Viral Hepatitis Surveillance--India, 2011-2013.

The burden of viral hepatitis in India is not well characterized. In 2009, the national Integrated Disease Surveillance Programme (IDSP) began conducting surveillance across all Indian states for epidemic-prone diseases, including foodborne and waterborne forms of viral hepatitis (e.g., hepatitis A and E). Information on outbreaks of all forms of viral hepatitis, including A, B, C, and E, also is collected. This report summarizes viral hepatitis surveillance and outbreak data reported to IDSP during 2011-2013. During this period, 804,782 hepatitis cases and 291 outbreaks were reported; the virus type was unspecified in 92% of cases. Among 599,605 cases tested for hepatitis A, 44,663 (7.4%) were positive, and among 187,040 tested for hepatitis E, 19,508 (10.4%) were positive. At least one hepatitis outbreak report was received from 23 (66%) of 35 Indian states. Two-thirds of outbreaks were reported from rural areas. Among 163 (56%) outbreaks with known etiology, 78 (48%) were caused by hepatitis E, 54 (33%) by hepatitis A, 19 (12%) by both hepatitis A and E, and 12 (7%) by hepatitis B or hepatitis C. Contaminated drinking water was the source of most outbreaks. Improvements in water quality and sanitation as well as inclusion of hepatitis A vaccine in childhood immunization programs should be considered to reduce the public health burden of hepatitis in India. Efforts to decrease the proportion of cases for which the etiology is unspecified, including expanding the IDSP to support hepatitis B and C testing, might help further elucidate the epidemiology of these diseases.

Eradicating successfully yaws from India: The strategy & global lessons.

Yaws, a non-venereal treponematosis, affecting primarily the tribal populations, has been considered historically as one of the most neglected tropical diseases in the world. In 1996, India piloted an initiative to eradicate yaws based on a strategy consisting of active case finding through house-to-house search and treatment of cases and their contacts with long acting penicillin. Thereafter, the campaign implemented in all 51 endemic districts in 10 states of the country led to the achievement of a yaws-free status in 2004. In the post-elimination phase, surveillance activities accompanied by serological surveys were continued in the erstwhile endemic districts. These surveys carried out among children between the age of 1-5 yr, further confirmed the absence of community transmission in the country. The experience of India demonstrates that yaws can be eradicated in all endemic countries of Africa and Asia, provided that political commitment can be mobilized and community level activities sustained until the goal is achieved.

The challenge of health & environment: profiling risks & strategic priorities for now & the future.

A substantial burden of communicable and non-communicable diseases in the developing countries is attributable to environmental risk factors. WHO estimates that the environmental factors are responsible for an estimated 24 per cent of the global burden of disease in terms of healthy life years lost and 23 per cent of all deaths; children being the worst sufferers. Given that the environment is linked with most of the Millennium Development Goals (MDGs), without proper attention to the environmental risk factors and their management, it will be difficult to achieve many MDGs by 2015. The impact of environmental degradation on health may continue well into the future and the situation in fact, is likely to get worse. In order to address this challenge, two facts are worth noting. First, that much of the environmental disease burden is attributable to a few critical risk factors which include unsafe water and sanitation, exposure to indoor smoke from cooking fuel, outdoor air pollution, exposure to chemicals such as arsenic, and climate change. Second, that environment and health aspects must become, as a matter of urgency, a national priority, both in terms of policy and resources allocation. To meet the challenge of health and environment now and in the future, the following strategic approaches must be considered which include conducting environmental and health impact assessments; strengthening national environmental health policy and infrastructure; fostering inter-sectoral co-ordination and partnerships; mobilizing public participation; and enhancing the leadership role of health in advocacy, stewardship and capacity building.

Non-communicable diseases in the South-East Asia region: burden, strategies and opportunities.

Non-communicable diseases (NCDs) are a global health and developmental emergency, as they cause premature deaths,exacerbate poverty and threaten national economies. In 2008, they were the top killers in the South-East Asia region, causing 7.9 million deaths; the number of deaths is expected to increase by 21% over the next decade. One-third of the 7.9 million deaths (34%) occurred in those <60 years of age (compared to 23% in the rest of the world). Of the total deaths in the South-East Asia region (14.5 million), cardiovascular diseases accounted for 25%, chronic respiratory diseases 9.6%, cancer 7.8% and diabetes 2.1%. NCDs are largely attributable to a few preventable risk factors, all of which are highly prevalent in the region-tobacco use, unhealthy diet, lack of physical activity and harmful use of alcohol. Key strategies for the prevention and control of NCDs include (i) reducing exposure to risk factors through health promotion and primary prevention, (ii) early diagnosis and management of people with NCDs, and (iii) surveillance to monitor trends in risk factors and diseases. Tackling NCDs calls for a paradigm shift: from addressing each NCD separately to collectively addressing a cluster of diseases in an integrated manner, and from using a biomedical approach to a public health approach guided by the principles of universal access and social justice. High levels of commitment and multisectoral actions are needed to reverse the growing burden of NCDs in the South-East Asia region.

