Title: The epidemiology of meningococcal disease in India
Abstract: Tropical Medicine & International HealthVolume 15, Issue 12 p. 1421-1435 Free Access The epidemiology of meningococcal disease in India David Sinclair, David Sinclair The South Asian Cochrane Centre, Christian Medical College, Vellore, IndiaSearch for more papers by this authorMarie-Pierre Preziosi, Marie-Pierre Preziosi Initiative for Vaccine Research, World Health Organization, Geneva, SwitzerlandSearch for more papers by this authorT. Jacob John, T. Jacob John Formerly of Christian Medical College, Vellore, India (Retired)Search for more papers by this authorBrian Greenwood, Brian Greenwood London School of Tropical Medicine and Hygiene, London, UKSearch for more papers by this author David Sinclair, David Sinclair The South Asian Cochrane Centre, Christian Medical College, Vellore, IndiaSearch for more papers by this authorMarie-Pierre Preziosi, Marie-Pierre Preziosi Initiative for Vaccine Research, World Health Organization, Geneva, SwitzerlandSearch for more papers by this authorT. Jacob John, T. Jacob John Formerly of Christian Medical College, Vellore, India (Retired)Search for more papers by this authorBrian Greenwood, Brian Greenwood London School of Tropical Medicine and Hygiene, London, UKSearch for more papers by this author First published: 05 November 2010 https://doi.org/10.1111/j.1365-3156.2010.02660.xCitations: 39 Corresponding Author David Sinclair, The South Asian Cochrane Centre, Christian Medical College, Vellore, India. E-mail: [email protected] AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Summaryen Objective To undertake a review of the literature on the epidemiology of meningococcal disease in India, with a view to informing future control policies. Methods We searched the PUBMED, EMBASE, Global Health, IMSEAR and MedIND databases for observational studies relating to the burden of endemic meningococcal disease in India, the occurrence and epidemiological characteristics of epidemics, and the prevalence of individual meningococcal serogroups. Results The relatively few reports identified suggest that the incidence of endemic meningococcal disease in India is low, but that occasional epidemics of meningococcal disease have been recorded for at least 100 years. The larger epidemics have affected mainly the cities of northern India and have almost universally been caused by meningococci belonging to serogroup A. These epidemics have showed a few characteristics, including a marked seasonality, which are similar to those of epidemic meningococcal A disease in Africa. Conclusions New serogroup A-containing meningococcal conjugate vaccines are now being developed and reaching the market, including an affordable monovalent serogroup A vaccine manufactured in India, but intended primarily for use in Africa. These new tools may have a role in containing future Indian epidemics, but their usefulness is dependent on early identification of epidemics. This will require a functional disease surveillance system with adequate laboratory support throughout India. L’épidémiologie des maladies à méningocoques en Indefr Objectif: Revue de la littérature sur l’épidémiologie des maladies à méningocoque en Inde, en vue d’informer les futures politiques de lutte. Méthodes: Nous avons effectué une recherche sur les bases de données PubMed, Embase, Global Health, IMSEAR et MedIND pour des études observationnelles relatives à la charge des maladies méningococales endémiques en Inde, la présence et les caractéristiques épidémiologiques des épidémies, ainsi que la prévalence des différents sérogroupes de méningocoques. Résultats: Les publications relativement peu nombreuses identifiées suggèrent que l’incidence des maladies méningococales endémiques en Inde est faible, mais que des épidémies occasionnelles de maladies méningococales ont été enregistrées depuis au moins 100 ans. Les épidémies les plus importantes ont touché principalement les villes du nord de l’Inde et ont été presque universellement causées par des méningocoques appartenant au sérogroupe