Lal, Shiv

Narain, Jai P.

English

Advanced Research Publications: Medical Journals

1                                                                                                                                                                     Editorial J. Commun. Dis. 2014; 46(1): 1- 3.                                                                                             ISSN: 0019-5138  Responding to the Challenge of Acute Encephalitis Syndrome/ JE in India Jai P Narain* and Shiv Lal ** Acute encephalitis syndrome (AES) has clearly emerged as one of the most pressing public health emergencies in India; every year in the hot and dry months of summer, from May to July, seasonal outbreaks occur, taking a heavy toll of life especially of children. The most severely affected states include Uttar Pradesh, Assam and Bihar, while the disease is endemic in as many as 171 districts in 19 states in the country.1An estimated 25% of the affected children die, and among those who survive, about 30- 40% suffer from physical & mental impairment. During 2013 alone, 7825 AES cases were reported to the NVBDCP, with 1273 deaths (case fatality ratio of 16 %).2 AES is an epidemic prone disease and during outbreaks the CFR is even higher than that noticed during non- epidemic months. The disease typically has an acute onset with or without high fever and progresses rapidly to a severe illness characterized by seizures. In many cases, it leads unfortunately to death in a matter of hours. Children below the age of ten years are predominantly affected.3 Those who survive have residual disability hindering a productive and high quality of life. In view of the rapid deterioration in clinical conditions and fatal outcomes, seeking of medical care early during illness and provision of care and clinical management in the beginning of illness could play an important role in preventing death and disability. The management of critically ill children is therefore the topmost priority. AES has a complex aetiology, with JE as one of the causative agents. However, from public health standpoint, all diseases during summer months presenting with seizures or convulsions of acute onset are categorized as a part of AES case definition and must be managed as such.4 Laboratory studies are necessary to identify the cause of encephalitis. A number of viruses have been isolated among the patients of the acute encephalitis syndrome including the JE virus.  A systematic review carried out recently reveals that prior to 1999, JE virus was found to be the main cause of AES, but after 2000, Chandipura and Enteroviruses have been identified as the most common agents, in both outbreaks and surveillance studies, 5 it is generally believed that JE virus today contributes to less than 10% of AES cases, while cause of other cases remains unknown. However, during the 2013 outbreak investigated by NCDC in Muzaffarpur, which is the epicentre of AES in Bihar, no etiological agent of infectious nature could be identified.6 Therefore, the inability to isolate an etiological agent presents a critical and fundamental challenge to effective prevention and management of AES. Without adequate knowledge of aetiology and mode of transmission, neither strategies for its prevention and management can be formulated, nor implemented effectively. Urgent efforts and systematic studies are required to ascertain the aetiology and to understand its infectious or non- infectious origin. A number of theories have been put forward based on clinical, laboratory, and ecological findings but these are yet to be confirmed conclusively.  This issue is especially relevant as far as the control and prevention of AES not caused by JE virus is concerned. One such theory relates to the possible link with litchi fruits. Since the outbreaks occur in litchi fruit growing region in India such as Muzaffarpur in Bihar, and Malda in West Bengal, and cases tend to peak during litchi harvesting season, these observations have led to various hypotheses regarding associations between consumption or contact with litchis and the development of this acute illness.6 Besides India, reports from *Senior Advisor (Epidemiology and EIS), National Centr  for Disease Control, 22- Shamnath Marg, Delhi 54. Adjunct Professor, Indian Institute of Health Management Research (IIHMR), Jaipur and New Delhi. Former Director, WHO Regional Office for South- East A ia., New Delhi ** Advisor, VBD, National Vector Borne Disease Control Programme. Former Spl. DGHS & Director, National Centre for Disease Control, Delhi  Correspondence to: Dr. Jai P Narain, Senior Advisor (Epidemiology and EIS), National Centre for Disease Control, 22- Shamnath Marg, Delhi 54. E- mail: narainjp88@gmail.com Editorial                                                                                                                                                                     2  ISSN: 0019-5138                                                                                            J. Commun. Dis. 2014; 46(1): 1- 3.  Vietnam during outbreaks and review of epidemiological data indicate litchi associated encephalitis.7, 8 Nevertheless, these potential associations have not been confirmed nor is the exact mechanism of action clear. Further epidemiological investigations are currently underway to elucidate the aetiology and the exact mode of disease transmission.  