Insecticide treated nets, antimalarials and child survival in India.

Malaria has been a complex public health problem affecting mainly the poor and the rural communities in India. Insecticide treated nets (ITN) and antimalarials are the two proven interventions for prevention and control of malaria. ITN has been amply demonstrated to be an effective intervention to protect children from malaria, and in preventing deaths due to falciparum malaria. Antimalarials are a therapeutic intervention for management of malaria, and prevention of complications due to Plasmodium falciparum infection. However, implementation of these interventions is fraught with problems of complex and multidimensional nature at the periphery. These can be addressed by optimizing the use of the 2 interventions, the insecticide treated nets and antimalarials, for area specific application and country specific needs, determined by the eco-epidemiological diversity of malaria in India. This article reviews the significant role of ITN in reducing child mortality, and the judicious use of antimalarials in the management of malaria patient, and the problems associated with the use of these interventions in protecting children against malaria in India.

Lymphatic Filariasis in East District, Sikkim.

East district of Sikkim has been considered as non-endemic for lymphatic filariasis (LF). However, a LF survey conducted during 2008 revealed microfilaria rate (mf rate) of 1.2%. The LF survey was carried out in 15 randomly selected villages and urban localities of East Sikkim. Out of 3,428 night blood smears collected and examined, 42 were found positive for Wuchereria bancrofti. Microfilaria (mf) carriers were detected from 5 surveyed villages and 5 urban localities of Singtam and Rangpoo with mf rate ranging from 0.5% to 4.2%. The mean mf density was 5.4 per 20cmm3 blood. All mf carriers were residents of east district, Sikkim except two persons who were from Bihar. The detection of microfilaria in young children who had never moved from the area indicates probable indigenous transmission. Out of 15 surveyed areas LF disease was found in 11 areas with prevalence ranging from 0.4% to 7.0%.(Disease rate was 1.6%) (1.7% for Males & 1.4% for females). One local individual was found with lymphoedema and also mf positive. Vector density ranged from 70 to 435 per ten-man-hours, sufficient for transmission of LF. 712 female Cx. quinquefasciatus were dissected to detect the filarial infection and none was found positive. The present survey findings indicate endemicity of filariasis in East district of Sikkim.

Study on The Eco-epidemiology of Chikungunya in U T of Lakshadweep.

An unusual increase in the incidence of viral fever was noticed in Androth and Kalpeni Island, U.T of Lakshadweep during November 2006. The Ecoepidemiology of the disease was studied in detail. The study indicated that Aedes albopictus is the predominant species (98.74%) and it exhibited a wide spectrum of breeding preferences with a clear-cut predilection for rat-damaged coconuts (RDCs). All the entomological indices were very high in both the Islands with a marked increase in Kalpeni Island. The clinical presentation of the cases was typical of chikungunya and the laboratory study confirmed this. Based on the investigation, control and preventive measures were planned, advised and implemented. The details regarding the bio-ecology of vectors, clinical presentation, laboratory investigations and effectiveness of control measures are discussed.

Red baby syndrome a new disease due to parvovirus B-19 observed in Kerala.

Red Baby Syndrome is a new disease seen in infants and young children. Dramatic onset of clinical symptoms with high intensity, short duration and lack of similarity with other cutaneous lesions makes it distinct. Of 50 such patients studied over a period of 5 years, half were below one year of age. Abrupt onset of high fever and generalized erythema involving the entire skin, which is swollen and tender is characteristic. These children were highly irritable and had paradoxical cry when cuddled. Rapid resolution of symptoms occurred in 7-10 days with extensive desquamation. Routine investigations were normal, C-reactive protein was raised only in 10 patients. Human Parvo virus B-19 IgM antibodies were positive in 15 out of 24 patients. Real time polymerase chain reaction was positive for human parvovirus B 19 DNA in one. Histopathological changes in the skin biopsy showed post infectious vascular injury pattern.

Status of Lymphatic Filariasis in Lucknow District, Uttar Pradesh.

Lucknow district was endemic for lymphatic filariasis (LF). During March 2008, LF survey was carried out in 14 randomly selected villages (six Primary Health Centres) and 4 Mohallas of Lucknow city. Out of 3,654 night blood smears (NBS) collected and examined, 209 were found positive for Wuchereria bancrofti (micrifilaria rate: 5.7%). Microfilaria (mf) carriers were detected from all surveyed villages and Mohallas. The age of these positive persons ranged from 6-70 years. In all areas, prevalence of microfilaraemia generally increased with age up to 21- 30 years. Males (6.7%) were more affected than females (3.9%). All mf carriers were residents of Lucknow district. Overall disease rate was 4.7%. In all, 175 individuals had disease manifestations of LF. Out of 108 males, 81 had hydrocele(75%). Disease rate was similar in males (4.7%) and females (4.8%). The mean mf density was 9.5 per 20 cmm blood, but no significant difference between males (9.4) and females (9.9). Vector density ranged from 150 to 810 per ten-man-hours. Infectivity and infection rates were 0.14%. The present survey indicates that filariasis is one of the major public health problems in surveyed areas.

Investigation of an outbreak of chikungunya in Malegaon Municipal areas of Nasik district, Maharashtra (India) and its control.

BACKGROUND & OBJECTIVES: An outbreak of chikungunya fever occurred in Malegaon town of Nasik district of Maharashtra state, India during February and March 2006. A total of 4530 fever cases were reported during this period including 1781 cases which were admitted in different hospitals of the town. An entomological and epidemiological investigation was carried out in the affected villages during the outbreak to study the possible causes of the outbreak and to isolate the virus responsible. METHODS: Entomological evaluation was done as per WHO guidelines. Sera samples were collected by venipuncture from clinically suspected chikungunya patients in hospitals and also during house-to-house survey in affected villages. IgM antibodies to dengue virus were detected using IgM capture ELISA (PANBIO) and by "Haemagglutination inhibition test" for detection of antibodies against Chikungunya virus. Acute sera samples were inoculated in cell lines for virus isolation. The isolates were confirmed by RT-PCR. RESULTS: On investigation, it was found that water storage containers like cement tanks, plastic containers or earthen pots placed in front of the individual houses were the potential breeding sites for Aedes aegypti. Entomological survey carried out in the most affected areas revealed high Aedes indices. House, container and breteau indices were found to be 27.2, 16.19 and 35.1, respectively. Out of the 13 acute sera samples collected, virus was isolated in 10 samples. The isolates were confirmed by RT-PCR and sequencing using primers from nsP1 gene of Chikungunya virus (CHIKV, Accession No. EF077609, EF077610). Of the 17 convalescent sera tested, significant level of HI antibodies to CHIKV was detected in five samples. One sample was positive for IgM antibodies against dengue virus. Based on clinico-epidemiological features and laboratory findings, the illness was confirmed to be of chikungunya viral disease. CONCLUSION: Control measures targeting the vector population and personal protective measures against the mosquito bites were instituted. Extensive IEC campaign with the involvement of community and religious leaders helped in containment of the disease.

Studies on leptospirosis outbreaks in Peddamandem Mandal of Chittoor district, Andhra Pradesh.

An outbreak of leptospirosis in Peddamandem Mandal, Chittoor district, Andhra Pradesh occurred during Aug to Oct 2005. Out of 86 single human sera samples of suspected cases collected during the investigation, 49 (56.97%) samples from seven villages were found positive for leptospirosis both by DGM tests and IgM antibodies. Out of total 49 positive cases 16 (47.05%) were male and 33 (69.46%) female patients. The mean age of the positive cases were 42.7 years. There was no significant differences in male and female ratio and age groups in affected population. The higher degree of seropositivity was observed in adult females as they were mainly engaged in both domestic and peridomestic works. Geographical clustering of cases was evident. All the 49 positive cases had fever (100%). Myalgia (42.9%), stiffness of calf muscles (55.1%) and headache (32.6%) were the other major clinical features observed. There was only 1 (2.04%) case with conjunctival suffusion. None of the case presented with jaundice. All the suspected cases were tested negative for malaria, typhoid and dengue fever. In Peddamandem, contaminated water stagnation due to heavy rainfall and frequent contact of barefooted villagers with the infected sources registered higher incidence of leptospirosis. Most of the cases were from the contaminated water logged areas of the affected villages. In the affected villages none of the individual occupational category showed a significant association with seropositivity. It indicated that the transmission was from the common single category source in the villages i.e. contaminated stagnant water. The villagers living with livestocks and rodents were significantly associated with seropositivity.

Bellary, India achieves negligible case fatality due to Japanese encephalitis despite no vaccination: an outbreak investigation in 2004.