Eradicating and eliminating infectious diseases: past, present and future.

During the past 60 years, a number of infectious diseases have been targeted for eradication or elimination, with mixed results. While smallpox is the only one successfully eradicated so far, campaigns on yaws and malaria brought about a dramatic reduction in the incidence in the beginning of the campaign but ultimately could not achieve the desired goal. There is again a renewed interest in disease eradication. The World Health assembly in May 2010 passed a resolution calling for eradication of measles by 2015; the target of polio eradication still remains elusive. In view of these developments, it is appropriate time to revisit the concept of disease eradication and elimination, the achievements and failures of past eradication programmes and reasons thereof, and possibly apply these lessons while planning for the future activities. This paper based on the Dr. A.L.Saha Memorial Oration describes various infectious diseases that have been targeted for eradication or elimination since 1950s, the potential direct and indirect benefits from disease eradication, and the issues and opportunities for the future.

WHO framework convention on tobacco control and its implementation in South-East Asia region.

The birth of the WHO Framework Convention on Tobacco Control (WHO FCTC) took place in response to the global tobacco epidemic and it became the most important global tobacco control instrument. Duly recognizing tobacco use as an important public health problem and in the wake of rising prevalence of and mortality related to tobacco use, almost all Member States of the South-East Asia Region signed and ratified the WHO FCTC. Following the ratification, Member countries have enacted comprehensive national tobacco control laws and regulations. Most countries have covered some important provisions, such as tax and price measures, smoke-free places, health warnings, a ban on tobacco advertising and promotion, and a ban on tobacco sales to minors. In spite of innumerable constraints and challenges, particularly human, infrastructural and financial resources, Member countries have been doing their best to enforce those legislations and regulations as effectively as possible. In order to educate the general public on the harmful effects of tobacco, mass health campaigns have been organized which are being continued and sustained. However, some of the important areas that need attention in due course of time are tax raises, illicit trade, tobacco industry interference and alternate cropping systems. All Member States in the Region are striving harder to achieving the goals and provisions of the Framework Convention through actively engaging all relevant sectors and addressing the tobacco issue holistically, and thus protecting the present and future generations from the devastating health, social, economic and environmental consequences of tobacco consumption and exposure to tobacco smoke.

Local governments and civil society lead breakthrough for tobacco control: lessons from Chandigarh and Chennai.

Smoke-free legislation is gaining popularity; however, it must accompany effective implementation to protect people from secondhand smoke (SHS) which causes 600,000 deaths annually. Increasing numbers of smoke-free cities in the world indicate that municipalities have an important role in promoting smoke-free environments. The objectives were to describe the local initiative to promote smoke-free environments and identify the key factors that contributed to the process. Observations were based on a case study on the municipal smoke-free initiatives in Chandigarh and Chennai, India. India adopted the Cigarette and Other Tobacco Products Act in 2003, the first national tobacco control law including smoke-free provisions. In an effort to enforce the Act at the local level, a civil society organization in Chandigarh initiated activities urging the city to support the implementation of the provisions of the Act which led to the initiation of city-wide law enforcement. After the smoke-free declaration of Chandigarh in 2007, Chennai also initiated a smoke-free intervention led by civil society in 2008, following the strategies used in Chandigarh. These experiences resonate with other cases in Asian cities, such as Jakarta, Davao, and Kanagawa as well as cities in other areas of the world including Mexico City, New York City, Mecca and Medina. The cases of Chandigarh and Chennai demonstrate that civil society can make a great contribution to the enforcement of smoke-free laws in cities, and that cities can learn from their peers to protect people from SHS.

From endotoxin to exotoxin: De's rich legacy to cholera.

Between 1951 and 1959, Sambhu Nath De made crucial discoveries on the pathogenesis of cholera that changed the course of our understanding of the disease. The discovery that cholera is caused by a potent exotoxin (cholera enterotoxin) affecting intestinal permeability, the demonstration that bacteria-free culture filtrates of Vibrio cholerae were enterotoxic, and the development of a reproducible animal model for the disease are considered milestones in the history of the fight against cholera. In this commentary, a classic article by De & Chatterje published in 1953 and its public health and research impact are highlighted.

Elimination of neglected tropical diseases in the South-East Asia Region of the World Health Organization.

