Wednesday, May 30, 2018

WHO Priority Diseases: Lassa fever

As I had mentioned yesterday in this column, we will be covering about the priority diseases as revised by the World Health Organization (WHO). The first to be covered is Lassa fever.

Here are some salient facts about Lassa fever.

·         Lassa fever is an acute viral hemorrhagic illness caused by Lassa virus, a member of the Arenavirus family of viruses.

·         Lassa virus is endemic in Benin, Ghana, Guinea, Liberia, Mali, Sierra Leone, and Nigeria and other countries in West Africa.

·         It is a zoonotic disease. Rodents (multimammate rats) are the animal reservoirs and shed the virus in their urine and feces.

·         Humans acquire the infection from contact with infected rodents through rodent urine or feces, inhalation of aerosolized rodent excretions, or consumption of infected rodents as a food source.

·         Person-to-person transmission can occur through direct contact with infectious body fluids (e. g., blood, urine, pharyngeal secretions, vomitus, or other body secretions), unprotected contact with potentially infectious material (e.g., touching vomitus) and mucosal exposure from splashes of body fluids.

·         Infection does not spread via casual contact such as hugging, shaking hands, or sitting near someone.

·         Persons with Lassa fever infection are not believed to be contagious prior to symptom onset.

·         The incubation period of Lassa fever is about 10 days (range 6-21 days).

·         Clinical picture: Gradual onset of symptoms in most patients. Symptoms are mild to begin with viz. low-grade fever, general weakness, malaise and so may be ignored. These are followed by headache, sore throat, muscle pain, chest pain, nausea, vomiting, diarrhea, cough, and abdominal pain. In severe disease, facial swelling, fluid in the lung cavity, bleeding from the mouth, nose, vagina or gastrointestinal tract and low blood pressure are present. Later stage may be characterized by shock, seizures, tremor, disorientation and coma.

·         In fatal cases, death usually occurs within 14 days on onset of illness.

·         The most common complication of Lassa fever is deafness, which may occur following either mild or severe illness.

·         Lassa fever is difficult to distinguish from other febrile illnesses, including malaria, shigellosis, typhoid fever, yellow fever and other viral hemorrhagic fevers. 

·         The overall case-fatality rate is 1%, while in hospitalized patients, the case-fatality rate is 15%.

·         Diagnosis is usually supported by a relevant history of exposure along with suggestive signs and symptoms.

·         Confirmatory test: ELISA to detect IgM and IgG antibodis and Lassa antigen. Serum IgM is detectable 10 to 21 days after symptom onset; serum IgG is detectable approximately 21 days after symptom onset. Serum reverse-transcription polymerase chain reaction is the preferred diagnostic tool but is expensive and requires technical expertise.

·         Early supportive care with rehydration and symptomatic treatment improves survival

·         Treatment in confirmed cases: IV ribavirin (Grade 1B); ribavirin may be administered orally, if IV ribavirin is not available.

o    IV ribavirin: 30 mg/kg (maximum 2 g) loading dose followed by 15 mg/kg (1 g max) IV 4-6 hourly x 4 days, followed by 7.5 mg/kg IV (500 mg max) 8 hourly x 6 days
o    Oral ribavirin: 35 mg/kg (2.5 g max), followed by 15 mg/kg (1 g max) orally 6 hourly x 4 days, followed by 15 mg/kg (1 g max) 8 hourly x 6 days

·         Prevention

o    Avoiding rodents (multimammate rats).
o    Consider all patients as infectious even if signs and symptoms are mild.
o    All standard, contact, and droplet precautions as well as correct use of appropriate personal protective equipment should be strictly adhered to.
o    Blood and body fluid specimens from patients with suspected Lassa fever infection should be considered highly infectious. Caution should be exercised when handling such material.
o    Postexposure prophylaxis with oral ribavirin for contacts with known or suspected Lassa fever infection with risk factors for transmission such as penetrating needle stick injury, exposure of mucous membranes or broken skin to blood or body fluids, and participation in procedures involving exposure to bodily fluids or respiratory secretions without use of personal protective equipment.