A. Ces épidémies ont montré des caractéristiques comprenant une saisonnalité marquée, similaires à celles de l’épidémie des maladies à méningocoque A en Afrique. Conclusions: De nouveaux vaccins conjugués contenant le méningocoque du sérogroupe A sont en cours de développement et arrivent sur marché, y compris un vaccin monovalent du sérogroupe A abordable, fabriqué en Inde, mais principalement destinéà l’Afrique. Ces nouveaux outils peuvent jouer un rôle en limitant de futures épidémies en Inde, mais leur utilité dépend de l’identification précoce des épidémies. Il faudra pour cela un système fonctionnel de surveillance des maladies avec le soutien approprié des laboratoires dans toute l’Inde. Mots-clés: méningocoque, Inde, épidémiologie Epidemiología de la enfermedad meningocócica en la Indiaes Objetivo: Realizar una revisión de la literatura sobre la epidemiología de la enfermedad meningocócica en la India con el fin de informar de cara a futuras políticas de control. Métodos: Se realizaron búsquedas en las bases de datos de PUBMED, EMBASE, Global Health, IMSEAR y MedIND de estudios observacionales relacionados con la carga de la enfermedad meningocócica en India, la incidencia y las características de epidemias, y la prevalencia de serogrupos meningocócicos individuales. Resultados: El número relativamente pequeño de artículos identificados sugiere que la incidencia de la enfermedad meningocócica en India es baja, aunque las epidemias ocasionales de enfermedad meningocócica han sido reportadas durante al menos los últimos 100 años. Las epidemias más grandes han afectado principalmente las ciudades del norte de la India, y han sido casi universalmente causadas por meningococos del serogrupo A. Estas epidemias han mostrado características, incluyendo una marcada estacionalidad, similares a aquellas de las epidemias por meningococo del grupo A en África. Conclusiones: Nuevas vacunas meningocócicas conjugadas que contienen el serogrupo A están siendo desarrolladas y van llegando al mercado, incluyendo una vacuna monovalente para el grupo A, asequible y manufacturada en India, pero principalmente intencionada para ser utilizada en África. Estas nuevas herramientas juegan un papel importante en la contención de futuras epidemias en la India, pero su utilidad depende de la identificación temprana de las epidemias. Para ello, se requiere un sistema de vigilancia de la enfermedad con un apoyo laboratorial adecuado alrededor de toda la India. Palabras clave: Meningococo, India, Epidemiología Introduction Infection with Neisseria meningitidis (the meningococcus) is common, although the majority of infections are transient and asymptomatic (Stephens 1999). The meningococcus can live harmlessly in the nasopharynx of up to 10% of healthy populations (Yazdankhah & Caugant 2004). This ‘carrier’ state facilitates the circulation of the bacteria within communities with transmission taking place via airborne respiratory secretions or through direct contact such as kissing (Stephens 1999). The factors that determine progression from harmless carriage to invasive disease are poorly understood, but they are influenced by both the virulence of the infecting strain and the susceptibility of the host (Stephens 1999; Yazdankhah & Caugant 2004). When disease occurs, its onset is often rapid and life-threatening, and the meningococcus remains one of the major causes of death and disability as a result of invasive bacterial disease (Schwartz et al. 1989; Rosenstein et al. 2001). Meningococci can be categorized into 13 distinct serogroups based on the composition of their capsular polysaccharide, although just six of these cause more than 90% of invasive disease worldwide (A, B, C, W135, X and Y) (Schwartz et al. 1989; Rosenstein et al. 2001). In the industrialized countries of Europe and North America, where serogroups B and C predominate, the disease is endemic with a low overall incidence and characterized by seasonal peaks and small clusters of cases (Harrison et al. 2009). In contrast, in an area of the African Sahel and sub-Sahel (known as