Dobbs and the viral encephalitis outbreak

Dobbs (Doctors Only BBS, http://dobbs.com.my/ ) is an Internet based electronic bulletin board for Malaysian doctors which has been in existence for one and a half years now. There are currently about 490 doctors registered with Dobbs.

The recent outbreak of viral encephalitis in Malaysia is naturally of great concern to medical practitioners in general. Interestingly, this outbreak has also generated much ongoing discussion within Dobbs. Perhaps it illustrates how modern electronic communications allows doctors scattered across the country to rapidly disseminate information as well as request for information and discuss issues.

The following are taken from ongoing Dobbs discussion on the subject and chronicles the development of the outbreak as "seen through the eyes" of online doctors.

The beginnings of the outbreak

The first inklings of the problem actually stemmed from a request for help from colleagues in Ipoh. This led to some exchange of information as well as offers of assistance. A listing of the ensuing discussion is reproduced as follows:

Messages posted to topic: Japanese B encephalitis


Subject: Request For Assistance
From:
Dr. Mohamad Sharif Fahruddin
Date: 16-Nov-98

I am posting this message on behalf of my colleagues at the Kinta Health Office. There has been a case of Japanese B encephalitis here in Ipoh and we would be grateful for assistance from our learned colleagues with regards to the overall management and control of this disease. Thanking you all in advance.

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Subject: RE: Request For Assistance
From:
Dobbs Admin
Date: 17-Nov-98

The WHO has published a guideline on JE treatment and there are more recent articles on the subject from Thailand. Unfortunately, there is still no antivirals for the condition and the treatment is mainly supportive.

If detailed information is needed, please contact me.

Prof. S.K. Lam Department of Medical Microbiology Faculty of Medicine University of Malaysia 50603 Kuala Lumpur Malaysia.

E-mail : lamsk@medicine.med.um.edu.my Tel. : 03-7502324 Fax : 603-7582801

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Subject: RE: Request For Assistance
From:
Dobbs Admin
Date: 26-Nov-98

The Jap B Vaccine is available now ( New stock just arrived )

The recomended schedule is one dose now and the second dose 1 week later, followed by booster 1 year later.

However, for those over 60 years and those going into an infected area, they recomend another dose 1 month after the first dose.

Since Ipoh is apparently having an out break, 11 confirmed cases so far, shouldn't we recommend a schedule of 0 . 1 week , 1 month and 1 year ?

Can someone please advice ?

BUSHIDO [hwang@pc.jaring.my] "Vir prudens non contra ventum mingit"

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Subject: RE: Request For Assistance
From:
Alan Teh
Date: 26-Nov-98

In view of the request for information on JE, herewith is a scanned document on WHO Technical Guidelines on Japanese Encephalitis kindly provided by Prof Ken Lam (lamsk@medicine.med.um.edu.my)

You may download the article from:

http://dept.med.um.edu.my/jpenwho.pdf

The file size is 1.3MB and it runs into about 30 pages. Sorry about the black edges but it's the best I could do for a "quick and dirty" scan.

You need Adobe Acrobat Reader (freeware) if you don't have this already - downloadable from www.adobe.com

Alan Teh

alanteh@pc.jaring.my

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Subject: RE: Request For Assistance
From:
Dobbs Admin
Date: 26-Nov-98

On Thu, 26 Nov 1998 05:42:07 -0800, dobbs@shoppe.com.my wrote:

>Alan Teh has posted a new message to DOBBS General BBS.

>You may download the article from: >http://dept.med.um.edu.my/jpenwho.pdf

Thanks Prof Alan & Prof Lam. That cleared up the confusion about the 3 rd dose.

There was another confusion:

A 51 yr pig trader came for vaccination. He goes to the affected farm in Ampang twice a day and all the workers in that farm had been vaccinated. Another colleague did not give him the vaccine because he is a diabetic and diabetes was listed as a contraindication in the drug literature.( together with acute febrile illness, infection,pregnancy, malignancies,diseases of the heart, kidney & liver & malnutrition states ) ( with the stipulation that " except where, in the opinion of the physician,the risk of infection far out-weighs the risk of vaccination" )

In view of his regular visits to the outbreak area and close contact with the animal host, and his mild diabetes controlled with Glucophage BD, he was given the vaccine after explaining the warning.

The WHO guidelines does not even mention diabetes as a contraindication.

>The file size is 1.3MB and it runs into about 30 pages. Sorry about the black edges but it's the best I could do for a "quick and dirty" scan.

Once again, thanks for your effort. > >You need Adobe Acrobat Reader (freeware) if you don't have this already - downloadable from www.adobe.com

Should have warned that it is 4.7 MB ! :-)

BUSHIDO [hwang@pc.jaring.my] "Vir prudens non contra ventum mingit"

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Subject: RE: Request For Assistance
From:
Dobbs Admin
Date: 26-Nov-98

I am given to understand that laboratory confirmation for the fatal cases has not been conclusive. If my WHO Centre can help, please let me know.

Hope the situation is under control.

Regards.

Prof. S.K. Lam Department of Medical Microbiology Faculty of Medicine University of Malaysia 50603 Kuala Lumpur Malaysia.

E-mail : lamsk@medicine.med.um.edu.my Tel. : 03-7502324 Fax : 603-7582801

---------- From: Dr FM Sharif[SMTP:msbf@pc.jaring.my] Sent: Wednesday, November 25, 1998 10:34 PM To: Lam Sai Kit, Kenneth Cc: Alan Teh Subject: Re: DOBBS Forum Posting--RE: Request For Assistance

Dear Prof Alan and Prof Lam,

Thanks for the info.