·         There is currently no vaccine that protects against Lassa fever

(Source: Uptodate, WHO)

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Tuesday, May 29, 2018

Was Nipah outbreak expected? WHO had sounded a note of caution in 2015

Was the current Nipah outbreak in Kerala expected? Could it have been prevented? I believe the answer to these questions is perhaps ‘yes’.

The World Health Organization (WHO) had sounded a note of caution in 2015 when it had published a list of top eight emerging pathogens likely to cause severe outbreaks in the near future, and for which few or no medical countermeasures exist.

The diseases included in the list were:

1.    Crimean Congo hemorrhagic fever
2.    Ebola virus disease 
3.    Marburg
4.    Lassa fever
5.    MERS
6.    SARS coronavirus diseases
7.    Nipah
8.    Rift Valley fever

Three other diseases - Chikungunya, severe fever with thrombocytopenia syndrome and Zika - were designated as 'serious', requiring action by WHO to promote R&D as soon as possible.

Other diseases with epidemic potential - such as HIV/AIDS, Tuberculosis, Malaria, Avian influenza and Dengue - were not included in the list because there are major disease control and research networks for these infections, and an existing pipeline for improved interventions.

The WHO revised this list in February this year. According to experts, there is an urgent need for accelerated research and development for the following diseases, given their potential to cause a public health emergency and the absence of efficacious drugs and/or vaccines

1.    Crimean-Congo hemorrhagic fever (CCHF)
2.    Ebola virus disease and Marburg virus disease
3.    Lassa fever
4.    Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
5.    Nipah and henipaviral diseases
6.    Rift Valley fever (RVF)
7.    Zika
8.    Disease X, which denotes a serious international epidemic could be caused by a pathogen currently unknown to cause human disease.

Nipah is one of the eight diseases in the list compiled by the WHO in 2015. Nipah again figures in the revised list published by WHO this year.

This should have been warning enough for appropriate authorities to be adequately prepared to prevent such outbreaks. There should have been a state of high alert for possible outbreaks of these diseases, which exist in India.

But, there are lessons to be learnt from the Nipah outbreak.

Monitoring systems should be in place preempt any future outbreaks. Disease surveillance should be continual and not episodic. It is also of utmost importance to increase public awareness about these diseases so that they can take due precautions. Otherwise, a small outbreak such as this may well turn into an epidemic. 

With geographical boundaries fast disappearing today, the pathogens get greater opportunity to rapidly travel around the world to different locations where they were previously unknown.

In the coming days, we will be talking about each of these diseases to increase knowledge and awareness about them.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Monday, May 28, 2018

Triggers and treatment approaches to acute heart failure differ worldwide

The first analysis of data from the International REPORT-HF show that triggers of acute heart failure and treatment approaches differ in different geographical regions of the world as also the drugs used as treatment.

While, ischemia/acute coronary syndrome (ACS)/infarction constituted 25.6% of cases of HF in the Southeast Asian region, nonadherence to diet and medications (19.2%) were the main cause in North America.

l In Southeast Asia, the other factors causing HF (in descending order) were nonadherence to diet and medications (5.4%), uncontrolled hypertension (5.2%), arrhythmia (4.7%) followed by pneumonia/respiratory process/infection (4.5%).

l Uncontrolled hypertension (8.2%), arrhythmia (7.6%), ischemia/ACS/infarction (3.5%) and pneumonia/respiratory process/infection (4.1%) were found to be the other triggers for HF in North America.

Treatment approaches also found to vary among the different regions globally.

l Inotropes were used more often in Southeast Asia Western Pacific, and Eastern Europe (11.3–13.5%) compared to other regions viz. Western Europe and North America (3.1–4.3%).

l The time between contacting medical services and receiving intravenous diuretics was 3.5 hours (average) in North American vs just over one hour in other regions. While, treatment with IV vasodilators within 6 hours of hospital contact was associated with a significantly shorter length of hospitalization across all regions, factors like renal function, systolic BP, signs of congestion on chest X-ray and cause of acute HF also influenced duration of hospital stay.

