CURRENT NATIONAL EID THREATS: INDIA

S ADHYALT COL PUBLIC HEALTH SPECIALISTINDIAN ARMY MEDICAL CORPS

INTRODUCTION

• World Health Day theme (1997) “Emerging Infectious Diseases: Global Alert-Global

Response”.• Wake-up call for countries- develop strategies to meet

challenges in combating EIDs• Wide gap between developed and developing

countries like India to deal with EIDs• Problems- vastness

- population• Rethink strategies at regional/national/international

levels

MODES OF EMERGENCE

Since 1973- Appx 50 newly identified infec dis & synd recog in India-• Some jumped from other species- Avian influenza &

Swine flu• Through food- Escherichia coli O157:H7, variant

Creutzfeldt-Jakob dis• Spread to new geographical areas via vector -Dengue

and MT Malaria• Specific geographical foci- JE & Chickungunya• Identified in other countries like China & spread - SARS

MODES OF EMERGENCE

• Major interest in EIDs directed at Zoonotic and Vector-borne Dis

• Diseases like HIV/AIDS, MDRTB, Malaria, Shigellosis, Tuberculosis, Hepatitis C and E, etc. also imp

MAJOR EID THREATS IN INDIA

• DENGUE• CHIKUNGUNYA• TUBERCULOSIS WITH HIV• MT MALARIA• PLAGUE• INFLUENZA• AVIAN INFLUENZA(H5N1): • SWINE FLU(H1N1):

DENGUE

• Seasonal phenomenon in North India esp in Delhi and surrounding areas• Post monsoon rise in cases in urban areas- recent trend. • Recent rise explained by –– rapid population growth– expanding urbanization– inadequate municipal water supplies– difficulties in refuse disposal– lead to an abundance of new breeding sites – human migration patterns disperse vectors and viruses into

new areas

Emerging trend illustrated as under-

Yr 2000 Yr 2001 Yr 2002 Yr 2003 Yr 2004 Yr 2005 Yr 2006 Yr 2007 Yr 20080

2000

4000

6000

8000

10000

12000

14000

DENGUE

DENGUE

• Rise in the Deaths -

Yr 2000 Yr 2001 Yr 2002 Yr 2003 Yr 2004 Yr 2005 Yr 2006 Yr 2007 Yr 20080

50

100

150

200

250DEATHS

Due to higher number of cases of the dangerous DHF compared to normal Dengue fever.

CHIKUNGUNYA

• No stranger to the India• First isolation in Calcutta, 1963• Several reports of infection in diff parts of India• Last outbreak occurred in1971• No active or passive surveillance in the country• It 'seemed‘ virus had 'disappeared' from India• Last 05 yrs Reports of large scale outbreaks in

several parts of Southern India

CHIKUNGUNYA

• Re-emrgence of virus in past 05 yrs – estimated over 20,000 cases occurred in India in 2005

• Incidence remained same level each subsequent years

• Precise reasons for the re-emergence an enigma• Postulated that– Virus underwent mutation and spread– Diminution of the herd immunity

ACUTE ENCEPHALITIS SYNDROME

• Endemic foci of JE exists in – Uttar Pradesh, Bihar, West Bengal and Andhra Pradesh

• Factor favoring its endemicity widespread paddy cultivation breeding of Aedes vector

• During past 4-5 yrs has risen to epidemic proportion in only eastern Uttar Pradesh and Bihar

• Disease now affecting children in age grp <15 yrs- postulated to be enterically transmitted ,NOT vector

borne

EMERGENCE of AES –UP & BIHAR

Yr 2000 Yr 2001 Yr 2002 Yr 2003 Yr 2004 Yr 2005 Yr 2006 Yr 2007 Yr 20080

1000

2000

3000

4000

5000

6000

7000

8000

Cases of AES

AES

Deaths also much higher

Yr 2000 Yr 2001 Yr 2002 Yr 2003 Yr 2004 Yr 2005 Yr 2006 Yr 2007 Yr 20080

200

400

600

800

1000

1200

1400

1600

1800

TUBERCULOSIS WITH HIV

• India - the TB capital of the world ;contributing to majority cases worldwide so what’s new?

