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Emerging Infectious

Diseases in Kerala

T Jacob John, FAMS, FNA


Vellore, INDIA
A litany of “emerging” IDs
• 1985 Dengue (& Aedes) (VX Mathew, CMC-ite)
• 1987 Leptospirosis (Kolenchery; M Kuriakose, G Koshy)
• 1987 HIV (CMC, Vellore)
• 1996 Japanese encephalitis (CRME Madurai)
• 1996 Melioidosis (CMC, Vellore)
• 1999 Leptospirosis “rediscovered” (KSIVID)
• 2002 Visceral Leishmaniasis (Trichur Med College, KSIVID)
• 2003 Dengue H’gic Fever (KSIVID)
• 2003 Hantavirus (Medical Trust, Cochin)
• 2004 Rickettsiosis (Tata hosp, KSIVID, CMC)
• 2006 Chikungunya (NIV Pune)
• 2007 What was “pakarchappani” of 2007?
The birth of an Institute
• 1995-96: Three outbreaks that shook Kerala:–
Cholera (Alleppey town), Malaria (Kasargode)
Jap Encephalitis (Alleppey & Kottayam Districts)

• Committee appointed: (TJJ, MR Das, Sivan Pillai)

• As recommended, KSIVID established for:


epidemiology (disease surveillance), entomology,
diagnostics (viro, bact, others), training, QC of all labs,
reagent security, outbreak detection and interception,
monthly disease bulletins
Kottayam District (pop 1.8 m) diseases,
July 1999-June 2001
(John TJ et al, IJMR 2004; 120: 86-93)

• Disease. No. in first 12 months. No. in second 12 months. Total


• Cholera/cholera-like 47 13 60
• Dysentery, acute 322 221 543
• Encephalitis 53 23 76
• Fever & bleeding tend 109 139 248
• Hepatitis, acute 160 89 249
• Malaria 89 54 143
• Measles 96 54 150
• Meningitis 75 23 98
• Typhoid fever 177 89 266
• Leptospirosis 233 221 453
• Varicella 33 21 54
• Mumps 39 47 86
• ---------- ------ ----- ------
• Total 1433 994 2427
Amoebic. Bacillary. Unclassified. 1999-2000

60

50

40

30

20

10

0
J A S O N D J F M A M J
Typhoid, Acute hepatitis, Cholera. 1999-2000

40

35

30

25

20

15

10

0
J A S O N D J F M A M J
An outbreak in Kottayam
• On 1-6 Jan 2000, the Dt disease surveillance officer received one postcard
each, reporting cholera-like illness.(SIGNAL 1)
• On 6th Microbiology dept of KTM Med College reported Vibrio cholerae
detected in a case (SIGNAL 2)

• On 7th, DSO and DMOH met Dt Collector and Dt Panchayat leaders and
declared Kottayam Dt cholera affected (Better to be safe than sorry)
• Dt Task Force and Panchayat Liaison Committees established
• Intensive health education = 13,670 sessions held within a week
• ORS distributed through 7120 new (additional) distribution points
• 378,640 wells were chlorinated within a week
• 104 cholera cases/1402 suspects, 8 deaths.
• 30 cases and 3 environmental samples positive for Vibrio cholerae

• NICED (Kolkata) Expert comment:


“Major calamitous epidemic averted due to timely intervention”
(John TJ et al, IJMR 2004; 120: 86-93)
Measles, Encephalitis. 1999-2000

25

20

15

10

0
J A S O N D J F M A M J
MALARIA 1999-2000
Falciparum, Vivax, Unclassified.
20

15

10

J A S O N D J F M A M J
Fever with bleeding, Leptospirosis 1999-2000

50

45

40

35

30

25

20

15

10

J A S O N D J F M A M J
MENINGITIS. 1999-2000
Pyogenic. Non-pyogenic. Unclassified.
20

15

10

J A S O N D J F M A M J
Frequency of Japanese Encephalitis episodes
in India (1996-2005)

Repeat Occurrences
10 Times
8-9 Times
5-7 Times
2-4 Times
No. of States with 1 Time
reported JE cases: 15
Two unused blueprints(2002)
(KSIVID proposed, no system to implement)

