Japanese encephalitis

detailed presentation on J.E.

1. JAPANESE ENCEPHALITIS Dr.T.Nikkin II year postgraduate Dept of Community Medicine SRMC&RI(SRU) 1

2. INTRODUCTION Japanese Encephalitis is a vector borne viral disease that occurs in South Asia, South East Asia, East Asia and the Pacific This disease affects both man and animals Caused by a Flavivirus (JEV) It is transmitted by the vector, mosquitoes belonging to the Culex species Globally, 30,000 to 50,000 new cases of Japanese Encephalitis are reported every year More than 3 billion people are at risk of developing the disease

3. HISTORY Genetic studies, suggest that JEV originated from an ancestral virus in the area of malay of Archipelago Clinical recognition dates back to 19 th century 1 st clinical case in 1871, at Japan Subsequent epidemics in Japan during 1924, 1927, 1934 and 1935 JEV was isolated from an infected brain tissue in 1924 Culex was found out as the vector in 1938 The disease then spread to Korea, China, Pakistan, India, Northern Australia and several other countries

4. GLOBAL SCENARIO

5. GLOBAL SCENARIO Nearly, half of the world’s population live in JEV endemic countries At present, most of the cases of Japanese Encephalitis are from China, India and South East Asian peninsula Country wise data are not available due to lack of proper certified diagnostic centres and underreporting in most countries As per WHO bulletin on Japanese Encephalitis, 58,000 cases were reported in 2011 Around 15,000 deaths occurred due to Japanese Encephalitis in 2011

6. INDIAN SCENARIO 1 st recognised in 1955, when cases from North Arcot District of Tamilnadu and Andhra Pradesh were admitted in CMC Vellore JE virus was isolated from wild culex mosquitoes in the same year Epidemics continue to occur in these states Since 1972, epidemic outbreaks have been reported from West Bengal, Uttar Pradesh, Assam, Bihar, Manipur, Pondicherry, Karnataka, Goa and recently from Kerala and Maharashtra As per 2014 data, 1657 cases of JE were reported in India with maximum number of cases from Assam(761 cases) 293 deaths reported(Assam – 160 deaths) Tamilnadu 36 cases and 3 deaths

7. INDIAN SCENARIO

8. JE VIRUS Japanese encephalitis Virus classification Group: Group IV ( (+)ssRNA ) Family: Flaviviridae Genus: Flavivirus Species: Japanese encephalitis virus

9. JE VIRUS Enveloped virus Closely related to West Nile fever virus and St.Luis Encephalitis virus Envelope helps in entry of the virus into the cell Based on the envelope gene 5 genotypes have been discovered(I-V) Muar strain, identified from a patient in Malaya in 1951 is the prototype strain of genotype V Indian strains are similar to the Muar strain and belongs to genotype V

10. NATURAL CYCLE OF DISEASE JE is a zoonosis Natural hosts of JE virus includes water birds of Ardeidae family(mainly pond herons and cattle egrets) Pigs play an important role in natural cycle and acts as Amplifier Host Pigs allow manifold virus multiplication without suffering from disease and maintain prolonged viraemia Man is a dead-end in transmission cycle because of very low viraemia and infection cannot be transmitted from man to mosquitoes

11. NATURAL CYCLE OF DISEASE

12. VECTOR Culex tritaeniorhynchus , a rice field breeding mosquito is the major vector for JE in most of the countries Other vectors include C.annulirostris in Australia, C.gelidus & C.fusocephala in India, Malaysia and Thailand, and C.vishnui in India Other mosquitoes such aedes and anopheles are also considered vectors for JE but the condition is very rare Mosquitoes are responsible for pig-mosquito-pig cycle as well as birds-mosquito-birds cycle

13. VECTOR Culex mosquitoes breeds in paddy fields, stagnant water and ditches They rest outdoors and are predominantly zoophilic in nature <2% of the mosquitoes feed on human beings and hence high density of mosquitoes is needed for human transmission to occur Most of the outbreaks occur in rural and periurban settings where paddy cultivation is done Mosquitoes once infected remains infected for lifetime

14. MODE OF TRANSMISSION Humans get infected by the bite of the infected Culex mosquitoes Man to man transmission does not occur The infection does not spread from human beings to the mosquitoes No reports of accidental laboratory infection, congenital infection or transmission from infected organ donors

15. CLINICAL FEATURES Incubation period ranges between 5 and 15 days Most of the infections occurs in childhood Adult infections are less frequent Mostly the disease is asymptomatic or mildly symptomatic About 1 in 250 infections shows symptoms of encephalitis 30% of persons who shows symptoms die from the disease 40 to 50% of persons who survive suffer from permanent neurological defects such as paralysis, recurrent seizures or inability to speak

16. CLINICAL FEATURES In symptomatic patients the disease manifests in three phases: Acute prodromal phase : before CNS entry by the virus - fever, G.I. disturbances, headache, malaise, etc 2) Encephalitic phase : After CNS entry by the virus - rapid onset of high fever, neck stiffness, seizures, spastic paralysis and death 3) Recovery phase : complete or partial recovery with neurological deficits, cranial nerve palsies occurs

17. DIAGNOSIS 1) Clinical : should be done carefully ruling out the other similar encephalitic conditions 2) Laboratory : Several laboratory tests are available for diagnosis Antibody detection: HI,CF,ELISA for Ig G and Ig M antibodies,etc Antigen detection: IFA, RTPCR for genome detection, Tissue culture and mouse brain inoculation Ig M ELISA is the method of choice, provided samples are collected 3 to 5 days after the infection.

