WHO Priority Diseases: Lassa fever

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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 Arenavirusfamily 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 AwardeeVice President CMAAOGroup Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Urgent need to formulate a national policy on compulsory screening of Critical Congenital Heart Diseases (CCHD) in India

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• Relevant stakeholders from the medical fraternity discuss the why and how of screening newborns for heart defects in a panel discussion in New Delhi
• The Government of Kerala is already working towards making CCHD screening mandatory in all their state-run hospitals

New Delhi, May 29, 2018: According to the National Family Health Survey, the infant mortality rate (IMR) in India stands at 34 per 1000 live births. About 10% of these infant deaths can be attributed to congenital heart diseases (CHD) alone. About 1.5 lakh infants are born with CHD in the country every year, a condition which can be detected with timely screening. Considering this, relevant stakeholders from HCFI, NNF and other institutions had come together to launch a campaign for formulating a national policy on making CCHD screening mandatory in all healthcare establishments in India. Dr Anne de-Wahl Granelli, a specialized biomedical scientist visiting India to raise awareness about CCHD screening was also part of the discussion.

The campaign followed a high-level meeting with Shri Manoj Jhalani, Additional Health Secretary, Ministry of Health and Family Welfare, Government of India. Masimo, a global leader in innovative non-invasive patient monitoring technologies is the technology partner for the initiative.

Current screening methods that include physical examination, fetal scan or a combination these two can only detect 72% of the cases. Various clinical studies have shown that addition of reliable pulse oximetry to screening protocols can potentially increase the detection rate to 92% which in the Indian context can approximately save about 52,000 babies. This will further have a direct impact on IMR.
Speaking during the discussion, Dr K K Aggarwal, President, Heart Care Foundation of India (HCFI), said, “Many newborns with critical CHD are symptomatic but not identified or diagnosed until after discharge. Such a delay in diagnosis increases the chance of frequent hospitalization and can cause mortality in the longer term. Newborn screening is thus an important strategy to ensure that no babies die due to lack of a proper screening mechanism. This issue requires the formulation of a national policy that will make screening for CCHD a priority even in primary healthcare establishments in the country. This can be made a reality if all relevant stakeholders join hands and support the cause.”
CCHD screening can also detect other birth defects including sepsis, respiratory disorders/lung pathology, persistent pulmonary hypertension, and transitional circulation. Countries that already have mandated and/or have adopted this screening methodology include USA, UAE, Saudi Arabia, Sweden, Norway, Sri Lanka, China, and Australia. USA already boasts of a 33% decline in infant deaths from CCHD in eight states due to timely screening.

Adding her inputs, Dr Anna Granelli, Head of Cardiology, NU Hospital Group, Trollhättan, Sweden said, “Pulse oximetry is a proven technology in detecting critical heart defects in infants. However, during my research, I gathered that not all pulse oximeters are the same. Institutions launching CCHD programmes should therefore choose a reliable technology after considering all aspects. Infants affected by CCHD can have poorer outcomes if there is a delay in diagnosis and treatment. Diagnosing these conditions before infants leave the hospital can prevent complications and more importantly, mortality. The time is appropriate and by sharing our experiences, I am sure we can bring about a positive development in this area in India as well and put in place a national policy for mandatory screening.”

Some signs of CCHD in infants include loss of healthy skin color; Cyanosis (a bluish tint to the skin, lips, and fingernails); rapid or troubled breathing, swelling or puffiness in the face, hands, feet, legs, or areas around the eyes; shortness of breath or tires easily during feedings; sweating around the head, especially during feeding; and poor weight gain.

“The current scenario in terms of the number of infants that die due to CCHD is grim. It further necessitates the need to implement a policy at the national level at the earliest. A pulse oximetry screening is not only inexpensive but takes less than 2 to 3 minutes per baby, with the benefits far outweighing the costs. The screening can even be carried out by an ASHA health worker with basic training. We are sure that this high-level meeting and discussion among relevant stakeholders will help us reach a consensus and get positive results,” said Dr BD Bhatia, President, The National Neonatology Forum.

Commenting on the subject, Dr Sitaraman Radhakrishnan, Director & HOD, Fortis Escorts Heart Institute, said “Pulse oximetry is a very simple and inexpensive tool to screen babies who are born with some critical CHD associated with low oxygen levels. Meticulous attention should be paid while analysing the oxygen readings taken by the instrument. Clear guidelines are available for this. However, there are many critical congenital heart diseases which may be associated with normal pulse oximetry results and screening should not be a substitute for a thorough clinical examination of the baby at the time of discharge from the nursery. It is also important that screening is also done during the infant’s first visit to the Paediatrician.”

“The primary benefit of newborn screening for CCHD with pulse oximetry is timely identification of infants with the condition prior to discharge from the hospital. Universal screening with Pulse Oximetry is better at detecting infants with critical CHD compared to physical examination alone. There is much to be gathered from the experience of other countries in making CCHD screening a priority.” opined Dr Smita Mishra, Pediatric Cardiologist, Jaypee Hospital.

The state of Kerala, few hospitals under the Government of Tamil Nadu, and other healthcare institutions such as the Manipal Group of Hospitals, St Martha’s Hospitals, Bangalore and CloudNine Hospitals have successfully adopted the screening mechanism. Others such as the Ram Manohar Lohia Hospital have recognized the importance of newborn CCHD screening and are working towards adopting it as a policy. All this makes it imperative to take it up on a national scale in India.

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

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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:

Crimean Congo hemorrhagic fever
Ebola virus disease
Marburg
Lassa fever
MERS
SARS coronavirus diseases
Nipah
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

Crimean-Congo hemorrhagic fever (CCHF)
Ebola virus disease and Marburg virus disease
Lassa fever
Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
Nipah and henipaviral diseases
Rift Valley fever (RVF)
Zika
Disease X, which denotes aserious 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

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