OBJECTIVE: To confirm the existence of the outbreak of suspected Japanese encephalitis, identify the source, to understand the circumstances due to which the outbreak was taking place and to suggest measures for its control. METHODS: The team visited Bellary from 4th to 10th Sept, 2004. The team interviewed the key persons and analyzed the records at District Surveillance Unit and Entomological Surveillance Unit and case records of suspected JE cases admitted in Encephalitis ward in Vijay Nagar Institute of Medical Sciences (VIMS). Eco-entomological survey was done in houses and surroundings of 3 randomly selected cases of Encephalitis in rural and urban areas of District Bellary. Their family members and neighbors were also asked for the awareness and presence of disease. Data was analyzed for epidemiological and clinical profiles. RESULTS: The suspected JE cases were being reported from end of June 2004. The cases were sporadic and out of 34 cases reported to VIMS (till 10th of September), 32 were from Bellary district and 2 were from adjoining Andhra Pradesh. Among these 32, 22 were from Bellary Taluk, which in turn were mainly concentrated (10 were reported) in urban Bellary. The case fatality rate was zero as no death was reported. Entomological surveillance (done by District Surveillance Unit) revealed a high outdoor presence of Culex tritaeniorhynchus as well as an indoor rising density of this mosquito from 2 per man hour catch in January to 22 in the month of August in the affected villages. On the contrary, the investigations on 7th and 8th September revealed high densities of An.subpictus and An. peditaenatus and nil of Culex species in the urban areas. Amplifier host of pigs and water birds were occasionally sighted in the area. CONCLUSION: A good community awareness of encephalitis, a prompt referral system and a good supportive treatment for the patients and a good surveillance system and response were observed. Very close proximity with amplifying hosts of pigs was avoided by the community, though piggeries were still not very far away (1-3 Km). These may explain the reduction in cases, deaths and disabilities due to this disease in this district over the years. Possibilities of mutant strain which is less virulent and/or a better immune status of at risk population may also need to be explored. The impact of the mass vaccination with SA 14-14-2, imported from China in Bellary during July, 2006 remains to be evaluated. This will further decrease the case load.

Evaluation of Og4C3 antigen ELISA as a tool for detection of bancroftian filariasis under lymphatic filariasis elimination programme.

Diagnosis of Lymphatic Filariasis by microscopic examination of thick blood films (TBF) collected between 8.30 pm to 12 midnight, though highly specific is operationally problematic. We evaluated the TropBio Og4C3 serum ELISA as a tool for detection of W. bancrofti microfilaria carriers using Dried Blood Spots (DBS). The study was carried out in two parts (i) to test the sensitivity and specificity of the ELISA test for detection of circulating filarial antigen (CFA) in microfilaria (Mf) carriers vis-à-vis the conventional thick blood film (TBF) microscopy and its persistence in different categories of individuals during the course of disease viz., Endemic normals (n=51), microfilaria (Mf) carriers (n=27), acute cases (n=27), chronic cases (n=50) and a control group of non-endemic normals (n=48) using sera samples and ii) to study the utility of finger prick Dried Blood Spots (DBS) collected on filter paper for detection of Mf carriers and its comparison with another antigen detection assay, the Immunochromatographic test (ICT).Considering the non-endemic normals and microfilaria carriers, the ELISA test was found to have 100% sensitivity and 94.12% specificity for detection of Mf carriers in sera samples. The CFA was absent in majority of the subjects tested under other categories with a positivity of 7.8% among endemic normals, 11.12% among acute cases, 7.84% among chronic cases and 6.25% among nonendemic normals. Comparison of finger prick DBS and sera samples by ELISA vis-à-vis the ICT, carried out on Mf carriers (n=91) and endemic normals (n=97), showed a positivity of 88 (96.7%) in DBS as against 86 (94.5%) in sera samples and 88 (96.7%) by ICT, amongst Mf carriers, with a statistically significant correlation in antigen units between sera and DBS samples (r = 0.959, p = 0.000) amongst the microfilaria carriers. Out of 97 endemic normals, 19 (19.6%) sera and 17 (17.5%) DBS samples tested positive by ELISA while as 12(12.4%) tested positive by ICT, again with a statistically significant correlation between the antigen units in sera and DBS samples (r = 0.942, p = 0.000). DBS prepared from 25 microl of blood were found to be as sensitive as 50 microl for antigen detection. Antigen positivity detected from DBS collected during day and night from known microfilaria carriers (n=27) showed a statistically insignificant difference (p = 0.125) and a significant correlation in antigen units (r = 0.820 and p = 0.013).In view of the comparable results of ELISA, ICT and TBF microscopy, it is concluded that the TropBio Og4C3 ELISA using finger prick DBS can be used as an alternate to TBF microscopy for detection of bancroftian Filariasis under the LFE programme.

Chikungunya viral disease in district Bhilwara (Rajasthan) India.

