Litchi consumption and missed meals continue to be associated with acute encephalopathy syndrome among children: an investigation of the 2019 outbreak in Muzaffarpur district, Bihar, India.

BACKGROUND: Muzaffarpur district in Bihar State of India recorded a resurgence of acute encephalopathy syndrome (AES) cases in the summer of 2019 after no reported outbreak in 3 y. Earlier studies generated evidence that litchi consumption and missing the previous evening's meal were associated with AES. We investigated the recent outbreak to understand the risk factors associated with AES. METHODS: We conducted a matched case-control study by comparing AES cases with healthy controls from case-households and the neighborhood community for risk factors like missing evening meal and litchi consumption before onset of AES. RESULTS: We recruited 61 cases and 239 controls. Compared with the community controls, case-patients were five times more likely to have reported eating litchi in the 7 d preceding the onset of illness (adjusted OR [AOR]=5.1; 95% CI 1.3 to 19) and skipping the previous evening's meal (AOR=5.2; 95% CI 1.4 to 20). Compared with household controls, case-patients were five times more likely to be children aged <5 y (AOR=5.3; 95% CI 1.3 to 22) and seven times more likely to have skipped the previous evening's meal (AOR=7.4; 95% CI 1.7 to 34). CONCLUSIONS: Skipping the previous evening's meal and litchi consumption were significantly associated with AES among children in Muzaffarpur and adjoining districts of Bihar.

COVID-19 pandemic: What can we learn for better air quality and human health?

The COVID-19 lockdown resulted in improved air quality in many cities across the world. With the objective of what could be the new learning from the COVID-19 pandemic and subsequent lockdowns for better air quality and human health, a critical synthesis of the available evidence concerning air pollution reduction, the population at risk and natural versus anthropogenic emissions was conducted. Can the new societal norms adopted during pandemics, such as the use of face cover, awareness regarding respiratory hand hygiene, and physical distancing, help in reducing disease burden in the future? The use of masks will be more socially acceptable during the high air pollution episodes in lower and middle-income countries, which could help to reduce air pollution exposure. Although post-pandemic, some air pollution reduction strategies may be affected, such as car-pooling and the use of mass transit systems for commuting to avoid exposure to airborne infections like coronavirus. However, promoting non-motorized modes of transportation such as cycling and walking within cities as currently being enabled in Europe and other countries could overshadow such losses. This demand focus on increasing walkability in a town for all ages and populations, including for a differently-abled community. The study highlighted that for better health and sustainability there. is also a need to promote other measures such as work-from-home, technological infrastructure, the extension of smart cities, and the use of information technology.

Jaundice outbreak likely caused by HEV in Amritsar, Punjab, India, 2013.

BACKGROUND: Hepatitis-E Virus (HEV) infection is endemic in Punjab, India. On 4th April 2013, public officials of Labour Colony, Amritsar reported > 20 jaundice cases occurring within several days. METHODS: We performed a case-control study to identify the cause and prevent additional cases of jaundice cases in Amritsar, Punjab, India in 2013. RESULTS: A total of 159 cases (attack rate 3.6%) and 1 death were identified in Labour and 5 adjoining colonies from January 1 to June 5, 2013. Persons with jaundice were more likely to report foul-smelling piped water (adjusted odds ratio [AOR], 4.0, 95% confidence interval [CI], 2.2-7.2) and used piped water for drinking (AOR, 5.1; 95% CI, 2.2-11.4) than persons without jaundice. Among 14 cases tested, all had anti-hepatitis E virus IgM, and none had anti-hepatitis A virus IgM. Additionally, 21/23 tap water samples from affected households had detectable fecal coliforms. An environmental investigation found that water pipelines were damaged during sewer construction and likely led to contamination of drinking water with hepatitis E virus. CONCLUSIONS: Hepatitis E outbreaks are common in India, to curb future outbreaks of hepatitis E; measures to ensure safe drinking water are urgently needed.

A cutaneous Anthrax outbreak in Koraput District of Odisha-India 2015.

BACKGROUND: Cutaneous anthrax in humans is associated with exposure to infected animals or animal products and has a case fatality rate of up to 20% if untreated. During May to June 2015, an outbreak of cutaneous anthrax was reported in Koraput district of Odisha, India, an area endemic for anthrax. We investigated the outbreak to identify risk factors and recommend control measures. METHOD: We defined a cutaneous anthrax case as skin lesions (e.g., papule, vesicle or eschar) in a person residing in Koraput district with illness onset between February 1 and July 15, 2015. We established active surveillance through a house to house survey to ascertain additional cases and conducted a 1:2 unmatched case control study to identify modifiable risk factors. In case control study, we included cases with illness onset between May 1 and July 15, 2015. We defined controls as neighbours of case without skin lesions since last 3 months. Ulcer exudates and rolled over swabs from wounds were processed in Gram stain in the Koraput district headquarter hospital laboratory. RESULT: We identified 81 cases (89% male; median age 38 years [range 5-75 years]) including 3 deaths (case fatality rate = 4%). Among 37 cases and 74 controls, illness was significantly associated with eating meat of ill cattle (OR: 14.5, 95% CI: 1.4-85.7) and with close handling of carcasses of ill animals such as burying, skinning, or chopping (OR: 342, 95% CI: 40.5-1901.8). Among 20 wound specimens collected, seven showed spore-forming, gram positive bacilli, with bamboo stick appearance suggestive of Bacillus anthracis. CONCLUSION: Our investigation revealed significant associations between eating and handling of ill animals and presence of anthrax-like organisms in lesions. We immediately initiated livestock vaccination in the area, educated the community on safe handling practices and recommended continued regular anthrax animal vaccinations to prevent future outbreaks.

Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study.

BACKGROUND: Outbreaks of unexplained illness frequently remain under-investigated. In India, outbreaks of an acute neurological illness with high mortality among children occur annually in Muzaffarpur, the country's largest litchi cultivation region. In 2014, we aimed to investigate the cause and risk factors for this illness. METHODS: In this hospital-based surveillance and nested age-matched case-control study, we did laboratory investigations to assess potential infectious and non-infectious causes of this acute neurological illness. Cases were children aged 15 years or younger who were admitted to two hospitals in Muzaffarpur with new-onset seizures or altered sensorium. Age-matched controls were residents of Muzaffarpur who were admitted to the same two hospitals for a non-neurologic illness within seven days of the date of admission of the case. Clinical specimens (blood, cerebrospinal fluid, and urine) and environmental specimens (litchis) were tested for evidence of infectious pathogens, pesticides, toxic metals, and other non-infectious causes, including presence of hypoglycin A or methylenecyclopropylglycine (MCPG), naturally-occurring fruit-based toxins that cause hypoglycaemia and metabolic derangement. Matched and unmatched (controlling for age) bivariate analyses were done and risk factors for illness were expressed as matched odds ratios and odds ratios (unmatched analyses). FINDINGS: Between May 26, and July 17, 2014, 390 patients meeting the case definition were admitted to the two referral hospitals in Muzaffarpur, of whom 122 (31%) died. On admission, 204 (62%) of 327 had blood glucose concentration of 70 mg/dL or less. 104 cases were compared with 104 age-matched hospital controls. Litchi consumption (matched odds ratio [mOR] 9·6 [95% CI 3·6 - 24]) and absence of an evening meal (2·2 [1·2-4·3]) in the 24 h preceding illness onset were associated with illness. The absence of an evening meal significantly modified the effect of eating litchis on illness (odds ratio [OR] 7·8 [95% CI 3·3-18·8], without evening meal; OR 3·6 [1·1-11·1] with an evening meal). Tests for infectious agents and pesticides were negative. Metabolites of hypoglycin A, MCPG, or both were detected in 48 [66%] of 73 urine specimens from case-patients and none from 15 controls; 72 (90%) of 80 case-patient specimens had abnormal plasma acylcarnitine profiles, consistent with severe disruption of fatty acid metabolism. In 36 litchi arils tested from Muzaffarpur, hypoglycin A concentrations ranged from 12·4 µg/g to 152·0 µg/g and MCPG ranged from 44·9 µg/g to 220·0 µg/g. INTERPRETATION: Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal and implementing rapid glucose correction for suspected illness. A comprehensive investigative approach in Muzaffarpur led to timely public health recommendations, underscoring the importance of using systematic methods in other unexplained illness outbreaks. FUNDING: US Centers for Disease Control and Prevention.

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.

Outbreaks of unexplained neurologic illness - Muzaffarpur, India, 2013-2014.

