Japanese encephalitis in India: an overview

Japanese encephalitis (JE)-epidemics have been reported in many parts of the country. The incidence has been reported to be high among pediatric group with high mortality. The incidence of JE in recent times is showing an increasing trend. It appears that JE may become one of the major public health problems in India, considering the quantum of the vulnerable pediatric population, the proportion of JEV infections among the encephalitic children and wide scattering of JE-prone areas. JE burden can be estimated satisfactorily to some extend by strengthening diagnostic facilities for JE confirmation in hospitals and by maintenance of contact with the nearby referral hospitals to collect the particulars on JE cases. Vaccination proves to be the best to protect the individual against any disease. In the case of JE, it is essential to immunize the pigs (amplifying host) also to interrupt the transmission of the disease     

Newer Vaccines against Mosquito-borne Diseases

Mosquitos are responsible for a number of protozoal and viral diseases. Malaria, dengue, Japanese encephalitis (JE) and chikungunya epidemics occur commonly all over the world, leading to marked mortality and morbidity in children. Zika, Yellow fever and West Nile fever are others requiring prevention. Environmental control and mosquito bite prevention are useful in decreasing the burden of disease but vaccination has been found to be most cost-effective and is the need of the hour. RTS,S/AS01 vaccine is the first malaria vaccine being licensed for use against P. falciparum malaria. Dengvaxia (CYD-TDV) against dengue was licensed first in Mexico in 2015. A Vero-cell derived, inactivated and alum-adjuvanted JE vaccine based on the SA14–14-2 strain was approved in 2009 in North America, Australia and various European countries. It can be used from 2 mo of age. In India, immunization is carried out in endemic regions at 1 y of age. Another inactivated Vero-cell culture derived Kolar strain, 821564XY, JE vaccine is being used in India. Candidate vaccines against dengue, chikungunya and West Nile fever are been discussed. A continued research and development of new vaccines are required for controlling these mosquito-borne diseases.     

Viral encephalitis of public health significance in India: Current status

Japanese encephalitis (JE) and rabies are 2 viral encephalitis that are of public health importance in India. JE is a zoonosis with the primary cycle occurring in arthropods (mosquito vectors) and vertebrate animals (primarily the pig), man being only an incidental ‘dead end’ host. Outbreaks have been seen in most parts of India except the north west. The disease presents with a prodromal stage, an acute encephalitic stage with coma, convulsions and variable deficits and a convalescent stage. Diagnosis can be made by viral isolation from CSF or brain, or serologic tests such as haemagglutination inhibition test and IgM antibody capture ELISA in CSF and blood. There is no specific treatment. Mortality ranges from 20–50% and almost half the survivors have sequelae. The most effective control measure besides control of mosquitos is vaccination. A killed mouse brain vaccine is being prepared in India and is safe and effective but expensive Rabies is a highly fatal encephalomyelitis primarily occurring in urban dogs and wild animals especially canines. It is endemic in India and affects an estimated 3 per 100,000 persons annually. The patient initially may display bizarre combative behaviour. The disease can be effectively prevented by post exposure vaccination. The nervous tissue vaccine is no longer recommended because of unacceptable neurotoxicity. Three cell culture vaccines are presently available with about equal efficacy     

Japanese encephalitis in India

Japanese encephalitis (JE), caused by a mosquito-borne virus was first recognised in India in 1955 and since then many major out-breaks from different parts of the country have been reported, predominantly in rural areas. Children are mainly affected, with morbidity rate estimated at 0.30 to 1.5 per 100,000 population. Case fatality rate has ranged from 10% to 60%, and up to 50% of those who recover may be left with neurological deficits. Reported incidence has generally been higher in males than in females, but subclinical infections have occurred equally in both sexes. A large number of subclinical infections occur each year during the transmission season. Diagnosis at the primary health centre (PHC) level is based on clinical symptoms only. Therefore, there is a need to develop simple tests for use at the peripheral level both for diagnosis and for epidemiological surveys. JE is a vaccine preventable disease, but there are many logistic problems for effective implementation of vaccination.     