An investigation of chikungunya outbreak cases was carried out in Bhilwara District, Rajasthan during Aug-Sep 2006. Fever with multiple joint pains was the first presenting feature. Aedes larval surveys indicate high Breteau index (78.6 to 200), House index (48.0 to 83.3) & Container index (41.1 to 73.6) above the critical index. Out of 40 sera samples tested, 12 showed HI antibodies for chikungunya virus in high titres and another five were positive for IgM antibodies against chikungunya. The clinico-epidemiological, laboratory and entomological investigations confirm that this episode of fever was due to chikungunya fever. Strengthening and intensification of surveillance along with educating the community were recommended for control of outbreak.

Study on the factors affecting the MDA programme in Kerala state.

The Mass Annual Single dose DEC administration (MDA) was initiated in India from 1997. In Kerala MDA was studied as a pilot project in Alappuzha and Kozhikode District from 2000-04 and the first round of MDA was launched in Kerala covering eleven endemic districts, in March 2005. On evaluation, the drug distribution coverage, compliance, etc. were found to be not satisfactory and a need to elicit the factors for poor performance of MDA is felt essential. The main reasons for poor performance of MDA in Kerala state were the lack of adequate prior information to the target population regarding the importance LF elimination programme and inadequate awareness. The fear of side reactions, antipropagonda, poor IEC activities repeated postponement of programme, insufficient time for mobilisation etc. were the other reasons for poor compliance. The purpose of the present study was to bring the observations to the notice of the authorities so that appropriate remedial measures are incorporated.

Mass drug administration against lymphatic filariasis: experiences from Kozhikode district of Kerala State.

The mass DEC drug administration to eliminate lymphatic filariasis in Kozhikode district was monitored from 2001 to 2003 to assess the drug distribution coverage, compliance, reasons for non-compliance, side reactions, mf prevalence and intensity, infection and infectivity rates in the vector. The drug distribution coverage and compliance were much below the required level. "No disease so not necessary" (42.5%) and "fear of side reactions" (25.2%) were the two major reasons for non-compliance. The adverse reactions were minimal. No appreciable changes were found in the mf prevalence and intensity. For the successful implementation of the MDA programme, proper planning, intense and timely efforts to motivate the community and innovative drug delivery strategies are required.

Prompt laboratory diagnosis in timely containment of a plague outbreak in India.

A focal outbreak of pneumonic plague occurred in a hamlet of village Hatkoti, district Shimla, Himachal Pradesh in the first fortnight of February, 2002. A total of 16 cases with 4 deaths were reported. Diagnosis of plague was confirmed by the laboratory in 10 (63%) cases. Y. pestis was isolated from clinical samples of 3 cases and confirmed by bacteriophage lysis. Molecular tests confirmed the presence of Y. pestis specific pla and F1 genes in 4 cases; DNA fingerprinting had identity with the known sequence of plague bacilli. Paired samples from 5 cases showed more than 4 fold rise and 1 case showed more than 4 fold fall in antibodies against F1 antigen of Y. pestis. The present communication emphasises that timely and systematic laboratory investigations give confirmatory diagnosis in shortest possible time which forms the backbone of the outbreak control in a timely fashion and prevents confusion and controversy.

Knowledge, attitude and practices about animal bites and rabies in general community--a multi-centric study.

Rabies a disease as old as our civilization, continues to be the most feared of all communicable diseases. Despite the availability the state-of-the-art tools which ensure near cent percent protection against rabies, India is the largest contributant to rabies mortality in the world. A multicentric study was carried out from April 2001 to September 2002 with the objective of assessing the knowledge, attitudes, beliefs and practices (KAP) about animal bites and rabies in the general community. The proforma for interviewing the general community was developed and used after field testing. The study was carried out at six selected centres across the country viz. Delhi, Hyderabad, Raipur, Jamnagar, Coonoor and Rajahmundry and was co-ordinated by National Institute of Communicable Diseases (NICD), Delhi, after thorough briefing of designated nodal officers. A total of 1129 (male: female :: 48.5: 51.5) persons in the age group of 18 to 80 years were interviewed in this study. Of these about 751% of the individuals had attended school at some level and rest were illiterates. 68.7% people had heard about rabies. In 60.7% of cases the community associates rabies with dog bite only. Knowledge about appropriate wound toilet was found to be inadequate. Only 360 (31.9%0/) people felt that washing the wound with soap and water was the best option. Application of indigenous products like chillies (11.4%), turmeric (5.6%), lime (6.8%), kerosene oil (2.3%), herbal paste (4.2%) etc was suggested along with visit to occult medicine practitioner (1.5%) as part of the bite wound management. People were not aware of number of injections needed for treatment of animal bites. Multiple reasons viz negligence and ignorance 354 (31.4%), fear of multiple painful injections 365 (32.3%), expensive treatment 169 (15%) and long course requiring daily visits to anti-rabies clinics 73 (6.5%) were cited as reasons for non-compliance of treatment. KAP study suggests that there is need to create awareness amongst the masses regarding epidemiology of the disease and merits of prompt and appropriate post exposure treatment through enhanced IEC activities.