18. CASE DEFINITIONS FOR JE REPORTING Clinical suspect : Febrile illness of variable severity associated with neurological symptoms ranging from headache to meningitis or encephalitis. Symptoms can include headache, fever, meningeal signs, stupor, disorientation, coma, tremors, paralysis (generalized), hypertonia , loss of coordination . Probable case: A suspected case with presumptive laboratory results: Detection of an acute phase anti-viral antibody response through IgM in serum/ elevated and stable JE antibody titres in serum through ELISA/HI/ Neutralising assay. 

19. CASE DEFINITIONS FOR JE REPORTING Confirmed case: A suspect case with confirmed laboratory result : JE IgM in CSF or 4 fold or greater rise in paired sera (acute & Convalescent) through IgM/IgG ELISA, HI, Neutralisation test or detection of virus, antigen or genome in tissue, blood or other body fluid by immuno-chemistry , immunoflourescence or PCR.

20. TREATMENT No specific antiviral medicine available for JE Clinical management is supportive Fluid and electrolyte balance is a must during the acute phase of the disease Seizure management is necessary Airway management is crucial

21. CONTROL MEASURES Control measures involves 2 strategies: 1) Control of the reservoir 2) Control of the vector Control of reservoir: - birds and various vertebrate animals acts as reservoirs - practically impossible to take care of reservoirs - pigs acts as amplifying hosts\ - pig rearing should be discouraged in areas where rice cultivation is widespread

22. CONTROL MEASURES 2) Control of vector: - insecticide spraying is out of option as vector mosquitoes breeds in paddy fields - eco management of paddy fields can be done (alternate wetting and drying instead of irrigation systems) - ultra low volume insecticide spraying by fogging has been found helpful to some extent - sterile male technique is a novel approach

23. PREVENTION 4 types of vaccines are available for use against JE 1) Mouse brain derived killed vaccine 2) Cell culture based killed vaccine 3) Live attenuated vaccine 4) Live chimeric vaccine

24. MOUSE BRAIN DERIVED KILLED VACCINE Nakayama or Beijing strains are used Widely used vaccine in the past Primary dose followed by 2 boosters Expensive and ideal for travelers Has severe adverse effects Banned from 2007 in India and in many other countries

25. LIVE ATTENUATED VACCINE Also called as SA 14-14-2 vaccine Presently used in India Two doses of 0.5 ml subcutaneously Safer upto 15 years of age Not recommended for adults Highly effective for use during mass campaigns

26. JENVAC V ero cell derived purified inactivated vaccine Indigenous vaccine, made using strains obtained from kolar,Karnataka 2 doses intramuscularly 28 days apart for routine immunization and single dose of 0.5 ml during epidemics 98% seroconversion after 2 doses Launched officially in October, 2013 Available in markets but not yet introduced into routine immunization schedule

27. NVBDCP & NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF JE /AES 1 st case of JE in India was reported on 1955, from vellore 1 st major epidemic outbreak was reported from Burdwan district of West Bengal, in 1973 Since then, many outbreaks have been reported from 171 districts in 19 states of India A major epidemic was reported in 2005, from eastern UP with 6000 cases and more than 1000 deaths This led to introduction of vaccine in high endemic areas of the country by NVBDCP, in the year 2006

28. NVBDCP & NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF JE /AES NVBDCP also developed guidelines for surveillance and case management of JE during the same year, 2006 Guidelines were updated again in 2009 In November, 2011, GOI developed a new programme for control and prevention of JE/AES This programme works under the NVBDCP Ministry of Health & Family Welfare(MOHFW) monitors the works of the programme

29. GOALS AND OBJECTIVES Goal is to reduce morbidity, mortality and disability due to JE/AES Objectives: 1) strengthen & expand JE vaccination 2) strengthen surveillance, vector control, case management and timely referral of serious & complicated cases 3) estimate disability burden & to provide rehabilitation services 4) improve nutritional status of children at risk for JE/AES 5) carrying out intensified IEC/BCC activities regarding JE/AES

30. ACTIVITIES JE vaccination has been introduced into the routine immunization schedule in 132 endemic districts More areas are added based on epidemiological surveillance 50 sentinel sites and 13 apex centres has been established for JE reporting and research Regular trainings are conducted for paediatricians , District medical officers and others regarding JE management & surveillance Entomology centres has been established throughout the country for research on vector mosquitoes

31. VACCINATION Mass JE vaccination campaigns are first conducted in endemic districts where, all children in the age group of 1 to 15 years will be vaccinated Later, JE vaccination is introduced into the routine immunization schedule of that district 2 doses, 0.5 ml, subcutaneously… 1 st dose along with measles vaccine at 9 months of age 2 nd dose along with the booster dose of measles at 18-24 months of age.

32. REFERENCES MANSON’S TROPICAL DISEASES, 23 rd edition MAHAJAN & GUPTA TEXTBOOK OF PREVENTIVE MEDICINE, 24 th edition MAXCY-ROSENAU-LAST PUBLIC HEALTH & PREVENTIVE MEDICINE, 18 th edition http://www.nvbdcp.gov.in/Doc/JE-AES-Prevention-Control(NPPCJA). pdf (Internet) accessed on 21/03/15 http:// www.icmr.nic.in/pinstitute/niv/JAPANESE%20ENCEPHALITIS.pdf (Internet) accessed on 21/03/15.