Malaria outbreak along the India-Bhutan border town of Saralpara, Assam, India.

BACKGROUND & OBJECTIVES: A remarkable progress is being made in the South-East Asia region in reducing the burden of malaria. While all countries are committed to malaria elimination, continued transmission at and across international borders poses a threat to achieving this goal. METHODS: We investigated an outbreak of malaria in the India-Bhutan border area in a district of Assam state, India. A line listing of cases occurring during the outbreak period was made and a house-to-house survey was carried out to identify additional cases in the community. Entomological investigation consisted of light trap collection of vectors. Patients and health workers were interviewed to obtain information on the possible mode of transmission and ongoing inter-country collaboration across the border. RESULTS: Between October 21 to November 18 2022, 37 cases of malaria (all Plasmodium vivax), were diagnosed in Saralpara area of Kokrajhar district of Assam, bordering Bhutan. Of these four were diagnosed in Sarpang hospital, Bhutan. Median age was 20 years (range 3 to 70 years). Male to female ratio was 1:1.2. In addition, 6 individuals with asymptomatic malaria were detected in the community through an active case finding campaign. No cases were however reported on Bhutan side of the border. Anopheles culicifacies and An. annularis were identified from light trap collection. Saralpara is a remote and forested area where most of the residents are poor and engaged predominantly in farming activities. Being a harvesting season, they tend to stay overnight to protect their harvest from elephants. The health authorities in India and Bhutan exchanged information regularly at district-to-district level on the outbreak including through available and easy modes such as WhatsApp, telephone as well as electronic mail and collaborated in coherently implementing preventive measures on both sides and in managing the cases. INTERPRETATION & CONCLUSION: The outbreak of malaria in Saralpara demonstrates the risk of malaria outbreak in remote and forested areas, with possibility of spill over to the other side of the border. The fact that two countries had excellent inter-country cross-border collaboration and prior commitment thereby preventing further transmission of malaria to Bhutan can serve as a best practice for cross-border control of malaria and other communicable diseases.

Modelling the impact of a smallpox attack in India and influence of disease control measures.

OBJECTIVES: To estimate the impact of a smallpox attack in Mumbai, India, examine the impact of case isolation and ring vaccination for epidemic containment and test the health system capacity under different scenarios with available interventions. SETTING: The research is based on Mumbai, India population. INTERVENTIONS: We tested 50%, 70%, 90% of case isolation and contacts traced and vaccinated (ring vaccination) in the susceptible, exposed, infected, recovered model and varied the start of intervention between 20, 30 and 40 days after the initial attack. PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated and incorporated in the model the effect of past vaccination protection, age-specific immunosuppression and contact rates and Mumbai population age structure in modelling disease morbidity and transmission. RESULTS: The estimated duration of an outbreak ranged from 127 days to 8 years under different scenarios, and the number of vaccine doses needed for ring vaccination ranged from 16 813 to 8 722 400 in the best-case and worst-case scenarios, respectively. In the worst-case scenario, the available hospital beds in Mumbai would be exceeded. The impact of a smallpox epidemic may be severe in Mumbai, especially compared with high-income settings, but can be reduced with early diagnosis and rapid response, high rates of case finding and isolation and ring vaccination. CONCLUSIONS: This study tells us that if smallpox re-emergence occurs, it may have significant health and economic impact, the extent of which will depend on the availability and delivery of interventions such as a vaccine or antiviral agent, and the capacity of case isolation and treatment. Further research on health systems requirements and capacity across the diverse states and territories of India could improve the preparedness and management strategies in the event of re-emergent smallpox or other serious emerging infections.

Jaundice outbreak likely caused by HEV in Amritsar, Punjab, India, 2013.

BACKGROUND: Hepatitis-E Virus (HEV) infection is endemic in Punjab, India. On 4th April 2013, public officials of Labour Colony, Amritsar reported > 20 jaundice cases occurring within several days. METHODS: We performed a case-control study to identify the cause and prevent additional cases of jaundice cases in Amritsar, Punjab, India in 2013. RESULTS: A total of 159 cases (attack rate 3.6%) and 1 death were identified in Labour and 5 adjoining colonies from January 1 to June 5, 2013. Persons with jaundice were more likely to report foul-smelling piped water (adjusted odds ratio [AOR], 4.0, 95% confidence interval [CI], 2.2-7.2) and used piped water for drinking (AOR, 5.1; 95% CI, 2.2-11.4) than persons without jaundice. Among 14 cases tested, all had anti-hepatitis E virus IgM, and none had anti-hepatitis A virus IgM. Additionally, 21/23 tap water samples from affected households had detectable fecal coliforms. An environmental investigation found that water pipelines were damaged during sewer construction and likely led to contamination of drinking water with hepatitis E virus. CONCLUSIONS: Hepatitis E outbreaks are common in India, to curb future outbreaks of hepatitis E; measures to ensure safe drinking water are urgently needed.