Outbreaks of an unexplained acute neurologic illness affecting young children and associated with high case-fatality rates have been reported in the Muzaffarpur district of Bihar state in India since 1995. The outbreaks generally peak in June and decline weeks later with the onset of monsoon rains. There have been multiple epidemiologic and laboratory investigations of this syndrome, leading to a wide spectrum of proposed causes for the illness, including infectious encephalitis and exposure to pesticides. An association between illness and litchi fruit has been postulated because Muzaffarpur is a litchi fruit-producing region. To better characterize clinical and epidemiologic features of the illness that might suggest its cause and how it can be prevented, the Indian National Centre for Disease Control (NCDC) and CDC investigated outbreaks in 2013 and 2014. Clinical and laboratory findings in 2013 suggested a noninflammatory encephalopathy, possibly caused by a toxin. A common laboratory finding was low blood glucose (<70 mg/dL) on admission, a finding associated with a poorer outcome; 44% of all cases were fatal. An ongoing 2014 investigation has found no evidence of any infectious etiology and supports the possibility that exposure to a toxin might be the cause. The outbreak period coincides with the month-long litchi harvesting season in Muzaffarpur. Although a specific etiology has not yet been determined, the 2014 investigation has identified the illness as a hypoglycemic encephalopathy and confirmed the importance of ongoing laboratory evaluation of environmental toxins to identify a potential causative agent, including markers for methylenecyclopropylglycine (MCPG), a compound found in litchi seeds known to cause hypoglycemia in animal studies. Current public health recommendations are focused on reducing mortality by urging affected families to seek prompt medical care, and ensuring rapid assessment and correction of hypoglycemia in ill children.

Kyasanur Forest disease outbreak and vaccination strategy,Shimoga District, India, 2013-2014.

We investigated a Kyasanur Forest disease outbreak in Karnataka, India during December 2013-April 2014. Surveillance and retrospective study indicated low vaccine coverage, low vaccine effectiveness, and spread of disease to areas beyond those selected for vaccination and to age groups not targeted for vaccination. To control disease, vaccination strategies need to be reviewed.

Preschoolers' parent-rated health disparities are strongly associated with measures of adiposity in the Lifeways cohort study children.

OBJECTIVE: To examine the relationship between lifecourse factors from preschoolers' microecosystem and their parent-reported (mother-reported) health (PRH), following them prospectively from preconception to age 5 years. To investigate if preschoolers' body mass index (BMI) and waist circumference were associated with preschoolers' PRH when controlled for lifecourse predictors. DESIGN: Lifeways cross-generation cohort study. SETTING: Ireland. PARTICIPANTS: Of 1082 families, 62% mothers responded on a health and lifestyle questionnaire at follow-up. Food frequency, BMI and waist circumference were measured. There were 547 family data sets available for analysis of children's PRH. MAIN OUTCOME MEASURE: Mother-reported children's PRH at age 5. Associations with child's individual and familial exposures from preconception to age 5 years examined using logistic regression. RESULTS: In univariate analysis, relatively positive rating of children's PRH were associated with children's lower intake of fats (OR (95% CI) 2.2 (1.1 to 4.3)), higher intake of fruits/vegetables (OR (95% CI) 2.2 (1.1 to 4.3)); as well as familial socioeconomic characteristics {higher household income (OR (95% CI) 3.0 (1.6 to 5.9)), non-entitlement to means-tested healthcare (OR (95% CI) 2.1 (1.0 to 4.3)), mothers' higher education (OR (95% CI) 1.9 (1.0 to 3.6))}, psychosocial characteristics {father's participation in study (OR (95% CI) 2.1 (1.0 to 4.3)), mothers' perceiving better support from partner (OR (95% CI) 2.3 (1.2 to 4.3)), children (OR (95% CI) 1.9 (1.0 to 3.7)) or relatives (OR (95% CI) 2.2 (1.1 to 4.1))}, parents' lifestyle {mothers' lower intake of energy (OR (95% CI) 2.2 (1.1 to 4.3)), fathers' non-smoking status (OR (95% CI) 2.2 (1.1 to 4.4))} and parents' health {mothers' self-rated health relatively positive (OR (95% CI) 5.1 (2.6 to 9.9)), fathers' self-rated health relatively positive (OR (95% CI) 3.0 (1.5 to 6.0))}. In multivariable analysis (χ(2)=34.2, df=21, N=303, R(2 )= 0.26, p<0.05), one of the two strong predictors of children's relatively positive PRH was child not being obese by International Obesity Task Force classification (OR (95% CI) 5.5 (1.4 to 21.0)), observed also using BMI (kg/m(2); OR (95% CI) 0.73 (0.58 to 0.93)) or waist circumference (cm; OR (95% CI) 0.89 (0.81 to 0.98)) as continuous variables. The other significant predictor was mothers' self-rated health relatively positive (OR (95% CI) 4.2 (1.5 to 12.2)). CONCLUSIONS: Preschoolers' health is adversely associated with obesity and this is independent of lifecourse and social and environmental inequalities. The findings suggest that reducing childhood obesity and improving maternal health may be useful ways to improve child's global health.