the ‘meningitis belt’), large epidemics of meningococcal disease occur frequently on a scale unparalleled in other regions. Most African epidemics have been caused by meningococci belonging to serogroup A, but outbreaks of serogroup C, W135 and X disease have also been recorded (Greenwood 1999, 2006; Molesworth et al. 2002; Girard et al. 2006; Harrison et al. 2009). The epidemiology of meningococcal disease in other parts of the developing world, particularly Asia, is not well described (Manchanda et al. 2006; Harrison et al. 2009). We have, therefore, undertaken a literature review of meningococcal epidemiology in India, where a new serogroup A meningococcal conjugate vaccine is being produced by the Serum Institute of India, with support from the Meningitis Vaccine Project (Das 2004). This vaccine has now been pre-qualified by the World Health Organization, and mass vaccination campaigns will start in Burkina Faso, Mali and Niger in the last quarter of 2010. This vaccine might also find a use in India as epidemics of meningococcal disease have occurred in New Delhi in 2005 and Meghalaya and Tripura in 2008/2009 (Sinha 2009). Methods The MEDLINE, EMBASE and Global Health databases were reviewed (with no date restrictions) for published studies using ‘mening*’ OR ‘septic?emia’ AND ‘India’ as search terms. The IMSEAR and MedIND databases were also examined using combinations of India AND one of ‘meningococcus’, ‘meningococcal’, ‘meningitis’, ‘septicaemia’, ‘septicemia’ or ‘sepsis’. The reference lists of all included papers were reviewed for additional back references relevant to this review. The search was conducted in July 2009 and identified 1536 articles. Screening of abstracts identified 253 for possible inclusion, of which 214 full-text copies (84.6%) were obtained. The reference lists identified a further 23 papers for possible inclusion. After this process, 237 papers were formally reviewed for relevant epidemiological data using the inclusion and exclusion criteria given in Table 1, and data from 99 papers have contributed to this review. Table 1. Inclusion and exclusion criteria Outcomes of interest Burden of meningococcal disease Risk factors for meningococcal disease Background incidence of sporadic meningococcal disease Demographic details of endemic and epidemic disease Burden of meningococcal disease on health services Geographical variation in disease Size and frequency of meningococcal epidemics Seasonal variation in disease Group prevalence Nasopharyngeal carriage Mortality and sequelae Other identified risk factors Meningococcal control Epidemic response Vaccination trials Inclusion Criteria Official statistics Randomized controlled trials, cross-sectional, or cohort studies including consecutive case series Epidemic reports Exclusion criteria Non-consecutive case series Series with incomplete reporting of results Non-Indian data Two additional unpublished reports were obtained from the Indian National Institute of Communicable Disease (NICD). Meningococcal meningitis is a mandatory notifiable disease in India. But reporting remains incomplete and inconsistent, partly because it is not enforced and partly because of the complex private–public mix of Indian healthcare providers (IDSP 2008). The majority of data presented here is therefore from observational hospital-based reports and likely to present an incomplete picture (Verghese 1990). Results Endemic meningococcal disease in India During non-epidemic periods, pyogenic meningitis [defined by cerebrospinal fluid (CSF) changes suggestive of bacterial infection] has been reported as the main diagnosis in up to 3.3% of acute admissions to tertiary paediatric hospitals in India (Achar & Rao 1953; Paul 1963; Ahmed et al. 1964; Srivastava et al. 1968; Gandhi 1969; Reddi et al. 1973; Tamaskar & Bhandari 1976; Nalwa 1978; Ayyagari et al. 1980; Venkatesh et al. 1985; Kabra et al. 1991; Chinchankar et al. 2002). In the largest study reported, which covered six paediatric departments (all from northern India) for the year 1989, 1.5% of hospital admissions (852/56 338) of