Japanese Encephalitis

Chhattisgarh

1. 17.01.2017 1 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

2. 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. 2 JE Outbreak in Sukma , Chhattisgarh October 2016

3. On 28 th 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. 3

4. 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 . 5

5. Village-wise distribution of cases positive for IgM ELISA for JEV

6. Line-list Of AES/JE Cases Date of Report 03/11/2016 Case ID Name & Address Dist. Name Block Name Sex Age Date of onest fever Seizure (Y/N) Type Of Sample Date to Sample Collection Lab 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

7. 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 .

8. 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.

9. 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

10. Epidemiology 12

11. 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 13 Epidemiology

12. 14 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.

13. JE virus causes at least 50 000 cases of clinical disease each year(children < 10 years) R esults in 10 000 deaths , 15 000 neuro -psychiatric sequelae . O utbreaks of JE have occurred in several previously non-endemic areas. It is a preventable disease and no specific antiviral treatment. 15 Public Health Importance http ://www.who.int/biologicals/areas/vaccines/jap_encephalitis/en/

14. Global Scenario

15. 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. 17 Extent of problem in India

16. 18 Endemic areas in India

17. 19 Epidemiological Triad

18. 20 Agent : ARBOVIRUSES Viruses of vertebrates transmitted by hematophagus insect vectors. Special characteristic: Ability to multiply in arthropods. M ore numerous in tropical than in temperate zones Flavivirus

19. Natural reservoir of infection Amplifier Hosts Accidental Host Dead end Host 21 Hosts

20. Irrigated rice fields Shallow ditches P ools of water Primarily outdoor resting in vegetation Fly range : 1-3 kms 22 Environment

21. 23 Vector Transmission Most common type of Mosquito : Culex vishnui group - Culex tritaeniorhynchus Culex vishnui Culex pseudovishnui Culex

22. 24 Pathogenesis

23. Susceptible population. High density of Culex mosquitoes. Presence of amplifying hosts such as pigs, water birds etc. Paddy cultivation. 25 Factors favouring outbreak

24. 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 26 Clinical Features

25. There is no specific treatment against the JE . M anaged symptomatically. I n the acute phase maintaining fluid and electrolyte balance and control of convulsions, if present . Maintenance of airway is crucial. 27 Treatment

26. 07-08-2014 28

27. 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. 29 Preventive and control measures

28. 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. 30 Challenges in Outbreak Management

29. 31 Sukma -District

30. 1. Surveillance 2. Personal and Specific Protection 3. Vector control 4. Segregation of Reservoir 5. Monitoring and Supervision 07-08-2014 32 Epidemic Management

31. IDSP-Surveillance system collects the information on epidemiologic, clinical & laboratory from the identified sites on a regular basis. Continuous monitoring of all factors influencing transmission and effective control of JE by team of District Surveillance Unit and reporting to concerned authority. Early recognition of impending outbreaks or epidemics. Sentinel surveillance sites are designated to monitor the trend of disease. 33 Continuous Disease Surveillance

32. 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 34 Personal and Specific Protection

33. 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 35 Vector control

34. 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. 36 Segregation of Reservoir

35. 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. 37 Monitoring & Supervision

36. History of JE. Endemic areas. Epidemiological factors. Role of Govt of Chhattisgarh JE vaccine. 38 Lessons learnt