INTRODUCTION

• Japanese Encephalitis is a viral disease

• caused by an arbovirus, group B (Flavivirus) transmitted by culex mosquitoes.

• It is transmitted by infective bites of female mosquitoes mainly belonging to Culextritaeniorhynchus, Culex vishnui and Culexpseudovishnui group.

• JE virus is primarily zoonotic in its natural cycle and man is an accidental host.

• JE virus is neurotropic primarily affects CNS.

DISTRIBUTION

• Occurs almost all Asian countries.

• Japan, Korea and some parts of china,

The disease is increasingly reported from.

Bangladesh,India,Pakistan,Nepal,Bhutan, Burma, Sri Lanka and Thailand In the form of-outbreaks, sporadic cases and endemic.

cont

• An estimated 50000cases of JE occurs globally each year with 10,000deaths and nearly 15,000disabled.

• The wast majority of the cases ie 85% occurein the childrens less then 15 yrs of age n nearly 10% of the cases ocuure over 60yrs

Problem statemement

•Endemic-India, China, Japan, and all of South East Asia.

•Leading cause of viral encephalitis in Asia, with 30,000 – 50,000 cases annually.

Problem in india

1952 - First evidence of JE viral activity during sero-surveys for arbo-

viruses.

1955 - First human case

1958 - First viral isolation.

1973 - First outbreak- Bankura and Burdwan in West Bengal.

1976 - Repeat outbreak in Burdwan.

1978

Widespread occurrence of suspected JE cases.

National level monitoring initiated by NMEP in 1978.

Initiation of immunization using inactivated mouse brain vaccine

• Andhra Pradesh

• Assam

• Bihar

• Haryana

• Kerala

• Karnataka

• Maharashtra

• Manipur

• Nagaland

• Tamil Nadu

• Uttar Pradesh

• West Bengal

Distribution of cases & deaths of JE in India since 1996.

Years Cases Deaths

1996 2244 593

1997 2516 632

1998 2120 507

1999 3428 680

2000 2593 556

2001 2061 479

2002 1765 466

2003 2568 707

2004 1695 367

2005* 4647 1045

Aetiology

• Cased by arbovirus of family Flavivirus.

Transmitted by the bite of five genera of

Culex,

Anopheles,

Aides,

Mansonia

Amergeres.

Epidemiology

• Infects - nearly 50,000 people

• Deaths -10,000

• zoonotic disease -pigs, birds and horses.

• Man -accidental host plays no role in propagating the virus.

cont

• Start -in the month of April-May, • Peak -August & September.

• Decline -by the end of September and the beginning of October, to level of in the month of November.

• 90% -ranging from mid July to October, coinciding with the rainy season and after the rainy season.

cont

• Death-30% of all patients.

• 30% to75%-disability.

Transmission

JE in man

• Incubation -5-15 days.

• Not all individuals bitten by the infected mosquitoes develop the disease.

• The ratio of overt disease of in apparent infection varies from 1:300 to 1:1000.

LethargySudden fever

Vomiting and diarrhea

Tremors or convulsions

Headache Change in consciousness

Irritability or restlessness

Common symptoms of encephalitis

Signs & Symptoms

• Symptoms can include headache, fever, meningeal signs, weakness, disorientation, coma, tremors, paralysis (generalized), loss of coordination, etc.

• Prodromal stage may be abrupt (1-6 hours), acute (6-24 hours) or more commonly subacute (2-5 days)

cont

a) Prodromal stage- fever,- headache, - malaise, - lasts 1-6 days.

a) Acute encephalitic stage: high fever, neck rigidity, , convulsions, death may occur.

c) Late stage & sequelae: symptoms of CNS involvement starts disappearing and convulsion are prolonged.The period between the onset of illness and death is about 9 days.

Dignosis

Clinical:

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.

cont

• Laboratory:

• Antibody detection: Heamagglutination Inhibition Test (HI), Compliment Fixation Test (CF), Enzyme Linked Immuno-Sorbant Assay (ELISA) for IgG (paired) and IgM(MAC) antibodies, etc.

• Antigen Detection: RPHA, IFA, Immunoperoxidase etc. • Genome Detection - RTPCR • Isolation - Tissue culture, Infant mice, etc • In view of the limitations associated with various tests,

IgM ELISA is the method of choice provided samples are collected 3-5 days after the infection.

Treatment of Japanese Encephalitis

There is no specific anti-viral medicine available against JE virus.

• Clinical management of JE is supportive and in the acute phase is directed at maintaining fluid and electrolyte balance and control of convulsions, if present. Maintenance of airway is crucial.

Control & prevention of J E

1. Early case detection and prompt treatment

2. Vector control. INTEGRATED VECTOR MANAGEMENT (IVM)

3. Vaccination

EARLY CASE DETECTION AND PROMPT TREATMENT

Early case detection

Prompt treatment

Building surveillance

networking

Improved access to

Rapid Diagnostic

Tests (RDTs)

Improved access to

treatment

VECTOR

CONTROL

BREEDING PLACES OF VECTOR MOSQUITOES• Constructi

on projects

• Discarded, Old tyres

• Coolers

• Plastic containers/cups

• Water storage tanks

• Barrels/Dustbins

• Junk yards

• Cocoanut shells

Indoor Residual Spray- DDT,

Malathion, Synthetic Pyrethroids

in selected high risk pockets

INTEGRATED VECTOR MANAGEMENT (IVM)

IVM (LARVIVOROUS FISH)

• Cost-effective,

• Environment-friendly

• Emphasis on perennial natural water bodies

as hatcheries due to climatic conditions.