These results from the REPORT-HF registry were presented at the ongoing Heart Failure 2018 and the World Congress on Acute Heart Failure in Vienna, Austria.

Unlike other registries, the REPORT-HF (REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure) is a dedicated HF global registry and collates data collected from patients in different regions of the world. The data compares regional differences in causes of acute heart failure, therapies, time to treatment and treatment outcomes in order to better understand the epidemiology of HF worldwide.

The Registry included 18,805 patients hospitalized with newonset (first diagnosis) heart failure (HF) or decompensation of chronic HF from 44 countries across seven regions: 1,622 patients in North America, 2,686 patients in Central and South America, 2,810 patients in Eastern Europe, 3,661 patients in Western Europe, 2,265 in the Eastern Mediterranean and Africa, 2,369 in Southeast Asia and 3,392 in the Western Pacific.

The median age of patients was 67 years, 52% were Caucasian, 31% were Asian, 5% were Black, and 61% were men.

(Source: ESC, May 26, 2018)

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Sunday, May 27, 2018

The Health Ministry advisory on Nipah virus

The Health Ministry has released an advisory on Nipah virus for the general public as well as healthcare workers. Although the govt. has said that “the Nipah virus disease is not a major outbreak and is only a local occurrence”, yet fears abound in the general public. Stories of suspected cases of Nipah are being reported from other states – Himachal Pradesh and Karnataka. Yesterday, I had mentioned about social ostracism of healthcare workers caring for the affected persons. So, this health advisory is very opportune.

Here are salient points from the advisory, which includes general information about the disease and preventive measures.

General information

  • Nipah virus, which commonly affects animals such as bats, pigs, dogs, horses, etc. can spread from animals to humans and can sometimes cause serious illness among humans.
  • Spread of Nipah virus to humans may occur after close contact with other Nipah infected people, infected bats, or infected pigs.
  • Bat secretions laden with virus can infect people during fruit tree climbing, eating/handling contaminated fallen fruits or consuming raw date palm sap/juice or toddy, the advisory mentioned.
  • Human-to-human infection can occur from close contact with persons affected with Nipah at home while providing care or close contact and in hospital setting if appropriate personal protective equipments are not used.
For the general public

  • The general public should avoid consuming raw date palm sap or toddy, half-eaten fruits from the ground and refrain from entering into abandoned wells and eat only washed fruits.
  • Bodies of those who died due to the disease should be handled in accordance with the government advisory. During this emotional moment, traditional rituals and practices may need to be modified to prevent the exposure of family members to the disease.
  • People who are exposed to areas inhabited by fruit bats/ articles contaminated by secretions such as unused wells, fruit orchards, etc. are likely to be at higher risk of infections. 
  • Persons with direct contact with sick pigs or their contaminated tissues, persons in close contact with a Nipah virus affected deceased during burial or cremation rituals or health care workers having direct contact with probable or confirmed cases without using standard precautionary measures are also at a high risk of developing the infection.

For healthcare personnel
  • Healthcare personnel should wash hands thoroughly with soap and water for 20 seconds after contact with a sick patient, practice precautions for infection control while handling Nipah cases (suspected/ confirmed), limiting use of injections and sharp objects. 
  • For aerosol generating procedures, personal protective equipment (PPE) such as individual gowns (impermeable), gloves, masks and goggles or face shields and shoe cover and the procedure should be performed in airborne isolation room.
  • All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected as per manufacturers' instructions and hospital policies.
  • If the use of sharp objects cannot be avoided, ensure that precautions are observed like never replace the cap on a used needle, never direct the point of a used needle towards any part of the body, do not remove used needles from disposable syringes by hand, and do not bend, break or otherwise manipulate used needles by hand, never re-use syringes or needles, dispose of syringes, needles, scalpel blades and other sharp objects in appropriate, puncture-resistant containers. 
  • Ensure that containers for sharps objects are placed as close as possible to the immediate area where the objects are being used (point of use') to limit the distance between use and disposal, and ensure the containers remain upright at all times.

(Source: PTI, May 24, 2018)

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA