A Prospective Hospital-based Surveillance to Estimate Rotavirus Disease Burden in Bhutanese Children under 5 Years of Age

As part of efforts to develop an informed policy for rotavirus vaccination, this prospective study was conducted to estimate the burden of rotavirus diarrhea among children less than 5 years old attended to the Department of Pediatrics, Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu, Bhutan. The duration of the study was three years, extending from February 2010 through December 2012. We estimated the frequency of hospitalization in the pediatric ward and dehydration treatment unit (DTU) for diarrhea and the number of events attributable to rotavirus infection among children under 5 years of age. During the study period, a total of 284 children (1 in 45) were hospitalized in the pediatric ward, and 2,220 (1 in 6) in the DTU with diarrhea among children residing in the Thimphu district. Group A rotavirus was detected in 32.5% and 18.8% of the stool samples from children hospitalized in the pediatric ward, respectively. Overall, 22.3% of the stool samples were rotavirus-positive, and the majority (90.8%) of them was detected in children under 2 years of age. From this study, we estimated that the annual incidence of hospitalization in the pediatric ward and DTU due to rotavirus diarrhea was 2.4/1000 (95% CI 1.7–3.4) and 10.8/1000 (95% CI 9.1–12.7) children, respectively. This study revealed that rotavirus is a major cause of diarrhea in Bhutanese children in Thimphu district and since no study has been performed previously, represents an important finding for policy discussions regarding the adoption of a rotavirus vaccine in Bhutan.     

Hamster-to-rat bone marrow xenotransplantation and humoral graft vs. host disease

Bone marrow transplantation (BMT) may induce tolerance across xenogeneic barriers. We have established a xenogeneic BMT model where hamster BM is transplanted into splenectomized LEW rat recipients resulting in high levels of engraftment. Unfortunately, graft vs. host disease (GVHD) with severe dermatitis developed in all rat recipients. We were successful in treating or preventing the dermatitis of this xenogeneic GVHD by the use of the T-cell suppressant tacrolimus. However, this compound did not prevent the development of a fatal liver injury in the rat recipients. This study was designed to elucidate the pathogenesis of this liver injury appearing in T-cell suppressed rat recipients of hamster BM. Splenectomized and irradiated (10 Gy) LEW rats received 300 x 106 unfractionated hamster BM cells. These BMT recipients were divided in 3 groups: Group I recipients (n = 8) did not receive further immunosuppression. Group II animals (n = 10) received tacrolimus 1 mg/kg/d for 7 d. Group III recipients (n = 6) were given the same daily dose of tacrolimus on a long-term basis. Chimerism was detected by flow cytometry. Cytotoxicity of recipient's sera against rat and hamster lymph node cells was measured by complement-dependent cytotoxicity (CDC) test. Immunofluorescence was used to detect hamster antirat antibodies on several recipient organs. In Group I, 2 out of 8 animals engrafted (25%) and survived for a median of 21 d showing the severe dermatitis characteristic of GVHD. In group II (n = 10), 9/10 rat recipients engrafted (90%) and survival was increased to a median of 53.7 days. However, these surviving recipients developed fatal GVHD not different from that observed in Group I recipients. All animals in Group III (n = 6) engrafted and did not show the characteristic dermatitis of GVHD. Their survival, however, was shortened to a median of 30.3 d by a severe liver injury. This injury was characterized by hepatocyte necrosis in zones 1 and 2 with polymorphonuclear (PMN) cell infiltration. Deposits of hamster immunoglobulins were present around the necrotic areas and in the portal veins. Moreover, antirat antibodies appeared in the circulation. These antibodies were sensitive to dithiothreitol (DTT) treatment indicating that they were of the IgM class. This study shows that xenogeneic GVHD may have a dual presentation in the hamster-to-rat model: a classical cellular GVHD not distinct to the allogeneic one and a humoral GVHD affecting solely the recipient liver. The degree of humoral injury is potentiated by T-cell suppression.     

Chikungunya Fever Outbreak,Bhutan, 2012

In 2012, chikungunya virus (CHIKV) was reported for the first time in Bhutan. IgM ELISA results were positive for 36/210 patient samples; PCR was positive for 32/81. Phylogenetic analyses confirmed that Bhutan CHIKV belongs to the East/Central/South African genotype. Appropriate responses to future outbreaks require a system of surveillance and improved laboratory capacity.     

A growing global network's role in outbreak response: AFHSC-GEIS 2008-2009

A cornerstone of effective disease surveillance programs comprises the early identification of infectious threats and the subsequent rapid response to prevent further spread. Effectively identifying, tracking and responding to these threats is often difficult and requires international cooperation due to the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by humans and animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department of Defense's (DoD) Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) identified 76 outbreaks in 53 countries. Emerging infectious disease outbreaks were identified by the global network and included a wide spectrum of support activities in collaboration with host country partners, several of which were in direct support of the World Health Organization's (WHO) International Health Regulations (IHR) (2005). The network also supported military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With IHR (2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.     

Mass Measles Rubella Immunization Campaign: Bhutan Experience

Background:

Bhutan has attained universal child immunization since 1991. Since then, immunization coverage is maintained at high level through routine immunization, periodic National Immunization Days, and mop up campaigns. Despite high immunization coverage, every year, significant numbers of clinically suspected measles cases were reported.

Objective:

To assess the cause of continuing high “suspected measles cases” and take appropriate public health measures.

Materials and Methods:

Febrile rash outbreaks occurred in several districts in 2003. These episodes were investigated. Simultaneously, a retrospective data search revealed evidence of congenital rubella syndrome (CRS) in the country.

Results:

Thirty five percent of the tested samples were positive for rubella but none for measles. There were evidences of the presence of CRS. This was discussed in the annual health conference 2004, amongst health policy makers and district heads who recommended that a possibility of inclusion of rubella as an antigen be looked into. A nationwide measles and rubella immunization campaign was conducted in 2006 followed by introduction of rubella vaccine in the immunization schedule.

Conclusion:

Febrile rash can be caused by a host of viral infections. Following universal measles immunization, it is pertinent that febrile rash be looked in the light of rubella infections. Following the introduction of rubella vaccination in the national immunization schedule, there has been significant reduction of febrile rash episodes, cases of rubella, and congenital rubella syndrome.     

Scrub typhus in pregnancy presenting with permanent hearing loss: A case report

As clinicians, we need to be vigilant about these rare and atypical presentations given the endemic nature of scrub typhus in southern belt of the country. Timely diagnosis and appropriate treatment is the key aspect to prevent further complications.