• Bed nets for high risk rural

tribal areas.

• Priority beneficiaries - Below

Poverty Line population

especially pregnant women

and children.

• Synthetic Pyrethroid tablet

formulation for treatment of

bed nets at individual level.

IVM (INSECTICIDE TREATED BED NETS)

vaccination

1. Mouse brain inactivated vaccine:

Dose 2 doses / subcutaneously at an interval 4 weeks apart.

Booster -after 1 year and then after 3 years.

Dose 0.5 ml for 1-3 year child.

1 ml for all above 3 years.

2. Cell culture inactivated vaccine: it is Beijing P3 vaccine and propagated in primery hestorkidney cells.

Dose - 0.5 ml for all ages.Doses -2Interval -1week

Route -sc Booster dose -after 6 months to 1 year and

then at third year..

3. Cell culture live attenuated vaccine : it SA 14-14-2 strain and is propagated in primary Hamster kidney cells.

single dose -0.5 ml

Route -subcutaneously

Booster -after 2 years.

Prevention & control• Govt of India: task force at a national level

in operation →reviews JE situations time to time.

• Under NVBDCP →technical support provided to states for outbreak investigation & control

Strategy

• Strengthening surveillance activities through sentinel sites in tertiary care institutions.

• Early diagnosis & proper case management at PHCs, CHCs, & hospitals.

• Behavior change communication of community to promote early case reporting, personal protection, isolation of amplifier host.

• Integrated vector control measures like fogging during outbreaks, spraying in animal dwellings, antilarval operations & personal protection.

• Capacity building through training of medical & nursing staff

• Development of a safe & standard indigenous vaccine. Vacination for high risk population, children of 1-15 yrs age.

• Epidemiological monitoring of disease for effective implementation of prevention & control strategies.

• Responding to out break situations

• Investigation of epidemic & its containment

• Community awareness through IEC activities

• Sentinel surveillance through serological & clinical surveilance.

THE STEPS TAKEN BY GOVT. OF INDIA TOWARDS PREVENTION

AND CONTROL OF AES/JE ARE AS FOLLOWS• JE vaccination campaign was launched during 2006 wherein 11

most sensitive districts in Assam, Karnataka and Uttar Pradesh were covered. Altogether 86 JE endemic districts in the states of Assam, Andhra Pradesh, Bihar, Haryana, Goa, Karnataka, Kerala, Maharashtra, Tamil Nadu, Uttar Pradesh and West Bengal have been covered.

• During 2009-2010 an amount of Rs.2.90 crores was allocated to the JE endemic states.

• Re-orientation training course on JE case management is a continuing process. Such orientating training courses were carried out in Andhra Pradesh, Assam, Haryana, Karnataka, Tamil Nadu, Uttar Pradesh and West Bengal during 2008 and 2009 respectively.

• The diagnostic facilities have been strengthened at 50 sentinel and 13 Apex Referral Laboratories including 15 sentinel sites established in Uttar Pradesh. These have been supplied with diagnostic kits free of cost from National Institute of Virology (NIV), Pune.

• Guidelines were developed on JE case management and on prevention and control of Entero-viruses which have been circulated to the states.

• For establishing a Physical, Medicine & Rehabilitation (PMR) department at BRD Medical College for treating physical disabilities due to AES/JE, MOU has been submitted to the state of Uttar Pradesh.

• One Vector Borne Disease Surveillance Unit (VBDSU) and one JE sub-office was established at BRD Medical College, Gorakhpur, Uttar Pradesh.

• Further, for establishing 50 bedded AES/JE treatment facilities at BRD Medical College, Gorakhpur, an amount of Rs.5.88 crores has been released under NRHM during 2009-10.

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Chikungunya

• Chikungunya (chik.-en-GUN-yah), also called chikungunya virus disease or chikungunya fever, is a viral illness that is spread by the bite of infected mosquitoes. The disease resembles dengue fever, and is characterized by severe, sometimes persistent, joint pain(arthiritis), as well as fever and rash. It is rarely life-threatening.

• Chikungunya occurs in Africa, India and Southeast Asia. It is primarily found in urban /peri-urban areas.

• Incubation 4-7 dys

Transmitted by Ades mosquito

Statement of the problem

• 1st found in Tanzania 1952-53

• First out break in india at Kolkota 1963-64

• Chennai 1965 viz gave rise to 300000 cases in chennai city alone

• The disease has reappered after 41 years during 2006 ther was largeoutbreak in indiawith 1.3 million officially reported cases spread over 16 states

• The states affected by chikungunya are Andhra Pradesh, Karnataka, Maharasthra, TamilNadu, Madhya Pradesh, Gujarat, Kerala, A&N Island, GNCT of Delhi, Rajasthan,Pondicherry, Goa.

