1. Unexplained Neurologic Illness in Children – Malkangiri, Odisha, India, 2014
Authors: Priyakanta Nayak1, Mohan Papanna1, Aakash Shrivastava1, Pradeep Khasnobis1, Ganesh Lokhande1, Anil Kumar1, Srinivas R Venkatesh1, Bikash Patnaik2, Madan M Pradhan2
Affiliation:
1. National Centre for Disease Control (NCDC), New Delhi, India 2. Directorate of Public Health, Odisha, India.
The authors acknowledge support of CDC India, The Directorate of Public Health, Odisha, National Vector Borne Disease Control Programme (NVBDCP), Odisha , District NVBDCP & District IDSP Team for their support and cooperation

2. BACKGROUND

3. Acute Encephalitis Syndrome in India
High incidence in children (> 16 cases /100,000 patient years)
2008 – 2014: 44,097 cases and 5,728 deaths1
50% of cases undiagnosed
Commonly affects rural communities with poor access to healthcare
Seasonal: outbreaks occur during summer (May- June)
Common aetiologies in India:
Japanese encephalitis virus (JEV)
Nipah
West Nile
Chandipura,
Herpes simplex virus 1.

4. Acute Encephalitis Syndrome in Malkangiri, Odisha
47 deaths due to acute encephalitis syndrome (AES) between
12th Nov 2014: District Hospital reported 4 deaths (Children, < 5 years) of unknown neurological illness
13th- 20th Nov 2014: 5 more deaths reported of similar illness
25th November: 2 India Epidemic Intelligence Service (EIS) officers deployed to investigate outbreak

5. OBJECTIVES To study epidemiological characteristics of outbreak
To propose recommendation for prevention and control of outbreak

6. METHODS

7. Case Finding
Case definition: Illness presenting with vomiting, altered sensorium and convulsions in a child < 10 years of age in Malkangiri district between 1st November- 7th December 2014
Enhanced passive surveillance: Reviewed medical records of all admitted children with signs of neurological illness (vomiting, altered sensorium, seizure) in district hospital, Malkangiri
Active Surveillance: House to house survey in 11 affected villages of Malkangiri district

8. Laboratory Investigation
Specimen:
Serum and CSF specimen from 4 admitted children
Serum specimen from 44 contacts collected
Laboratory: Regional Medical Research Centre, Bhubaneswar and National Institute of Virology, Pune
Evaluation:
Serum: Blood smear for malaria parasite, IgM for Dengue, IgM enzyme-linked immunosorbent assay (ELISA), and reverse transcriptase polymerase chain reaction (RTPCR) for JE, Nipah, West Nile, Chandipura, and Herpes Viruses
CSF: RTPCR for JE, Nipah, West Nile, Chandipura, and Herpes Viruses

9. Entomological Investigations
Specimen: Mosquito samples collected from 11 affected villages in Malkangiri district by entomologists
Laboratory: Vector Control and Research Centre field station, Koraput
Evaluation: RTPCR assay for detection of JE Virus

10. RESULTS

11. Descriptive Epidemiology
15 cases (60% female)
Case fatality rate: 93% (14/15)
Median age: 3 years (range: 1- 4 years)
Attack rate: 4% (15/340) in Korukonda Block
Hospitalization rate: 60% (9/15)
Median time between illness onset and hospital admission: 48 hours (range: hours)

12. Clinical Features Clinical Features Number Percentage Vomiting 15 100%
Altered sensorium
Convulsion 9
60%
Fever 0%
Neck rigidity

13. AES cases by Illness onset date (n=15)
Investigation
Started
Number of Cases/Deaths
November 2014
December 2014
Illness onset Date

14. Distribution of cases in Malkangiri (n=15)

15. Laboratory Investigation
Specimen
Test
Organism
Result
Case (n=4)
Control (n=44)
Blood
Blood smear
Malaria parasite
Negative
IgM ELISA
Dengue
IgM ELISA and RTPCR
JEV
Chandipura
Nipah
West Nile
Herpes Simplex
CSF
RTPCR
Not Applicable
1/ 4 Positive

16. Entomological Investigations
Specimen
Species
Number
Test
Results
Culex
Mosquitoes
C. tritaeniorhynchus 16
JEV RTPCR
Negative
C. vishnui 31
C. bitaeniorhynchus 57
C. whitmorei 10
C. gelidus 1
C. quinquefasciatus

17. Conclusion Unexplained neurological illness in Malkangiri, 2014
Unusual in-term of:
Seasonality (Nov-Dec)
Restricted age group (< 5 years)
Atypical clinical features (No fever, No neck rigidity)

18. Recommendation Set up a hospital based surveillance system
Strengthen the laboratory capacity and surveillance for early identification of causative organism
Co-ordinate with animal health department to inform disease outbreak in livestock
Sensitize health workers to identify AES cases
Conduct vector survey in AES reported villages
Further investigate to confirm outbreak and identify risk factors

19. Please Contact: Dr Priyakanta Nayak Epidemic Intelligence Service (EIS) Officer India EIS Programme, NCDC, Delhi Mob: , Mail ID:
Thanks