JE on the other hand, is caused by a virus, which is transmitted through the bite of infected mosquitoes. The main reservoirs of the JE virus are pigs and water birds (Ardeidae) and, in its natural cycle, virus is maintained through certain mosquito species in these animals. Man is an accidental host and does not play a role in JE transmission. Though both sexes are affected, males usually outnumber females. Inapparent infections outnumber the symptomatic JE cases; the ratio may range in between 250:1 to 1000:1. The disease shows a scattered distribution with not more than 1- 2 cases being reported per village, on an average. JE can be prevented by various public health measures such as control of mosquitoes, protection from mosquito bites by using mosquito nets, protective clothing, and keeping the pigs (the animal reservoir of JE) away from human dwellings are advocated, besides JE immunization. Against this background, it is clear that a strong laboratory based surveillance system is an essential pre- requisite for an effective disease control. AES/ JE surveillance in India is poor and actual disease burden and its determinants are also not fully known, therefore, intensified surveillance for JE is urgently required. NVBDC has recently developed a national “Acute Encephalitis Syndrome (with Special Reference to Japanese Encephalitis) surveillance guidelines” for reporting Acute Encephalitis Syndrome cases (AES)/ suspected JE cases and confirmed JE cases as per standard case definition.9 For surveillance purposes according to WHO's guidelines, JE is also reported under the broad heading of “acute encephalitis”.10  Considering the urgency and the serious nature of the problem, Government of India has set in motion a multi- pronged strategy encompassing preventive, case management and rehabilitation aspects developed through detailed inter- ministerial consultations. This comprehensive approach to AES/ JE prevention and control is being implemented by the Ministry of Health and Family Welfare, Ministry of Drinking Water and Sanitation, Ministry of Housing and Urban Poverty alleviation, Ministry of Social Justice and Empowerment, Ministry of Women and Child Development, and Human Resource Development with a budget allocation of INR 4038 crores (USD approx. 660 million) for the period from 2012- 13 to 2016- 17. The program will initially be implemented in 60 priority districts in 5 states namely Assam, Bihar, Tamil Nadu, Uttar Pradesh, and West Bengal. The major activities include public health interventions, expansion of JE vaccination, improved case management, medical and social rehabilitation, provision of drinking water and sanitation, and improved nutrition. Clearly, epidemiological studies to ascertain the cause and how the disease spreads and how the case fatality rates can be minimized remain the topmost priority under this initiative. The program is to be monitored and evaluated based on measurable and time- bound monitoring indicators. This special issue of Journal of Communicable Diseases contributed by the leading experts in India is an effort to put all the available information and evidence together in one document, covering epidemiology, surveillance and laboratory diagnosis, prevention and control policies and initiatives relating to AES/ JE. We hope that health care workers, policy makers, researchers, and academia in the country will find the issue useful in their work and it will in some measure contribute to the greater understanding of this critically important public health problem. References 1. Operational Guidelines: National Programme for Prevention and Control of JE/AES. NVBDCP, 2014. Available at: www.nvbdcp.gov.in/Doc/JE-AES-Prevention-Control(NPPCJA).pdf 2. Directorate of National Vector Borne Disease Control Programme- Delhi. Details of AES/JE Cases and Deaths from 2008-2014. Available at: http://www.nvbdcp.gov.in/Doc/je-aes-cd-Aug14.pdf  3. Japanese Encephalitis: A manual for Medical Officers of Health, Epidemiology Unit, Ministry of health, PATH. Available 3                                                                                                                                                                     Editorial J. Commun. Dis. 2014; 46(1): 1- 3.                                                                                             ISSN: 0019-5138  at: http://www.epid.gov.lk/web/attachments/article/141/JE%20book.pdf 4. Sahni GS. The re-occurring epidemic of heat stroke in children in Muzaffarpur, Bihar, India. Annals Trop Med Pub Health 2013; 6(1): 89-95. 5. Joshi R, Kalantri SP, Reingold A, Colford JM Jr. Changing landscape of acute encephalitis syndrome in India: a systematic review. Natl Med J India 2012; 25(4): 212-20. 6. NCDC newsletter. July-Sept 2013; 2(3). Available at: http://nicd.nic.in/writereaddata/linkimages/Newsltr04143506613236.pdf 7. John TJ, Das M. Acute encephalitis syndrome in Muzaffarpur: hypothesis of toxic origin. Cur Sci 2014; 106(9): 1184. 8. Paireau J, Tuan NH, Lefrancois R, Buckwalter MR, Nghia ND, Hien NT et al. Litchi-associated acute encephalitis in children, Northern Vietnam, 2004-2009. Emerg Infect Dis 2012; 18: 1817–1824. 9. Guidelines for surveillance of acute Encephalitis Syndrome (with special reference to Japanese Encephalitis). NVBDCP, 2006. Available at: www.nvbdcp.gov.in 10. Guidelines: Clinical management of Acute Encephalitis Syndrome including Japanese Encephalitis, Govt of India, NVBDCP, 2009. Available at: http://www.nvbdcp.gov.in/Doc/Revised%20guidelines%20on%20AES_JE.pdf 

Responding to the Challenge of Acute Encephalitis Syndrome/JE in India

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Responding to the Challenge of Acute Encephalitis Syndrome/JE in India

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