children aged <12 years were diagnosed as cases of acute bacterial meningitis (Kabra et al. 1991). Quantifying the proportion of these cases of meningitis that were attributable to N. meningitidis infection (or to any other pathogen) is difficult because of the large proportion of patients (often with significant mortality) in whom no organism was identified. This low diagnostic yield is likely to be due to a combination of antibiotic use prior to culture, lack of 24-h laboratory facilities and practical difficulties in sampling and culture techniques (Venkatesh et al. 1985; Kalra 1989; Pandit et al. 2005; Manchanda et al. 2006). The microbiological results obtained in 33 case series of pyogenic meningitis are presented in Table 2. Neisseria meningitidis was a rare isolate (median detection rate 1.9%, range 0.0–20.0%), and some of the higher rates may represent the extension of reported or unreported epidemics (Achar & Rao 1953; Ahmed et al. 1964; Ayyagari et al. 1980; Bhat et al. 1991; : Bhaumik 1998; Chinchankar et al. 2002; Deivanayagam et al. 1993; Gandhi 1969; Hemalatha et al. 2002; Jain et al. 2000; Javadekar et al. 1997; John et al. 2001; Kabra et al. 1991; Kalra & Dayal 1977; Kumar et al. 1980; Mani et al. 2007; Minz et al. 2008; Pal & Sant 1982; Panjarathinam & Shah 1993; Paul 1963; Reddi et al. 1973; Sahai et al. 2001; Shameem et al. 2008; Shivaprakash et al. 2004; Singhi et al. 2002a,b, 2004; Srivastava et al. 1968; Suvarna Devi et al. 1982; Tamaskar & Bhandari 1976; Taneja & Ghai 1955; Venkatesh et al. 1985; Vincent et al. 1987). Table 2. The proportion of Neisseria meningitidis isolates in case series of endemic bacterial meningitis Study ID State Year Age group No. of cases Microbiological resultNo. of cases (%) N. meningitidis* Streptococcus pneumoniae Haemophilus influenzae None Achar and Rao (1953) Tamil Nadu 1950–1951 Paeds 98 12† (12.2) 38 (38.8) 45 (45.9) 0 (0.0) Taneja and Ghai (1955) Delhi 1953–1955 <12 years 33 0 (0.0) 11 (33.3) 0 (0.0) 18 (54.5) Ahmed et al. (1964) Tamil Nadu 1953–1960 <12 years 87 2 (2.3) 29 (33.3) 33 (37.9) 15 (17.2) Paul (1963) Delhi 1956–1959 <12 years 48 3‡ (6.3) 22 (45.8) 10 (20.8) 10 (20.8) Srivastava et al. (1968) Uttar Pradesh 1964 <12 years 33 1 (3.0) 0 (0.0) 0 (0.0) 17 (51.5) Gandhi (1969) Gujarat 1966–1967 <12 years 60 10‡ (16.7) 12 (20.0) 4 (6.7) 33 (55.0) Reddi et al. (1973) Andrha Pradesh 1970–1971 Paeds 85 1‡ (1.2) 25 (29.4) 5 (5.9) 45 (52.9) Tamaskar and Bhandari (1976) Madhya Pradesh 1971–1972 <12 years 21 3†‡ (14.3) 6 (28.6) 3 (14.3) 5 (23.8) Kalra and Dayal (1977) Uttar Pradesh 1966–1969 1 month–12 years 196 10‡ (5.1) 19 (9.7) 0 (0.0) 126 (64.3)§ Ayyagari et al. (1980) Chandigarh 1976–1978 Paeds 176 1‡ (0.6) 72 (40.9) 11 (6.3) 59 (33.5) Kumar et al. (1980) Chandigarh 1977–1979 1 month–12 years 66 0 (0.0) 25 (37.9) 17 (25.8) 18 (27.3) Suvarna Devi et al. (1982) Orissa 1978–1981 <15 years 70 3 (4.3) 13 (18.6) 13 (18.6) 41 (58.6) Pal and Sant (1982) Maharashtra – – 64 15‡ (23.4) 23 (35.9) 0 (0.0) 0 (0.0) Venkatesh et al. (1985)¶ Tamil Nadu 1982 9 day–12 years 44 0 (0.0) 4 (9.1) 8 (18.2) 24 (54.5) Bhat (1991) Pondicherry 1972–1980 Paeds 256 0‡ (0.0) 54 (21.1) 6 (2.3) 167 (65.2) Vincent et al. (1987) Kerala 1983–1984 1 month–12 years 51 8‡ (15.7) 2 (3.9) 0 (0.0) 24 (47.1) Kabra et al. (1991) Various 1989 <12 years 852 21 (2.5) 22 (2.6) 8 (0.9) 720 (84.5) Deivanayagam (1993) Tamil Nadu 1989–1990 2 months–11 years 114 1 (0.9) 15 (13.2) 28 (24.6) 59 (51.8) Panjarathinam and Shah (1993) Gujarat 1990 <10 years 135 0 (0.0) 5 (3.7) 0 (0.0) 96 (71.1) Javadekar et al. (1997) Gujarat – Paeds 50 4‡ (8.0) 2 (4.0) 1 (2.0) 42 (84.0) Bhaumik (1998) Delhi – 12–75 years 30 6†‡ (20.0) 9 (30.0) – 15 (50.0) Jain et al. (2000) Delhi – 3 months–12 years 32 6 (18.8) 13 (40.6) 7 (21.9) 0 (0.0) Sahai et al. (2001) Pondicherry 1994–1996 1 month–12 years 100 0 (0.0) 12 (12.0) 17 (17.0) 65 (65.0) John et al. (2001) Tamil Nadu 1997–1998 0–60 years 61 0‡ (0.0) 13 (21.3) 1 (1.6) 37 (60.7) Singhi et al. (2002a) Chandigarh – 1 month–12 years 107 0† (0.0) 3 (2.8) 23 (21.5) 76 (71.0) Singhi et al. (2002b) Chandigarh 1998–1999 3 months–12 years 69 3 (4.3) 14 (20.2) 6 (8.7) 43 (62.3) Chinchankar et al.