Acute Encephalitis Syndrome Surveillance, Kushinagar District, Uttar Pradesh, India, 2011–2012

Manish Kakkar

, Elizabeth T. Rogawski, Syed Shahid Abbas, Sanjay Chaturvedi, Tapan N. Dhole, Shaikh Shah Hossain, and Sampath K. Krishnan

Author affiliations: Public Health Foundation of India, New Delhi, India (M. Kakkar, E.T. Rogawski, S.S. Abbas); University College of Medical Sciences, New Delhi (S. Chaturvedi); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (T.N. Dhole); Centers for Disease Control and Prevention, New Delhi (S.S. Hossain); Office of the World Health Organization Representative to India, New Delhi (S.K. Krishnan)

Abstract

In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011–June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23% had illogical entries. AES incidence was highest among boys <6 about="" aes="" age="" and="" apanese="" area="" available="" avoid="" be="" but="" cases="" control="" could="" data="" development="" during="" effect="" encephalitis="" epidemiology="" estimate="" etiology="" evidence="" for="" health="" history="" in="" incomplete="" inferences="" interventions="" japanese="" laboratory="" largely="" little="" low-quality="" made.="" measures="" monsoon="" not="" of="" p="" peaked="" prevention="" provide="" public="" records="" resources.="" results="" season.="" so="" support="" surveillance="" the="" this="" to="" vaccination="" waste="" were="" years="">

Acute encephalitis syndrome (AES) is a clinical condition caused by infection with Japanese encephalitis virus (JEV) or other infectious and noninfectious causes. A confirmed etiology is generally not required for the clinical management of AES. Thus, surveillance for JEV infection in India has focused on identifying AES cases rather than JE cases; this approach is more feasible given the limitations of public health resources (1). However, identification of the etiologic agent is necessary for planning relevant interventions. The standard for determining the etiology of AES is examination of cerebrospinal fluid (CSF) during the acute phase of illness; pathogen-specific IgM capture ELISA or nucleic acid amplification techniques are used to detect pathogens in the CSF. Serologic tests for pathogen-specific antibodies and virus detection in serum are also recommended. However, examination of CSF is preferred because serologic test results may indicate the presence of antibodies in the serum, but the AES may have a cause different than the agent producing the detected antibodies (1–3).
A good quality surveillance system with laboratory support is essential for understanding the causes of AES and responding appropriately. Accordingly, the National Vector Borne Diseases Control Programme in New Delhi, India, has developed guidelines for AES surveillance that promote the need for a strong surveillance system as a critical component for any control activities. In these guidelines, the goals outlined for AES surveillance are to 1) assess and characterize the burden of JE, 2) detect early warning signals for an outbreak, 3) assess the effect of vaccination, and 4) guide future strategies (1). The National Vector Borne Diseases Control Programme has also implemented several measures to strengthen local health systems, including building on the capacity of the health workforce to provide better clinical management, extending referral diagnostic facilities by upgrading the existing Baba Raghav Das (BRD) Medical College facilities and setting up a National Institute of Virology field unit; and establishing a dedicated surveillance unit in the Department of Preventive and Social Medicine at BRD Medical College to provide improved surveillance and outbreak responses (4).
From the 1970s until around 2010, JEV infection was considered to be the leading cause of AES in the traditional JE belt of India, which includes Kushinagar District in the state of Uttar Pradesh (5–11). However, because of a large number of JE cases of unknown etiology, AES patterns alone have not suggested a clear picture of the epidemiology of the disease. In recent years, despite of the introduction of a JE vaccine, an increased number of AES cases have been reported in India, including Uttar Pradesh, and the disease has spread to new districts, urban areas, and villages without pigs, which are not usually associated with JE transmission (12,13). Thus, the assertion that JEV is the leading cause of AES has been questioned, and other infectious agents, such as enteroviruses, have been reported as a cause of AES in Uttar Pradesh and other parts of India (14–19). A substantial contributor to the ambiguity about the etiology of AES could be the fact that surveillance data for AES have not been analyzed to assess reasons for the increased cases and other reported causes. We examined the completeness and quality of AES surveillance data from Kushinagar District, an area where JEV is highly endemic. Herein, we discuss the ability to make inferences about AES epidemiology and etiology from these data and the implications of our findings for policy planning and program implementation.