手足口病在中国大陆的流行现状及诊治进展

近几年来,手足口病在我国大陆广泛流行,发病率呈逐年上升趋势,已成为严重的公共卫生问题而备受关注.肠道病毒71型(EV71)和柯萨奇病毒A组16型为主要病原体.95%的重症和死亡病例年龄小于3岁.目前尚无特效抗肠道病毒药物,主要是对症处理和脏器支持治疗.高效价静脉注射丙种球蛋白近期有望用于临床试验,其疗效有待观察.危重患儿应用糖皮质激素仍有争议.EV71疫苗正在研制中,大规模接种尚需时日.多学科合作进行前瞻性、多中心研究对控制手足口病流行和攻克诊治中的难题十分必要.

Abstract：

Hand,foot and mouth disease has become more widespread in mainland China in recent years and has shown an increasing trend in the annual prevalence, which has attracted considerable attention as a major public health problem. Enterovirus 71 (EV71) and coxsackievirus A16 (Cox A16) are major pathogens. Ninety-five percent of severe patients and death cases were younger than 3 years old. Unfortunately,there is no effective anti-enteroviral drug for hand, foot and mouth disease, therefore symptomatic treatment and supportive care remain as the mainstream therapy. Intravenous immunoglobulin (IVIG) is expected to be used in recent clinical trials, but its efficacy remains to be seen. Glucocorticoid therapy is still controversial in critical cases. EV71 vaccine is under development; however, it takes time to launch a mass vaccination. Multidisciplinary prospective, multicentral study is essential to control the spread of hand, foot and mouth disease and to tackle the problems of diagnosis and treatment.     

Pneumococcal Vaccines – How Many Serotypes are Enough?

Streptococcus pneumoniae causes meningitis, pneumonia, septicemia, arthritis, sinusitis and otitis media specially in children and over 65 y age groups. It contributes significantly to under-five mortality and morbidity worldwide as well as in India. Use of pneumococcal vaccine seems to be the most effective measure to decrease the disease burden and reduction of under-five mortality. Many countries have already included Pneumococcal Conjugate Vaccines (PCV) in their National Immunization Programmes (NIP). Government of India has announced recently to include PCV13 in NIP in a phased manner. Superiority of a vaccine over the other depends upon serotype coverage, vaccine efficacy, cost effectiveness and safety profile. These facts will be discussed for the vaccines available in India. Further research is warranted to know the disease burden and develop vaccines to have more serotype coverage.     

Rotavirus in India: Forty years of research

Rotavirus was first identified as a human pathogen just over 40 years ago, and work on this pathogen in India started shortly thereafter. Subsequent studies have confirmed its pre-eminent role in gastroenteritis in children in India. Standardized surveillance has enabled the documentation of the high burden of disease, and has demonstrated that there is considerable geographic and temporal variation in strain circulation. Internationally licensed vaccines, vaccine candidates based on indigenous strains and out-licensed strains have been tested for safety, immunogenicity and efficacy; three vaccines are now licensed in India and are used in the private sector. Public sector vaccination has begun, and it will be path-breaking for Indian vaccinologists to measure impact of vaccine introduction in terms of safety and effectiveness. So far, India has kept pace with international epidemiologic and vaccine research on rotavirus, and these efforts should continue.     

Animal bites: the current management guidelines

Rabies is a major public health problem in India. It is mainly transmitted by stray dogs, which form an overwhelming population in the country. Dogs are responsible for upto 95% of animal bites requiring antirabies treatment. In view of the exceptionally high fatality rate of human rabies, the prevention of infection after exposure is of utmost importance. With the availability of safe and effective tissue culture vaccines prevention of this dreaded disease is virtually assured by immediate and appropriate post exposure treatment. This is a three pronged approach including proper wound management, judicious use of antirabies serum and modern tissue culture vaccines. In India, Neural Tissue Vaccine is still used for post exposure treatment in public sector, though effective, this vaccine has serious side effects. The production and use of tissue culture vaccine should be encouraged with the aim to phase out neural tissue vaccine. WHO recommends use of intradermal route of inoculation of Tissue Culture Vaccine which makes the treatment very economical. However, this route as yet, is not approved by Drug Controller, Government of India (DCGI). There are no uniform guidelines for management of animal bite cases in India. In this article an attempt is made to discuss various aspects of animal bite management.     