(2002) Maharashtra 1997–1999 1 month–5 years 54 1 (1.9) 21 (38.9) 14 (25.9) 10 (18.5) Hemalatha et al.(2002) Andrha Pradesh 1998–2000 1–5 years 120 7 (5.8) 20 (16.7) 6 (5.0) 70 (58.3) Shivaprakash et al. (2004) Karnataka – Paeds 204 2‡ (1.0) 8 (3.9) 3 (1.5) 177 (86.8) Singhi et al. (2004) Chandigarh 1993–1996 1–12 years 88 1 (1.1) 11 (12.5) 9 (10.2) 60 (68.2) Mani et al. (2007) Karnataka 1996–2005 All ages 385 4 (1.0) 238 (61.8) 7 (1.8) 101 (26.2) Shameem et al. (2008) Karnataka 2003–2007 Paeds 236 18† (7.6) 94 (39.8) 61 (25.8) 0 (0.0) Minz et al. (2008) Tamil Nadu 1997–1999 0–4 years 97 0 (0.0) 2 (2.1) 6 (6.2) 81 (83.5) Case series from Delhi 1966/1967, Delhi/Mumbai/Calcutta 1985/1988 and Delhi 2005/2006 have been excluded because of the known presence of meningococcal epidemics. The inclusion criteria for the case series above were based on clinical suspicion plus biochemical changes in cerebrospinal fluid (CSF) suggestive of bacterial infection except Achar & Rao 1953; Jain et al. 2000; Pal & Sant 1982 and Shameem et al. 2008 who only included cases with positive identification of a causal organism. The criteria for inclusion in Gandhi 1969 and Kabra et al. 1991 are unclear. *Confirmed cases: Clinical features plus culture +ve or antigen detection +ve for N. meningitidis. †Probable or confirmed cases. A probable case: Clinical features plus Gram-negative diplococci on smear or petechial rash. ‡Confirmed cases by CSF culture only. Antigen detection tests were either not done or incompletely reported. §69 patients did not undergo successful CSF sampling. ¶This paper contains additional unpublished data for Tamil Nadu 1967/1969, 1974/1977 showing N. meningitidis isolations consistently below 3%. We found only one study which provided an adequate denominator to define the incidence of bacterial meningitis (Minz et al. 2008). This was a 2-year prospective study, conducted in southern India, whose primary aim was to estimate the burden of invasive Haemophilus influenzae type b disease in children aged <5 years. Surveillance was conducted throughout all secondary and tertiary hospitals that served a defined population, and through verbal autopsy of children who died without attending medical facilities. The authors estimated that the incidences of probable bacterial meningitis (defined as clinical signs plus CSF leukocytosis >100 WBC/μl) and of culture positive meningitis of any cause in children under 5 years of age were 37 per 100 000 per year (95% CI 27–50) and 15.9 per 100 000 per year (95% CI 8–23) respectively. These figures are low by international standards and may not be representative of the whole country. We found few data on the incidence of septicaemia. One study from Chandigarh suggested that the burden of septicaemia was similar to that of meningitis; 1222 (2.8%) and 1126 (2.6%) of 43 800 emergency department attendances in 1995–2000 were attributable to meningitis or septicaemia respectively (Singhi et al. 2003). However, in seven case series of childhood or adult septicaemia, N. meningitidis was not isolated from over 6000 samples (Bhakoo et al. 1968; Somu et al. 1976; Das et al. 1978; Yardi et al. 1984; Pathare et al. 1988; Arora & Devi 2007; Garg et al. 2007). There is little information on the serogroups responsible for endemic meningococcal disease in India. Ayyagari et al. (1987) reported that between 1980 and 1984 only 12 strains of meningococcus were isolated at the Postgraduate Institute of Medical Education and Research in Chandigarh, of which eight were serogroup A and four serogroup C. We found only a single case report of proven group B meningococcal disease in India (Suri et al. 1994). Epidemic meningococcal disease in India Occurrence The earliest reports of cerebrospinal fever (an early term for meningococcal meningitis, not necessarily excluding other aetiologies) in India were summarized by Patel 1926: ‘The first authentic report of a case is by Vandyke Carter, who records four cases in Bombay where he was working at famine fever in 1878. Lieut.-Colonel Dimmock recognized the disease in epidemic form amongst the convicts of the Shikarpur Jail during the cold season of 1883–1884. Since 1881, cases have been reported all over India from various jails, army barracks, etc., but in Bombay proper cases began to arrive in municipal hospitals in the year 1912. They were diagnosed as cerebro-spinal fever from clinical signs only until 1921, when the present observations began.’ (Patel 1926). Patel (1926) then reported 170 consecutive cases from Bombay (Mumbai) during the years 1921–1924. He described cerebrospinal fever as ‘a disease of winter and spring’, ‘of overcrowding and poverty’, and as ‘affecting mainly adult males over the age of 20 years’– astute observations that mimic the epidemiology of documented meningococcal epidemics in India today. The first records of widespread epidemic disease among the general population appear in the 1930s. This epidemic peaked between February and June, 1934, with 2953 reported cases and 1793 deaths (Ahuja & Singh 1935). The major towns of northern India – Delhi, Kolkata and Ahmadabad – were particularly affected; though, widespread outbreaks were recorded (Sen et al. 1934; Tyrell & Kapur 1935; Vengsarkar 1947). Since the 1930s, India has experienced three documented periods of increased meningococcal disease (with cases always reported first in New Delhi), with an apparent periodicity of approximately 20 years, and with small isolated outbreaks in between (Figure 1, Table 3) (Verghese 1990; NICD 2009). Figure 1Open in figure viewerPowerPoint The distribution of Indian epidemics over time and place. Data are adapted from the studies presented in Table 3. Where multiple reports of the same epidemic exist, the most complete figures were used. Data were included for each year when the number of cases was stated to be significantly higher than that for a normal year. Epidemics are shown proportional to size. The vertical red columns represent the periods of generalized epidemics. Table 3. Timeline of Indian meningococcal epidemics Year Main source Description Number of cases (%) Suspected Probable/confirmed* Deaths 1884 Lal and Yacob (1935) Shikarpur Isolated outbreak in a prison ? ? ? 1886–1901 Ahmad and Roy (1940) Alipore, Isolated outbreak in a prison Data for 1886 and 1901 only 18 53 ?? 11 (61.1) 36 (67.9) 1921–1924 Patel (1926) Mumbai, Maharashtra: Described as a case series during an ‘epidemic’ No assessment of any wider epidemic is available 170 ‘most’ 99 (58.2) 1927–1934 Ardeshir (1935) Nasirabad, Maharashtra Isolated outbreak in a military training camp Peaked in 1930 with 15 cases 47 ? 26 (55.3) 1932–1933 Lal and Yacob (1935)† Lahore (Pakistan) Isolated outbreak in a prison 27 ? 11 (40.7) 1934 Tyrell and Kapur (1935) Indore, Madhya Pradesh Data presented are from a single hospital Makes reference to wider Indian epidemic 40 ? 10 (25.0) 1934 Ahuja and Singh (1935) Ahmedabad, Figures are from official records for Dec 1933 to June 1934 Described as ‘a considerable increase’ 592 ? 271 (45.7) 1934 Ahuja and Singh (1935) Delhi UT Figures are from official records Described as ‘a severe outbreak’ 390 ? 265 (67.9) 1934–1939 Ahmad and Roy (1940) Kolkata, West Bengal Reports rose from 149 in 1932 to 1193 in 1935 and 1674 in 1939 1193 1674 ? ? ? ? 1936 Vengsarkar (1947) Mumbai, Maharashtra Reports rose from 7 in 1933 to 356 in 1936 and stayed high until 1939. 356 ? 231 (64.9) 1934–1939 Vengsarkar (1947) Other areas affected 1934–1939: NW Frontier province (Pakistan), Punjab, Bihar, Orissa, Bengal (Bangladesh/West Bengal), Mumbai and Rajasthan No data available 1961–1962 Lal et al. (1963) Delhi UT Isolated outbreak in a military training camp 27 11 (40.7) 2 (7.4) 1966–1967 Pattanayak et al. (1967) New Delhi, Delhi UT Collated data from 5 hospitals Reports rose from 243 in 1965 to 616 in 1966. 