratory distress, pneumonitis (inflammation of lung tissue), encephalitis (inflammation of the brain), kidney failure and then multi-organ failure. If untreated, it can kill. 

Two of the people, who came to AIIMS for treatment – a 16-year-old girl from Uttarakhand and 21-year-old man from Delhi – died due to the infection, according to a hospital official. “They came to the hospital in a very critical condition with organ failure and had to be put on ventilator immediately,” the source said. 

Another reason why doctors may not suspect scrub typhus is that it is usually spread by mites, which are commonly found in hilly areas. But, it can also be spread by fleas, lice and ticks too. 

A lot of precious treatment time is wasted because of this. “The samples were sent to the bacterial lab only after dengue and chikungunya had been ruled out. To get the test for chikungunya, a patient has to wait for at least six days to get accurate results, this means we get to test the sample more than a week after the symptoms appear,” said Dr Chaudhary. 

The disease, if diagnosed on time, can be completely cured just with antibiotics. “Dengue and chikungunya are self-limiting viral diseases that do not have any treatment, apart from management of symptoms. In scrub typhus, however, administering antibiotics on time can save lives,” she said.

Unwelcome surprise: The chiggers that spread scrub typhus are in Chile

Via NPR's Goats and Soda blog: Unwelcome Surprise: The Chiggers That Spread Scrub Typhus Are Not Just In Asia And Australia. Excerpt:

Nobody wants to be attacked by a chigger. These six-legged mite larva — so small they're invisible to the naked eye — have a powerful bite that causes severe itching. They also transmit a disease called scrub typhus, named for the forest undergrowth, or scrub, that is home to the chiggers.  

Up until now, scrub typhus has been a regional problem. The chiggers, officially called Orientia tsutsugamushi, that spread that disease were thought to live in East and Southeast Asia as well as Northern Australia. The countries where scrub typhus shows up, including Pakistan and parts of Russia, form a long and wide geographic area called "the tsutsugamushi triangle." 

Within that triangle, when people come to clinics with complaints of rash, headache, high fever and muscle pain, scrub typhus is on the radar screen of possible diagnoses. With the correct diagnosis, the illness is highly treatable. 

But now scrub typhus has made an appearance in the Western hemisphere: Three patients were diagnosed between January 2015 and February 2016 in Chiloe Island off the coast of southern Chile, almost 7,500 miles away from where the disease is typically found. 

"It's a big surprise," says Dr. David Walker, pathologist and director of the Center for Biodefense and Emerging Infectious Diseases at the University of Texas Medical Branch in Galveston. 

Discovering scrub typhus in Chile, of course, has implications for the people in the rural area where it turned up. "But it also has global significance," says Dr. Thomas Weitzel, an author of a study in the September 8 issue of the New England Journal of Medicine. "It means it might also exist in other countries in South America or even in Africa," says Weitzel. "Worldwide, we have to rewrite all the chapters of this disease and think wider."

India: Acute encephalitis syndrome in Gorakhpur identified as scrub typhus

Via ProMED-mail: Acute encephalitis syndrome - India (02): (Uttar Pradesh). Excerpt:

Source: a correspondent who has requested anonymity [edited] 

The Gorakhpur encephalitis (AES) [acute encephalitis syndrome] mystery has been [resolved]. It is scrub typhus, a mite-borne bacterial disease, caused by Orientia tsutsugamushi. 

An ICMR [Indian Council of Medical Research] sponsored investigation during August-September 2014 identified the etiology. Out of 249 acute encephalitis syndrome (AES) cases investigated, 152 (61 percent) of the cases were attributable to scrub typhus either by IgM ELISA, IFA or PCR. A pathognomonic eschar was evident in 20 per cent of the AES cases we investigated. 

Scrub typhus is generally an acute febrile illness involving multiple organs. Encephalitis is a late manifestation with high mortality. Scrub typhus is a treatable bacterial disease with excellent clinical response from doxycycline and azithromycin treatment. If left untreated for over a week, scrub typhus may lead to encephalitis, myocarditis, or multi-organ failure. Early administration of doxycycline during the 1st week of the febrile phase can prevent clinical complications in scrub typhus. In severe cases of scrub typhus, early and appropriate administration of intravenous azithromycin or doxycycline may save lives. 

Seasonality of scrub typhus in Gorakhpur coincides with monsoon (July-September). Scrub vegetation during this season enhances transmission. 

Early case identification and appropriate doxycycline therapy at community levels during monsoon will reduce the incidence of encephalitis. 

-- 

Communicated by: ProMED-mail <[email protected]> 

[This report adds another dimension to the etiologies of acute encephalitis syndrome (AES) in northeastern India. A 22 Sep 2015 report indicated that there were 10 834 AES cases in 2014. That report describes AES as, "a group of clinical neurologic manifestations caused by a wide range of viruses, bacteria, fungi, parasites, spirochetes, chemicals and toxins" (http://zeenews.india.com/news/health/health-news/india-had-over-10000-acute-encephalitis-syndrome-cases-in-2014_1800724.html). 

Previous ProMED-mail posts have implicated Reye syndrome, consumption of lychees, and heat stroke, as well as Japanese encephalitis virus infections, as responsible for AES. Now, scrub typhus is added to the list. Although "gold standard" diagnostic tests for scrub typhus were employed in the above study, there is no mention that these other etiologies were ruled out. One should note that 61 percent of the samples tested were scrub typhus positive, leaving 39 percent of the AES cases without a diagnosis. 

The contributor of this report is thanked, and one hopes that this study will lead to testing for scrub typhus as other AES cases occur

India: Japanese encephalitis claims 52 lives in Assam

Thanks to Marvin Speciner for alerting me this story. Via NDTV, a PTI report: Japanese Encephalitis Claims 52 Lives in Assam. Excerpt:

GUWAHATI:  Altogether 52 people have died and 318 others have been affected by Japanese Encephalitis this year in Assam with the disease assuming alarming trend during recent months in the state. 

Among the worst affected districts are Dibrugarh, Tinsukia, Sibsagar, Golaghat, Dhemaji and Kamrup (Rural) with 52 deaths and 318 others testing positive since January this year, a senior Health department official said today. 

The highest number of eight deaths has been reported from Sibsagar followed by six each in Dibrugarh and Jorhat districts and five in Nalbari since last month. 

He said in some districts, cases of acute encephalitis have also been included leading to inflated data but these were not cases of Japanese Encephalitis. 

Tinsukia has the highest of 29 positive cases followed by Dibrugarh with 28, Golaghat with 24, Dhemaji with with 22, Kamrup (Rural) with 21, Barpeta with 17 and Darrang and Cachar with 15 each, he said. 

The state Health department has taken measures to check the disease. The steps include reserving five to six beds in each district hospital and five beds in the medical colleges for the affected patients. 

All districts have been directed to ensure proper investigations and treatment with diagnostic kits provided to the hospitals, the official said. 

Adequate medicines are available, while awareness meetings are being held in all the districts and medicated mosquito nets are being provided in the rural areas. Regular fogging is being carried out under the prescribed guidelines.

Meanwhile, FluTrackers has a remarkable thread on the current encephalitis outbreak, including the likelihood that "acute encephalitis syndrome" results from scrub typhus.