Appropriate strategy for immunisation of children in India IV: Measles and its control,priority number one

Although a hidden health problem, measles is the commonest vaccinepreventable disease and the most common preventable cause of death among our underfives. These facts, plus the availability of a safe and effective vaccine make measles vaccination the highest priority in the control of communicable disease in India. The use of the pulse vaccination strategy will result in better coverage rates than the conventional strategy of immunisation in fixed health centres. India’s annual requirement of measles vaccine is 20 million doses. For economy and uninterrupted supply, measles vaccine must be manufactured in India without any further delay. The opinions expressed here are those of the authors and not necessarily of the supporting institutions.     

Serosurveillance for Japanese encephalitis in children in several districts of West Bengal, India

AIM: To evaluate the prevalence of antibodies to flaviviruses, particularly Japanese encephalitis (JE) in children. METHODS: Virological and serological investigations were conducted into JE, along with dengue 2 (Den2) and West Nile viruses, in the Flavivirus group. The paediatric age group (up to 10 y), in the districts of Burdwan, Bankura, Midnapore and Purulia of West Bengal, India, was assessed for recent activity of these viruses, for 4 consecutive years from 1996 to 1999. In total, 2260 sera samples were collected, of which 204 were from acute fever cases; only 72 paired sera were available. There was a significantly higher incidence of fever cases in children belonging to the schedule caste and schedule tribes. These communities occupy the lowest level in the society and are closely associated with pigs. RESULTS: No virus could be isolated from the sera collected from fever cases. The results of the serological survey showed the presence of antibodies to JE virus in only 13.3% of the contact sera, 33.3% of acute sera and 22.1% of convalescent sera investigated. Only 3.1% of the contact sera had antibodies to Den2 and no antibodies were found against West Nile virus. This indicates that the JE virus is in recent circulation in the population of these four districts, and as the majority of children lack substantial immunity to JE virus, they may be affected by an epidemic. CONCLUSION: Children up to 10 y of age in the four districts of West Bengal are mostly non-immune to JE virus. If an outbreak occurs, the majority of these populations may be affected.     

Is it right time to introduce mumps vaccine in India’s Universal immunization program?

Measles, mumps and rubella are vaccine preventable diseases. However, morbidity and mortality due to these diseases remain largely unnoticed in India. Measles has received much attention; mumps and rubella still need to garner attention. According to the World Health Organization, near-elimination of mumps could be achieved by maintaining high vaccine coverage using a two-dose strategy. However, Government of India has not yet decided on mumps vaccine. In this review, we have reviewed sero-prevalence studies, vaccine studies, outbreak investigations, virus isolation and virus genotyping studies on mumps. Overall, mumps seems to be a significant public health problem in India, but does not garner attention due to the absence of a surveillance and documentation system. Thus, inclusion of mumps antigen in the Universal immunization program would have added advantages, the economic burden imposed by the cost of the vaccine offset by a reduction in disease burden.     

Preventing varicella: Recommendations for routine two-dose varicella immunization in children

All Canadian provinces and territories have had routine immunization programs for one-dose varicella vaccination since 2007, a strategy that has reduced varicella disease rates dramatically. However, breakthrough cases still occur, and some cases are severe. There is increasing evidence that immunity to one dose of the vaccine can wane in a vaccinated population, and the disease may be shifting to an older age group that can experience more severe disease and more complications. This statement presents the rationale for a two-dose immunization strategy in Canada, as well as recommendations for a routine two-dose varicella vaccine schedule for all Canadian children. Children who have received one dose of varicella vaccine and have not had breakthrough infection should receive another dose of varicella vaccine.     

Hepatitis B vaccination : Myths and controversies

Hepatitis B has attracted a lot of attention in recent times. It has been suggested that it is a widely prevalent disease and an important cause of morbidity and mortality in our country. A dispassionate analysis of available data suggests that the prevalence of disease may be much less than believed hitherto, and the morbidity and mortality due to the disease may have been overestimated. Vertical transmission from mother to child at the time of delivery may be an important contributor to overall carrier rates in the community which warrants that the first dose of vaccine be administered within 24–48 hours of birth to all newborns. In view of this, the suggestion that Hepatitis B vaccine be incorporated in the National UIP also has many logistical difficulties, apart from a doubtful cost benefit ratio. This may therefore be not warranted at present. Also it would appear that the routine use of Hepatitis B vaccine in older individuals cannot be justified on epidemiological grounds in India and the widespread practice of holding camps for administering Hepatitis B vaccine to school children and other older citizens need to be re–examined.     

