Multiple epidemics of lethal fevers in India

Newsdesk Infectious disease surveillance update An increasing number of cases of African trypanosomiasis, or sleeping sickness, has been reported in both travellers returning from East African and by Medicins Sans Frontieres. The dramatic resurgence of disease in subSaharan Africa follows its virtual elimination from Africa during the 1960s. Dr Eskild Petersen of the Statens Serum Institut in Copenhagen told TLID that many years of slow progress in trypanosomiasis control have rapidly vanished due to wars and general disorder. He noted that political instability and a lack of commitment from local governments are more important for disease control than are new drugs and insecticides. There are many affected countries, including, most prominently, the Democratic Republic of the Congo, Angola, Uganda, Sudan, and Tanzania. A lack of data on the situation in many countries makes control more difficult. An estimated 60 million people are at

risk of infection by Trypanosoma brucei gambiense (West African sleeping sickness) and the more serious T brucei rhodesiense (East African sleeping sickness). As of December 11, ten people are confirmed dead in an ebola outbreak in Gabon, West Africa. In the world’s first documented outbreak since Uganda last year, the Gabon ministry of health and an international team from WHO is responding promptly. The outbreak of local transmission of dengue fever in Hawaii appears to have slowed down. Janice Okubo of the Hawaii department of public health told TLID that as of December 3 there have been a total of 89 confirmed cases, including 64 on the island of Maui, 20 on Oahu, and 5 on Kauai. The most recent confirmed case had onset of illness on November 11. No cases have been found on the island of Hawaii. An extensive public outreach programme has been put into place

including teams of workers that have travelled door-to-door to educate residents in the areas that have been most affected, such as the windward side of the island of Oahu, and to point out locations with standing water. With the arrival of colder weather in the USA, the West Nile virus activity has ceased in the northern states. The geographic range of the mosquitoborne infection expanded greatly during 2001, with a total of more than 40 human cases reported, including cases in Florida, Maryland, New Jersey, New York, Connecticut, Pennsylvania, Massachusetts, Louisiana, and Georgia. West Nile virus infections in horses have been confirmed in over 400 horses in 19 states. The prospect for continued expansion of the range of this infection in the western hemisphere, including areas in which winter frosts do not occur, is of concern to public health authorities. Dan S Shapiro

Multiple epidemics of lethal fevers in India leptospirosis during the monsoons for the past 3 years. Earlier, in 1996, an outbreak of dengue in Delhi affected over 10 000 people with 423 deaths, while in 1994 parts of Western and central India were struck by a plaguelike disease, the nature of which is still not clear.

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India is a regular target for epidemics of fever of unknown origin, says a report in the Indian journal, Down to earth (November 15, 2001; 10: 26–36). What is worse, continues the report, the state is doing little to combat them. The article describes the epidemic in February 2001 in Siliguri, in West Bengal. The disease, which manifested as a fever that ended in respiratory failure, was believed to be an encephalitis which affected 66 patients causing 45 deaths. While the preliminary report of the Indian Council for Medical Research was that the suspected organism was a mutating measles virus, it now appears that the organism responsible was probably a Nipah or Hendra-like virus. Similarly in July 2001, in Sarguja district in Chattisgarh, eastern India, a gastroenteritis of uncertain aetiology took 46 lives. Later, 18 children died of an encephalitis in Rae Bareli in the north Indian state of Uttar Pradesh in late August and early September 2001. Other cities that have been affected routinely in this fashion are Mumbai which has had epidemics of

Mother comforts son during dengue outbreak.

It is likely that increasing deforestation, changing agricultural practices, global warming, as well as poor hygiene and sanitation, are to blame. What makes the problem serious is that the state has not been able to act fast enough or comprehensively in most of these epidemics. Remarkably, for a country

THE LANCET Infectious Diseases Vol 2 January 2002

where infectious disease is rife, there are very few specialist physicians in this field. Retired General D Raghunath, Principal Executive of the Dorabji Tata Centre for Research in Tropical Diseases, Bangalore, echoes this view. “Unless we have more experts in the field of infectious disease, we will continue firefighting every time an epidemic hits us. A significant number of Indian physicians are not up-to-date with the latest advances in tropical medicine and are resistant to accepting the field as specialised. Furthermore, clinical microbiology has not yet got its due in India. “To combat this, the centre has started holding continuing medical education programmes regularly. He adds, “to combat these epidemics, we need to have more public health laboratories and have a better surveillance system. Also, an important fact is that while the state is responsible for the health of the citizens, private medical enterprise makes for about 70% of the medical care. Overpopulation has led to outstripping of our resources.” Sanjay A Pai

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For personal use only. Reproduce with permission from The Lancet Publishing Group.