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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
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BACKGROUND
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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.
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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
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OBJECTIVES To study epidemiological characteristics of outbreak
To propose recommendation for prevention and control of outbreak
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METHODS
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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
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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
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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
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RESULTS
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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)
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Clinical Features Clinical Features Number Percentage Vomiting 15 100%
Altered sensorium Convulsion 9 60% Fever 0% Neck rigidity
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AES cases by Illness onset date (n=15)
Investigation Started Number of Cases/Deaths November 2014 December 2014 Illness onset Date
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Distribution of cases in Malkangiri (n=15)
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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
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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
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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)
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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
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Please Contact: Dr Priyakanta Nayak Epidemic Intelligence Service (EIS) Officer India EIS Programme, NCDC, Delhi Mob: , Mail ID: Thanks
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