• Advent of HIV/AIDS HIV- TB co-infection • Cure rate low drug non availability, poor compliance inadequate diag facilities.• HIV- TB co infection led to further in cure rate and

MDR TB.• Advent of DOTS and coverage of whole country -

detection & cure rates have shot up appreciably

TB CASES UNDER DOTS

HIV-TB COINFECTION

• Problem of TB among HIV +ve still remains high• With better diagnostic facilities this is coming to

limelight more often nowadays• HIV seroprevalence among TB patients increased

considerably from 2.6% in 1988 to 5% by 2006• Risk of developing tuberculosis among HIV +ve in

age gp 25-34 yrs is as high as 4.2 times• Of all new cases of Tuberculosis in India, 1.2% are

infected with HIV.

MT MALARIA

• India loc in Tropics home for Malaria.• With extensive use of chemical insecticide the disease

was brought under control in the 60s• Since late 70s disease bounced back with vengeance• Newer foci of infections are the major challenges like –– the tribal belts of central India– dry areas of Rajasthan and – Urban Malaria

• Predominant disease type in these areas is not the BT but the dangerous MT malaria causing high fatality

MALARIA & MT MALARIA TREND

Trend of Malaria in past decade shown downward trend

On the other hand % of cases due to MT malaria on the rise Yr 2001 Yr 2002 Yr 2003 Yr 2004 Yr 2005 Yr 2006 Yr 2007 Yr 2008 Yr 2009

0.00

0.50

1.00

1.50

2.00

2.50

ratE/100

Yr 1976 Yr 1984 Yr1991 Yr 1996 Yr 2002 Yr 20090.00

10.00

20.00

30.00

40.00

50.00

60.00

%

PLAGUE

• India home to Plague since centuries - regular outbreaks & high case fatalities till late 19thcentury

• Suddenly vanished to the point of elimination in 20th century collateral benefit of NMEP

• In 1994 - large outbreak of Plague in Beed district of Maharashtra and Surat in Gujarat with high CFR

• Reason attributed -post natural calamity scenario increase & displacement of rodent population

• Regular monitoring of situation

PLAGUETre Trends of Cases and Deaths -

1955-1960 1961-1966 1967-1972 1973-1978 1979-1984 1985-1990 1991-1996 1997-20020

200

400

600

800

1000

1200

1400

1600

Cases Death

INFLUENZA

• In India, endemic/seasonal influenza had been generally ignored in public health

• Knowledge about epidemiology and clinical features are from research studies

• Both pandemics H2N2 (1957) and H3N2 (1968) circulated in India

• National Institute of Virology (NIV) started influenza surveillance in Pune in 1976

• H3N2 and B viruses annual season outbreaks in Pune• Seasonal H1N1 appeared in the 1990s

INFLUENZA

• Since 1980s there were several studies on viruses in acute respiratory diseases in children

• Showed 4-15% +ve nasopharyngeal specimens• Highly pathogenic avian influenza A/H5N1 virus

emerged as pan-zootic in 2003- alerted country • February 2006 affected poultry farms in junction of

Maharashtra, Gujarat& Madhya Pradesh• During 2008 and 2009- infected farm chicken in several

districts in West Bengal, Assam, Tripura and Sikkim

H5N1

• First case of Highly Pathogenic Avian Influenza was reported in February 2006

• Culling of all the poultry within 3 Km of foci of infection to contain spread of infection

• Subsequent isolated outbreaks were also similarly controlled by stamping out the disease.

• Extensive surveillance of human population in affected areas.

• No transmission of disease to human.

OTHER EIDs

Some other EIDs which have caused havoc but have been confined locally-

• Outbreaks of cases of Leptospirosis among farm workers in Andaman and Nicobar Islands and Southern India

• The Nipah virus outbreak in Jan-Feb 2001 in Siliguri in W Bengal (66 cases of Encephalitis identified with CFR 74%)

• Human Rickettsioses infections among residents and travelers in thickly forested regions

CONCLUSION

“The lesson is that if there’s a case anywhere, the disease is still a threat everywhere”.

• India is thus under constant threat of many such EIDs though they may seem to have been brought under control

• In the current age of rapid travel, international commerce, and global communication, artificial borders and geographic distance cannot isolate the health and safety problems in one community from another

• Only answer - have an efficient Public Health System in place.

Dick Thompson , WHO