Longitudinal follow-up of the relationship between dietary intake and growth and development in the Lifeways cross-generation cohort study 2001-2013.

In this paper we will review evidence on the early life and familial influences on childhood growth and development, with particular reference to the Lifeways cross-generation cohort study in the Republic of Ireland. The Lifeways cross-generation cohort study was established in 2001-2013 through two maternity hospitals in the Republic of Ireland and was one of many new cohort studies established worldwide in the millennium period. Mothers were recruited at first booking visit, completing a self-administered questionnaire, which included a 147 item semi-quantitative FFQ. Longitudinal follow-up is ongoing in 2013, with linkage data to hospital and general practice records and examination of children when aged 5 and 9 years. The study is one of very few containing data on grandparents of both lineages with at least one grandparent recruited at baseline. There have been consistent associations between parental and grandparental health status characteristics and children's outcomes, including infant birth-weight, BMI when child was aged 5 years and childhood wheeze or asthma when child was aged 3 and aged 5 years. In conclusion, empirical evidence to date shows consistent familial and cross-generational patterns, particularly in the maternal line.

Familial intergenerational and maternal aggregation patterns in nutrient intakes in the Lifeways Cross-Generation Cohort Study.

OBJECTIVE: The current study prospectively examines the intra-uterine hypothesis by comparing maternal, paternal and grandparental lineage influences on children's diet and also maternal­child aggregation patterns during pregnancy and early childhood. DESIGN: Prenatal dietary information was available for expectant mothers, fathers and up to four grandparents through a detailed validated semi-quantitative FFQ. At 6-year follow-up, when children averaged 5 years of age, dietary information was re-collected for mothers and a subset of maternal grandmothers using the same FFQ. Child's FFQ version was used for children. Anthropometric and sociodemographic variables were also collected. SETTINGS: Three-generation familial cohort representative of the contemporary Irish national population. SUBJECTS: Children aged 5 years (n 567) and their parents and grandparents. RESULTS: Associations for energy, macronutrient and fibre intakes were compared using Pearson's correlations, intra-class correlations (ICC) and linear regression models, adjusted for energy and potential confounders. Significant, moderatestrength positive correlations were observed for nutrient intakes in children's nuclear families (ICC (range)50?22­0?28). The father­child associations (r (range)5 0?13­0?20) were weaker than the mother­child associations (r (range)50?14­0?33). In general, associations were stronger for maternal postnatal intake­child intake than for maternal prenatal intake­child intake, except for percentage of energy from fat (adjusted b50?16, 95% CI 0?05, 0?26; P50?004), which was stronger for maternal prenatal intake, specifically in non-breast-fed children (adjusted b50?28, 95% CI 0?12, 0?44; P50?001). Among all grandparents, correlations were significant only for maternal grandmother­mother pairs (r (range)50?10­0?36). Significant positive ICC were observed for nutrient intakes of maternal grandmother­mother­child triads (ICC (range)50?12­0?27), not found in paternal lines. CONCLUSIONS: These findings suggest that maternal-environment programming influences dietary intake.

Unmetabolized folic acid prevalence is widespread in the older Irish population despite the lack of a mandatory fortification program.

BACKGROUND: In 2006 the Food Safety Authority of Ireland recommended mandatory folic acid fortification of flour for the prevention of neural tube defects in addition to the existing extensive voluntary folic acid fortification culture in place there. This recommendation is now suspended until further scientific evidence surrounding safety becomes available. The safety issues include concerns about the masking of vitamin B-12 deficiency and potential cancer acceleration, both of which may be of concern for the elderly population. OBJECTIVE: The aim of this study was to measure the basal (fasted) concentrations of unmetabolized folic acid in the plasma of an elderly population group exposed to this liberal voluntary fortification of foodstuffs in Ireland. DESIGN: We invited participants aged 60-86 y from the Lifeways Cross-Generation Cohort Study to participate in this project. After providing informed consent, the participants were invited to provide fasting blood samples and to complete a standard food-frequency questionnaire and a questionnaire on recent and habitual intakes of folic acid. Samples were assayed for total plasma folate, red blood cell folate, homocysteine, and unmetabolized folic acid. RESULTS: A total of 137 subjects with a mean age of 67.4 y were studied. Unmetabolized folic acid was detected in 94.1% of the cohort with a mean concentration of 0.39 nmol/L (range: 0.07-1.59 nmol/L), accounting for 1.3% of total plasma folate. CONCLUSION: These results indicate unmetabolized folic acid in plasma in most of this elderly Irish cohort, even after an overnight fast. These results should be considered carefully by those legislating in this area.