The neglected tropical diseases (NTDs), which affect the very poor, pose a major public health problem in the South-East Asia Region of the World Health Organization (WHO). Although more than a dozen NTDs affect the region, over the past five years four of them in particular - leprosy, lymphatic filariasis, visceral leishmaniasis (kala-azar) and yaws - have been targeted for elimination. These four were selected for a number of reasons. First, they affect the WHO South-East Asia Region disproportionately. For example, every year around 67% of all new leprosy cases and 60% of all new cases of visceral leishmaniasis worldwide occur in countries of the region, where as many as 850 million inhabitants are at risk of contracting lymphatic filariasis. In addition, several epidemiological, technological and historical factors that are unique to the region make each of these four diseases amenable to elimination. Safe and effective tools and interventions to achieve these targets are available and concerted efforts to scale them up, singly or in an integrated manner, are likely to lead to success. The World Health Assembly and the WHO Regional Committee, through a series of resolutions, have already expressed regional and global commitments for the elimination of these diseases as public health problems. Such action is expected to have a quick and dramatic impact on poverty reduction and to contribute to the achievement of the Millennium Development Goals. This paper reviews the policy rationale for disease control in the WHO South-East Asia Region, the progress made so far, the lessons learnt along the way, and the remaining challenges and opportunities.

Re-emerging chikungunya fever: some lessons from Asia.

Chikungunya is an arboviral infection that re-emerged in several Asian countries during 2005-2006 after a long period of quiescence. Several microbial, climatic, social and economic factors influenced the occurrence of this disease as well as the rapidity with which it swept across many countries resulting in significant morbidity. Prevention and control of such diseases require not only a strong public health infrastructure but also a precise understanding of the factors that provide a conducive environment for the virus to propagate and infect a large number of people in a short time period. A multipronged response with an active role by the communities is critical for combating chikungunya and other emerging infectious diseases. The paper discusses important lessons that can be learned from the recent outbreaks of chikungunya fever in Asia.

Pandemic (H1N1) 2009: epidemiological, clinical and prevention aspects.

The influenza pandemic caused by the new H1N1 virus has by now affected all the continents of the world. However, the extent and likely impact are still uncertain. Like seasonal flu, the illness is mild and self-limiting in a great majority of cases, with only 1%-2% of patients requiring hospitalization. In a few cases, the clinical course can deteriorate in a matter of hours, leading to severe complications and eventually death. The risk of complications is higher among those who have preexisting diseases, such as asthma, heart disease and kidney disease, and among pregnant women. In such cases, antiviral treatment should not be delayed pending laboratory confirmation. The preferred antiviral drug is oseltamivir, and zanamivir is an alternative. Antiviral treatment is not necessary for those who are otherwise healthy, and have mild or uncomplicated illness. It is beneficial for patients with progressive lower respiratory tract disease or pneumonia, and those with underlying medical conditions and pregnant patients. As the supply of antivirals is limited, they should be used judiciously and where appropriate. There is a limited supply of pandemic influenza vaccine available in a few countries and efforts to produce it in India are presently underway. Effective personal preventive measures include shielding one's mouth and nose while coughing and sneezing, frequent washing of hands with soap, avoiding mass gatherings and voluntary isolation by symptomatic individuals. While at present the virus is causing a mild disease, the next wave may be more severe. Hence, enhanced surge capacity of health services is required for the clinical management of an increased patient load.

Preventing avian influenza in humans: the role of simple public health interventions.

An influenza pandemic due to influenza virus A H5N1 subtype is considered highly likely. Strategies for prevention and control of a pandemic include actions that need to be taken by the national authorities and communities. The availability of a vaccine and antiviral drugs in sufficient quantities for billions of people in the developing world is doubtful. Simple cost effective public health interventions can significantly reduce the risk of contracting infection. These interventions include precautions that will prevent people from contracting infection from sick or dying poultry and their products, human cases and a contaminated environment. Specific measures are based on principles of cutting short the transmission of infection in humans and inactivating the virus at its source. The paper describes context specific actions that can be implemented in both rural and urban settings by the communities themselves.

Epidemiology of HIV-TB in Asia.

Tuberculosis (TB) has, for centuries, continued to remain a public health problem of enormous importance, particularly in the developing world, taking a heavy toll of those at their prime of life. The emergence of human immunodeficiency virus (HIV infection) and its close association with TB poses an even greater challenge to the health systems in general and TB programmes in particular, in African and Asian countries. HIV is considered to be the most potent risk factor for progression to active TB among those infected both with TB and HIV; as a result, TB is the most common life threatening opportunistic infection associated with HIV, and biggest cause of death among patients with acquired immunodeficiency syndrome (AIDS). In areas hard-hit by HIV, TB is increasing, leading to greater case load, thereby overstretching the already fragile health infrastructure. The deadly relationship between HIV and TB, each potentiating the effect of the other, requires a clearly defined strategy taking into consideration the natural history of the co-infection and its progression to clinical TB (and AIDS). It is clear that the only way to fight this is by bringing the two programmes to join forces and work creatively and innovatively. The strategy should include not only preventing HIV through community-based behavioural interventions and limiting progression to clinical TB through the use of isoniazid preventive therapy, but also early diagnosis and treatment of HIV-associated TB and AIDS using DOTS strategy and combination antiretroviral therapy respectively. The strategy probably would not succeed unless both the programmes are first strengthened before attempting to forge collaboration based on mutual strengths and comparative advantages. In addition, mobilizing national and international response, building partnerships and mobilizing resources will help a great deal in mounting an appropriate and effective response to HIV/TB in the Asian context.