616 116 (18.8) 129 (20.9) 1968–1969 Bhalla et al. (1972) Hyderabad, Andhra Pradesh Isolated outbreak in a military training centre 47 25 (53.2) 2 (4.3) 1969 Sathe (1971) Aurangabad, Maharashtra Isolated outbreak in a prison 10 2 (20.0) 1 (10.0) 1985–1988 Basu (1986a,b)/Verghese (1990) New Delhi, Delhi UT Collated data from 7 hospitals Reports rose from 1204 in 1983 to 6133 in 1985 and remained high until 1988 6133 ?‡ 799 (13.0) 1985 Basu (1986a,b) Other areas affected 1985: Assam (25), Bihar (37), Gujarat (195), Haryana(20), Karnataka(25), Madhya Pradesh (32), Maharashtra (1573), Rajasthan (473), Tamil Nadu (22), Tripura (2), Sikkim (55), Uttar Pradesh (334), West Bengal (471), Goa Daman & Diu (30). Data are for suspected cases reported to National Institute of Communicable Disease (NICD) 1985/1987 Bhavsar et al. (1989) Surat City, Gujarat Total 197 cases from Nov 85 to Jun 87 Peak in 1986 with 160 cases 197 66 (33.5) 34 (17.3) 1989 Sehgal (1987) Kalahandi, Orissa An outbreak of unexplained death in a rural population 32 (+87 possible) 29 (?) 2 (+87 possible) 1997 Nagraj et al. (1998) Baddi village, Chandigarh Isolated outbreak in a factory 8 2 (25.0) 4 (50.0) 2005–2008 NICD (2009) New Delhi, Delhi UT Overview data from NICD Cases continue in 2009 867 ?‡ ? (%) 2008 NICD (2009) Meghalaya Overview data from NICD Cases continue in 2009 Approximately 2000 ? Approximately 200 (10) 2009 NICD (2009) Tripura Overview data from NICD Cases continue in 2009 Approximately 200 ? Approximately 50 (25) The data presented for general population epidemics are the most complete reports available, but are likely to underestimate the true size of the epidemic. *Confirmed case: Clinical features plus culture +ve or antigen detection +ve for Neisseria meningitidis, probable case: clinical features plus Gram-negative diplococci on smear, or a petechial rash. †The Ref Lal and Yacob (1935) and all values associated with it is in italics in Table 3 as technically this trial was in Pakistan not India (although it was India at the time of the trial). ‡Data from smaller case series show N. meningitidis isolation rates of approximately 40–50%; 1985 (Gulati & Mehta 1985; Singh et al. 1987, 1988), 2005 (Duggal et al. 2007). During these epidemic periods, hospital-based reports record a leap in both the number of admissions caused by suspected bacterial meningitis, and in the proportion of positive N. meningitidis isolations (rising to 40% or 50% of all suspected cases) (Pattanayak et al. 1967; Ghosh & Ghosh Roy 1970; Basu 1985). The majority of reports related to clinically suspected meningitis, but three reports (of small case-series) suggested that meningococcal septicaemia also occurred in significant numbers during these epidemics (Seghal et al. 1986; Paul et al. 1988; Saha et al. 2006). The largest Indian epidemic on record began in New Delhi in the winter of 1984 (Basu 1985, 1986a,b; Gulati & Mehta 1985; Prasad et al. 1985; Taneja 1985; Bhave & Gaikwad 1986; Seghal et al. 1986; Ayyagari et al. 1987; Deorari et al. 1987; Sarkar et al. 1987; Singh et al. 1987, 1988; Paul et al. 1988; Talukdar et al. 1988; Annapurna et al. 1989; Verghese 1990; Saha et al. 2006). Data from this epidemic are presented graphically in Figure 2. In 1985, at the peak of the epidemic, 6133 cases and 799 deaths were reported. These figures, though widely quoted, represent only those cases who presented to the seven major hospitals in New Delhi (Basu 1986a,b). The true scale of this epidemic in New Delhi, or indeed in the wider Indian community, is unknown. A conservative estimate of the magnitude of the epidemic, based on the proportion of the population covered by the seven sentinel hospitals, suggests that the figure for New Delhi could have been at least double the 6133 recorded11 In 1987, the population of New Delhi was approximately 6.8 million, and the bed-to-population ratio was 2.29/1000 (source http://delhiplanning.nic.in/Economic%20Survey/chapter_16.htm). The total number of beds at the seven hospitals (using 2009 figures) estimates the population coverage at 3.4 million. However, (i) the number of beds w
Publication Year: 2010
Publication Date: 2010-11-05
Language: en
Type: review
Indexed In: ['crossref', 'pubmed']
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