Mother's attitude towards child's health education and play in ICDS and non-ICDS areas

To lay the foundation for proper physical and psychological development of children is one of the stated objectives of Integrated Child Development Services Scheme, which is operational in India since 1975-76. This objective can not be achieved unless a positive change in maternal attitude is accomplished. The present investigation was conducted in an oldest project area of India to assess this change using an adjacent Non-ICDS area as control. Majority of the mothers in both the areas were apathetic towards the health, education and play of their children. Nevertheless one encouraging trend was also observed. Significantly higher number of mothers in ICDS area had positive attitude in all the three variables in comparison to mothers in Non-ICDS area. It appears that ICDS Scheme has given the start but to have more acceptable answers, in depth investigations at national level are needed.     

H.<Emphasis Type="Italic">influenzae type b</Emphasis> (Hib) vaccine – controversies

Hib vaccine is the 8th vaccine knocking at the door to be included in the EPI the world over. However there are some controversies that need to be addressed, especially when it comes to use of this vaccine in India. It is difficult to culture Hib unless one uses sheep blood enriched media for culture. There is a lack of good community based data on Hib burden in India. This makes many feel that Hib is rare in India. However this is not true. There are many studies that have looked at this closely. Hib is a common cause of meningitis and pneumonitis in children less than 5 years old in India. There is wide spread problem of multi–drug resistance by Hib in India. Mortality of meningitis is as high as 100% if third generation cephalosporins are not used in time. Of the survivors of meningitis, 60% develop long-term sequelae. Hib vaccine is very effective and can lead to 99% reduction with mass vaccination in just 2–3 years. It is also a very safe vaccine. Of the conjugated vaccines available in India all are equally effective and safe and there is nothing to choose one over the other. There is a need to give a booster dose at 15–18 months of age. Even UK, which never gave the booster dose, is seriously thinking of changing their practice and give a booster dose. Lastly the combination vaccines of Hib with IPV, DPwT/DPaT, and Hepatitis B are safe and effective and should be encouraged to improve the compliance. The use of Hib vaccine is recommended in India, for those who can afford the vaccine.     

Measles in India,a neglected problem

It is extimated that about 21 million preschool children acquire measles virus infection and 16 million develop clinical measles, annually, in India. Casefatality rate vary from 1 to 16 percent, depending upon the availability of health care and the nutritional status. Nearly 10 percent of preschool mortality is caused by measles. It is estimated that 200,000 children die annually in India due to measles or its complications. Measles vaccine is effective and safe, and is urgently needed in India. There is no justification for not including measles immunisation in the Expanded Programme on Immunisation in India. Measles vaccine should be made available, free of cost, to every child, as a first step towards its control.     

Health research strengthening and operational research needs for improving child survival in India

Health research can be utilized to improve the policies, interventions and outputs of the health systems, and ultimately the health of individuals and population. This requires systematic evaluation of evidence and its integration into national policies and programs after suitable adoption at the local level. It has been noted that there has been limited focus upon strengthening health research in India, due to weak research systems or institutional mechanisms, lack of trained human resources and enabling environment, absence of well defined priorities, perceived low quality of research, and inadequate funding. Though various vertical and integrated health programs for improving child survival in the country have been introduced, the decline in child mortality has been excessively slow. Operational research, a sub theme of health research, which uses systematic research techniques to provide evidence to the policymakers and program managers, can be used to assess programmatic issues and improve their effectiveness. This article analyzes the current situation of health research in India, describes briefly the process of operational research, and summarizes the areas of programmatic concern and priority topics for future research in five key fields of child health (Newborn health, Immunization, Malnutrition, Disease prevention and control, health systems strengthening). Finally, it outlines the immediate need of strengthening health research system in the country for improving child survival through increased funding, development of institutional mechanisms, building pool of talented researchers and provision of an enabling environment, to facilitate health and operational research in a scientifically credible manner and to ensure wider dissemination of results.     