Detection of M. tuberculosis in clinical samples of diversified nature by IS6110 based PCR.

Performance of the polymerase chain reaction technique based on IS6110 sequence was evaluated in clinical samples obtained from pulmonary and extrapulmonary cases of tuberculosis. One hundred and seventy two samples were processed for detection of M. tuberculosis by ZN stained smear examination, LJ medium culture, BACTEC radiometric culture and PCR tests amplifying 123bp region of IS6110 sequence. A significant difference was seen in the sensitivities of different tests, the figures being 83% for PCR test, 35.2% for smear examination, 47.16% for LJ culture and 53.45% for BACTEC culture (p < 0.05). However, no significant difference was found as far as specificity was concerned. PCR test sensitivity in. pulmonary and extrapulmonary clinical samples were 90.14% and 77.27% respectively and found to be significantly higher (p < 0.05) when compared with those of other tests. The mean detection time for M. tuberculosis was 24.03 days by LJ medium culture, 12.89 days by BACTEC culture and less than one day by PCR test. PCR based on IS6100 sequence is highly sensitive method for the early diagnosis of pulmonary and extrapulmonary tuberculosis.

Congenital CMV infection in symptomatic infants in Delhi and surrounding areas.

Many viral infections are associated with significant maternal and fetal consequences during pregnancy among which cytomegalovirus is one of the most important agent, globally. Both primary and recurrent infection due to this virus can result in fetal infection. Samples from Congenital Anoammaled babies are referred to NICD from Delhi based Government hospitals and surrounding areas for diagnosis of congenital infections like Toxoplasm, Rubella, CMV and Herpes. In the present study, accumulated data is presented for the most common teratogenic virus--Cytomegalovirus prevalence as a causative agent for congenital infection in New Born babies at Delhi and surrounding areas. 96 samples from symptomatic babies in the age group of few days to 6 months exhibiting different congenital anomalies, were reported between 1 st Jan 04 to 30 th April/05. All the blood samples were tested for the detection of CMV (IgM) antibodies using m-capture ELISA technique. 18(18.75%) samples from babies showed positive titres for CMV-IgM antibodies. None of the mothers of positive babies were found positive for CMV-IgM antibodies but all were serologically exposed to CMV virus previously as their serum samples were positive for CMV-IgG antibodies indicating primary infection in the past or reactivation/reinfection with a different strain of CMV in the early pregnancy.

Avian influenza outbreak investigation and containment.

Influenza A viruses cause pandemics at recurring yet unpredictable intervals. The past three pandemics had origin from birds. Although the viruses of avian influenza are not easily transmitted to humans, this may change due to either mutation or genetic reassortment. There is still an opportunity to pre-empt the pandemic. It is believed that if the surveillance system for animal health is able to detect infection in poultry quickly followed by rapid and safe culling of infected and exposed poultry and the surviellance system for human health is able to detect first human cases quickly followed by rapid containment measures including strategic use of antiviral drugs, the pandemic could be averted. This article discusses the principles and major steps of avian influenza outbreak investigations and containment.

Overview of avian influenza.

The current outbreak of H5N 1 avian influenza affecting an unprecedented number of countries is a cause of concern worldwide. As on 26th June, 2006 outbreaks in poultry or wild birds have been reported from 54 countries. In India the first outbreak of avian influenza virus Awas reported in Navapur district in Maharashtra in February 2006 followed by detection of H5N1 in a neighbouring district of Gujarat. No case of human infection has yet been reported in India. Avian influenza virus belongs to influenza type A which is a part of family orthomyxoviridae. Transmission occurs by direct or indirect contact. Clinical symptoms on human is of typical influenza like. Laboratory investigations involves a number of tests confirming diagnosis of avian influenza. The treatment includes general supportive and antiviral therapy with oseltamivir. Prevention and control strategies can held to minimise the public health risk to highly pathogenic avian influenza. There are some dos and don'ts for the community which should be strictly followed.