India epidemic intelligence service: Advocating for a unique mentor-based epidemiology training program.

To strengthen epidemiological capacity in the country, the Government of India in 2012 initiated a unique, competency-based training in epidemiology. Modeled along the United States Epidemic Intelligence Service (EIS), this 2-year mentor-driven and practical-oriented program, based on "learning by doing," is being implemented by the National Centre for Disease Control in Delhi, in close collaboration with the US Centers for Disease Control and Prevention, Atlanta. In its 4th year now, many lessons learned so far are being used to expand the program, without compromising on the technical quality. Many including the trainees who have completed the program speak highly of the epidemiological skills imparted in real time and feel that if the India EIS program is "regionalized" and expanded rapidly, it could in due course transform public health in the country.

Risk factors for death during a resurgence of influenza-A (H1N1) pdm09 in Punjab State in 2013.

BACKGROUND: In 2013, high mortality from influenza-A (H1N1) pdm09 (pH1N1) was observed in Punjab, India. OBJECTIVES: To describe cases and deaths of 2013 pH1N1 positives, to evaluate the high case fatality ratio and risk factors for pH1N1-associated mortality among the hospitalized cases in Punjab for 2013. METHODS: A case-control study was conducted and compared those who died from confirmed pH1N1 with those who survived in the hospital between January 1, 2013, and April 30, 2013. Sociodemographic and clinical details were extracted from hospital records and from telephone interviews with controls and next of kin of cases using pretested questionnaires. Logistic regression analysis was performed. RESULTS: A total of 182 laboratory-confirmed pH1N1 cases (99 males and 83 females) were hospitalized in 30 hospitals in Punjab; 42 (23%) patients died. Those who died were significantly more likely to be younger than 50 years of age (adjusted odds ratio [AOR] =10.6, 95% confidence interval [CI] =1.8-21.1), be obese (AOR = 16.7, 95% CI = 1.6-170.7), and have visited more than two health-care facilities before laboratory confirmation (AOR = 25.8, 95% CI = 5.4-121.6). CONCLUSIONS: The health-care community should have a high index of suspicion for influenza, and general community should be sensitized about risk factors and to seek medical advice early in the illness.

Eradicating successfully yaws from India: The strategy & global lessons.

Yaws, a non-venereal treponematosis, affecting primarily the tribal populations, has been considered historically as one of the most neglected tropical diseases in the world. In 1996, India piloted an initiative to eradicate yaws based on a strategy consisting of active case finding through house-to-house search and treatment of cases and their contacts with long acting penicillin. Thereafter, the campaign implemented in all 51 endemic districts in 10 states of the country led to the achievement of a yaws-free status in 2004. In the post-elimination phase, surveillance activities accompanied by serological surveys were continued in the erstwhile endemic districts. These surveys carried out among children between the age of 1-5 yr, further confirmed the absence of community transmission in the country. The experience of India demonstrates that yaws can be eradicated in all endemic countries of Africa and Asia, provided that political commitment can be mobilized and community level activities sustained until the goal is achieved.

Viral Hepatitis Surveillance--India, 2011-2013.

The burden of viral hepatitis in India is not well characterized. In 2009, the national Integrated Disease Surveillance Programme (IDSP) began conducting surveillance across all Indian states for epidemic-prone diseases, including foodborne and waterborne forms of viral hepatitis (e.g., hepatitis A and E). Information on outbreaks of all forms of viral hepatitis, including A, B, C, and E, also is collected. This report summarizes viral hepatitis surveillance and outbreak data reported to IDSP during 2011-2013. During this period, 804,782 hepatitis cases and 291 outbreaks were reported; the virus type was unspecified in 92% of cases. Among 599,605 cases tested for hepatitis A, 44,663 (7.4%) were positive, and among 187,040 tested for hepatitis E, 19,508 (10.4%) were positive. At least one hepatitis outbreak report was received from 23 (66%) of 35 Indian states. Two-thirds of outbreaks were reported from rural areas. Among 163 (56%) outbreaks with known etiology, 78 (48%) were caused by hepatitis E, 54 (33%) by hepatitis A, 19 (12%) by both hepatitis A and E, and 12 (7%) by hepatitis B or hepatitis C. Contaminated drinking water was the source of most outbreaks. Improvements in water quality and sanitation as well as inclusion of hepatitis A vaccine in childhood immunization programs should be considered to reduce the public health burden of hepatitis in India. Efforts to decrease the proportion of cases for which the etiology is unspecified, including expanding the IDSP to support hepatitis B and C testing, might help further elucidate the epidemiology of these diseases.