1. District level Mosquito Monitoring and Management


Program (MMMP) – to predict, detect, intercept all
vector-borne outbreaks. Task force established.
Had that been implemented, Kerala could have
averted the tragic DHF outbreak in 2003 and the
chikungunya outbreak in 2006-7

2. Kerala Human Leptospirosis Elimination Program


(KLEP) – approved by the Ministry, but not
implemented in spite of about 500 deaths annually
throughout the State
Promedmail 20030626.1574
• It may look an irony that a `mysterious' fever, assuming the
proportion of an epidemic, has claimed over 100 lives, besides
infecting many others, in a `health-conscious' and highly
literate State like Kerala during the past one week. The
Additional Director of Health Services, P.K. Sivaraman,
himself has confided that 616 persons have contracted
leptospirosis (rat fever) in the State until 22 Jun 2003. Though
the official figures of death toll in the past one week are 53,
unofficial records show that not less than 115 persons have
succumbed to the illness. The crucial question is whether the
existing system is enough to take up the task, especially when
towns and villages have been turned into waste-dumping
yards, posing serious health hazards. Many hospitals do not
have any proper biomedical waste disposal facility as
prescribed by the Bio-Medical Waste Management and
Handling Rules, 1998 despite reports of liquid waste from
hospitals reaching water bodies.
Hepatitis outbreak in Kottayam
(Arankalle V et al IJMR 2006; 123: 760-769
John TJ IJMR 2006; 124:451-452)

• Started 2004 Sep 1st wk; peaked 3rd wk; lasted till 1st
wk Dec 2004. Investigated by NIV in Jan 2005
• Largest HA outbreak in India; many medical, nursing
& paramedic S&S affected; a few died
• Kerala adults: many are non-immune to HAV

• Kerala teaches the lesson: Intolerance of infectious


diseases, the basic tenet of Public Health, does not
necessarily emerge from high literacy of the public
The infamous fever outbreaks
• 2006: last state to be affected, but totally
unprepared

• Became political football: was there or was there


not outbreak? Opposition said yes,
Government said No

• Did any one die of chikungunya fever?


HM said no, CM said yes (96)
July 2007: 173 deaths (Gov) vs 562 (Oppsn)
2007: epidemic recurred
• Unprecedented magnitude, but denied by Gov

• Some places 30% affected; no data

• Army invited, central teams came 5 times, no


clarity about anything – magnitude, cause(s),
case-fatality, age, clinical criteria, “tomato fever”

• Our Med Coll “professors” remained silent


A Kerala news item
(Med India.com 14-7-07)

• GoI allotted to Kerala Rs 40 million to


“combat” fever outbreak

• Go-Kerala allotted 10 million each to 2 worst


affected Dts, Kottayam, Pathanamthitta

• Also 500,000 each to all other affected Dts


The official version !!
(India Health News 19-6-07)

• Assembly announcements on June 19, 2007


On “Chikungunya fever” in Kerala:
2003 Æ 1.85 million
2004 Æ 1.41 million
2005 Æ 1.8 million
2006 Æ 236,804
2007 Æ 1.06 million (no epidemic)
Also,
• 18-07-2007. Typhus fever in Kozhikode
According to Natl Health Policy

• All “disease control” is under GoI MoH :-


• TB, Malaria, Filariasis, Leprosy, HIV, Polio
• Childhood vaccinations also under GoI

• No “priority” for other diseases

• Outbreak Dx & Control also “vertical”


God forbid, but just in case…
How competent is Kerala?

• Yellow fever if it reached Kerala?

• Henipah virus disease if it occurred?

• Influenza outbreak in its early phase?

• Any other new or resurgent disease?


So, Kerala urgently needs:
• Govt. level policy definitions

• Roles of Minister, Secretary, DHS, DMOHs, KSIVID, to be clearly defined

• All party-agreement to protect “health system” from political interference

• DHS, DMOHs must be trained in Public Health

Epidemiology; Disease Surveillance;


Public Health Ethics; Outbreak Investigation;
Making Case Definition; Intervention Planning;
Supervising Implementation; Monitoring & Evaluation;
Documentation; Bulletin Publishing.
No one is more incompetent than
the one who falsely believes to be competent

THANK YOU