中国学者对百日咳的研究历史及现状

百日咳是主要由百日咳杆菌引起的一种传染性强的急性呼吸系统疾病,主要见于发展中国家未接种相应疫苗的儿童。1978年我国实施计划免疫、普及儿童白百破疫苗接种以后,百日咳发病率明显下降,由使用疫苗前的100/10万～200/10万降低到20世纪90年代后的1/10万以下;近十年来,虽然百日咳发病率仍然保持在低水平,但一些地区出现反弹,局部地区还有暴发流行,发病率超过1/10万。该文就中国学者在百日咳的流行病学、实验室检测、治疗及疫苗等方面的研究历史及现状予以综述,强调卫生工作者对百日咳不能放松警惕,并应对其进行深入研究。     

Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years — India, 2013 and updates on immunization

Justification

There is a need to review/revise recommendations about existing vaccines in light of recent developments in the field of vaccinology where new developments are taking place regularly at short intervals.

Process

Following an IAP ACVIP meeting on 3rd and 4th August, 2013, a draft of revised recommendations for the year 2013 and updates on certain new vaccine formulations was prepared and circulated among the meeting participants to arrive at a consensus.

Objectives

To review and revise recommendations for 2013 Immunization timetable for pediatricians in office practice and issue statements on new vaccine formulations.

Recommendations

The major change in the 2013 Immunization timetable was made in the recommendations pertaining to pertussis immunization. Taking in to the consideration of recent outbreaks of pertussis in many industrialized countries using acellular pertussis (aP) vaccines and subsequent finding of faster waning of the same in comparison to whole-cell pertussis (wP) vaccines and superior priming with wP vaccines than aP vaccines, the committee has now recommended wP vaccines for the primary series of infant vaccination. Guidelines are now also issued on the preference/selection of a particular aP vaccine in case it is not feasible to use wP vaccine, and use of Tdap vaccine during pregnancy. The administration schedule of monovalent human rotavirus vaccine, RV1 has been revised to 10 and 14 weeks from existing 6 and 10 weeks. Recommendation is made for the need of booster dose of live attenuated SA-14-14-2 JE vaccine. Updates and recommendations are issued on new typhoid conjugate vaccine, inactivated vero-cell culture derived SA-14-14-2 JE vaccine, inactivated vero-cell derived Kolar strain, 821564XY JE vaccine, and new meningococcal conjugate vaccines. This year the recommended immunization schedule with range for persons aged 0 through 18 years is being published together instead of two separate schedules. A subcategory of ‘general instruction’ is added in footnotes. The comments and footnotes for several vaccines are revised and separate instructions for ‘routine vaccination’ and ‘catch-up vaccination’ are added in the footnotes section wherever applicable.     

Experience with the prevention of invasive Haemophilus influenzae type b disease by vaccination in Alaska: the impact of persistent oropharyngeal carriage

OBJECTIVES: To report the epidemiology of invasive Haemophilus influenzae type b (Hib) disease in high-risk Alaska Native infants before and after universal infant Hib vaccination and evaluate an increase in invasive Hib disease in 1996 after changing Hib vaccine type. STUDY DESIGN: Statewide laboratory surveillance for invasive Hib disease has been conducted since 1980. Three cross-sectional Hib carriage studies were conducted in 1997 and 1998. RESULTS: The invasive Hib disease rate in Alaska Natives decreased from 332 cases per 100,000 children <5 years old in 1980-1991 to 17:100,000 in 1992-1995 but increased primarily in rural areas to 57.9:100,000 after a switch in Hib vaccine types. Carriage studies in 5 rural Alaska Native villages showed oropharyngeal Hib carriage as high as 9.3% in children aged 1 to 5 years; in contrast, carriage in urban Alaska Native children was <1%. CONCLUSIONS: Although Hib disease has decreased in Alaska, the rate of Hib disease and carriage in rural Alaska Natives did not decrease to the same extent as in non-Natives and urban Alaska Natives. Use of polyribosylribitol phosphate-outer-membrane protein conjugate vaccine for the first vaccine dose is critical to disease control in this population with continued transmission in infants <6 months of age. The ability to eliminate Hib carriage and disease may be affected by population characteristics, vaccination coverage, and Hib vaccine type used. This may pose a challenge to global elimination of Hib.