Affected

States/UTs2008 2009 20010 20011*

Andhra Pradesh 5 591 116 89

Goa 52 1839 1429 395

Gujarat 303 1740 1709 393

Haryana 35 2 26 1

Jharkhand 0 0 0 487

Karnataka 46510 41230 8740 1039

Kerala 24685 13349 1708 56

Madhya Pd. 0 30 113 76

Meghalaya 0 0 16 0

Maharashtra 853 1594 7431 1994

Orissa 4676 2306 544 236

Punjab 0 0 1 0

Rajasthan 3 256 1326 427

Tamil Nadu 46 5063 4319 2620

Uttar Pradesh 11 0 5 0

West Bengal 17898 5270 20503 951

A& N Island 0 0 59 0

Chandigarh 0 0 0 1

Delhi 14 18 120 8

Lakshadweep 0 0 0 0

Puduchery 0 0 11 0

Total 95091 73288 48176 8773

Transmission

• Chikungunya is spread by the bite of an

Aedes mosquito, primarily Aedes aegypti.

• Humans are thought to be the major source,

or reservoir, of chikungunya virus for

mosquitoes. Therefore, the mosquito usually

transmits the disease by biting an infected

person and then biting someone else. An

infected person cannot spread the infection

directly to other persons.

Host

• Man

• Age: all ages

• Sex: both

Signs & symptoms• Abrupt onset of fever

• Severe joint pain.

• Other S/S

Muscle pain,

Headache,

Nausea,

Fatigue and rash.

• Joint pain is often very debilitating,

Diagnosis

• Chikungunya is diagnosed by blood tests (ELISA). Since the clinical appearance of both chikungunya and dengue are similar, laboratory confirmation is important especially in areas where dengue is present.

• Diagnosis by Real Time – Polymerase chain reaction (RT–PCR) Test

Treatment

• There is no specific treatment for chikungunya. Supportive therapy that helps ease symptoms, such as administration of non-steroidal anti-inflammatory drugs, and getting plenty of rest, may be beneficial.

• Infected persons should be isolated from mosquitoes as much as possible in order to avoid transmission of infection to other people.

Vector control measures

1.Indoor space spraying:

Pyrethrum extract after dilution is sprayed

Advantages of Indoor pyrethrum space spray:

Non-toxic to humans and other non-target organisms

Not developed resistance

Equipment is cheap, and easily available

2 Outdoor space spraying

Ultra Low Volume (ULV) Spray:

Minimum volume of liquid insecticide formulation

Organo-phosphorous insecticides (malathion)

More cost-effective than thermal fogging

Control and prevention

• Avoiding mosquito bites. Eliminating mosquito breeding site

• Use mosquito repellents on skin and clothing

When indoors, stay in well-screened areas. Use bed nets if sleeping in areas that are not screened or air-conditioned.

• By elimination of all potential vector breeding places near the domestic or peridomestic areas.

• Not allowing the storage of water for more than a week.

• Straining of the stored water by using a clean cloth once a week to remove the mosquito larvae from the water and the water can be reused. The sieved cloth should be dried in the sun to kill immature stages of mosquitoes.

Use of larvicides• Where the water cannot be removed but used for

cattle or other purposes,Temephos can be used once a week at a dose of 1 ppm(parts per million).

• Pyrethrum extract (0.1% ready-to-use emulsion) can be sprayed in rooms (notoutside) to kill the adult mosquitoes hiding in the house.Biological control

• Like introduction of larvivorous fish, namely Gambusiaand Guppy in water tanksand other water sources.

********

Kala azar LeishmaniaDonovani

1-4Months

13 million cases worldwide

•Control reservoir •Treatment•Sand fly control•Personal prohylaxis

•K.A controle prog•National health polocy 2002

•Elim 2010

Dengue Aedes aegypti 3- 10 dys 50million each year

•V cntrol•Envi managnt•H edu

•2003-04 conciderd asVb diseases•Namp utilization

Je Culextritaeniorhynchus

5-15 dys 5lack/10000 globaly

•Early case detection• Tretmnt•Vector control•Vaccine

•2003-04 conciderd asVb diseases

Chickunguny Aedes 4-7 dys 1390322 in india 2006*

•Vector control•Persnl prophlaxis

•NAMP guidelinesUtilized

Disease Cstive orga Icubation Burden Control mes Gvt Plans

•NVBDCP

r e f e r e n c e s

• K Park: text book of preventive and social medicine; edt -18 & 21

• Text of Public Health and Community Medicine: Armed Force Pune

• Davidson`s Principles and practice of medicine

• Sundarlal Adarsh Pankaj: text book of community medicine; edt-1st

• www.whoindia.int/chi

• www.nvbdcp.com

• Topley & Wilsons Text book of parasitology 9th

(Edn), 428-524

• O P Ghai Text book of preventive and social medicine, 161-162

• Harrisons Text book of Medicine, 15th (Edn),1428-1430

• Ananth Narayans Text book of Microbiology, 2nd

(Edn),209-211

THANK YOU ALL