I have given Prof Lam's contact number to the Kinta Health Officer. I don't know whether she has contacted you or not. Anyway I will pass this to her.

Thanks.

Sharif, Ophthalmologist ( helping out my health colleagues) Ipoh.

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Subject: RE: Request For Assistance
From:
Muruga Vadivale
Date: 05-Mar-99

Just a note to inform those who would like additional information on Japanese Encephalitis- may get it from this site at http://www.vadscorner.com/je.html

 

 

Subsequent developments

The next inkling of unusual features in this outbreak was also discussed in Dobbs in early March 1999:

Messages posted to topic: Thoughts on the JE outbreak

Subject: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 09-Mar-99

My concerns about the JE outbreak:

I wonder if we are dealing with a new strain of the virus or something else altogether?

1. Most current admissions to the hospital where I work have been vaccinated

2. Even the older folk are affected

3. Vast majority of patients are IgM negative in blood and csf

4. I hear even the pigs are dying

I would be interested to hear what the public health doctors have to say Sounds like the MOH better call in the CDC for help IMHO


Subject: RE: Thoughts on the JE outbreak
From:
Muruga Vadivale
Date: 09-Mar-99

Heard that there is a HOTLINE in MOH to ask questions.......not sure of the number.

I wonder if anyone is doing an epidemiology study on all cases with suitable controls.....the answer is there....I am sure there are more than enough cases to come to a preliminary hypothesis.

Best regards,

M.Vadivale

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Subject: RE: Thoughts on the JE outbreak
From:
Dr Neoh Wee Keong
Date: 09-Mar-99

>1. Most current admissions to the hospital where I >work have been vaccinated

By whom ? How ? Which vaccine ? I would be interested to find out more details regarding the vaccination . Peoples are confused by many version of stories given by various peoples . Some thought that their children were protected because they had HIB vaccination !

> I mean we should take things seriously ala HK >authorities and the chicken avian virus epidemic.

Agreed totally . A special task force should be set up and headed by an Epidemiologist( not politicians) to handle this epidemics . Would MMA like to give this suggestion to MOH ?

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 09-Mar-99

They had the standard JE vaccine I think though I do not know how many doses - it may not be protective if the vaccination is not complete. If complete, the worry is a mutant strain to which the vaccine is ineffective

Alan Teh

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 09-Mar-99

One epidemic after another! That seems to be the bad luck of Malaysia in recent times.

But, is it so?

When is an epidemic an epidemic?

In Malaysia, it seems to be so only when the newspapers decide that to be so. I think we badly need a well formulated public health strategy to deal with epidemics in this age of IT.

Dr Chong Hoi Hee [drchong@pc.jaring.my]

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Subject: RE: Thoughts on the JE outbreak
From:
Muruga Vadivale
Date: 11-Mar-99

Here are some FAQ and answers by Prof.Lam S.K.

For more information on JE visit http://www.vadscorner.com/je.html

M.Vadivale

JE FAQs

In response to the many questions from medical personnels as well as the general public about the JE outbreak, I have decided to post some answers to these frequently asked questions.

1. Can JE be spread if I come into contact with an infected person?

Infected mosquitoes of the Culex family transmit JE after feeding on viremic animals, especially pigs. A mosquito feeding on a viremic person will not get infected because there is not sufficient virus in the blood to infect it. Man then is a dead end host for JE virus. One cannot be infected by JE through direct contact with an infected person.

2. I am staying in Seremban and not associated with pig farms. Should I be vaccinated?

The current policy of the Ministry of Health is to vaccinate those at high risk. These would be people working in pig farms, their families and those living within 2 kilometers of the farms since that is the flight range of the mosquito. Staying in an urban area such as Seremban does not constitute a high risk.

3. Is it necessary to receive 3 doses of the vaccines? Can I get away with only two?

Although the manufacturer recommends 2 doses within 1-2 weeks, it is best to get a 3rd dose 30 days after the first dose to get adequate protection. Two doses will give about 80% protection but 3 doses will provide up to 95% protection. Boosters are recommended every 3 years.

4. What is the best available test(s) to confirm a case? How long will it take to get the results?

Detection of JE IgM antibody is the best available test and in non-fatal cases, almost all patients should be positive within one week of disease onset. The test takes only a few hours to perform. In fatal cases, IgM serology may be negative. Other tests such polymerase chain detection of viral RNA or virus isolation are useful.

5. Is it possible to be infected with JE and not become sick?

Yes, one can get asymptomatic infection or a very mild disease. As a matter of fact, the ratio of symptomatic to asymptomatic is 1:300.

6. Can pigs die from JE? Is pork safe to consume?

This has not been documented. JE can cause spontaneous abortion in pregnant sows. Pork is safe to consume since the virus cannot survive in the meat and meat products.

7. Why are we seeing cases mainly in adults when we know that JE is usually associated with children?

This is an unusual feature of the current outbreak. In other outbreaks around the world, children are the victims. There is still a lot we do not understand about our JE outbreak.

8. Is the vaccine effective? Why are there deaths among those vaccinated?

The vaccine is effective in over 90% of those receiving 3 doses but there is still some who will not get protection. No vaccine is 100% effective. In those who died despite adequate vaccination, we have to prove that the cause of death is JE before we say that the vaccine failed to protect. It must be remembered other viruses and complications from underlying illnesses can be confused with JE.

9. Are the measures taken to control the outbreak adequate and appropriate?

JE is a zoonotic infection and transmitted by mosquitoes. The multiprong approaches taken to date are correct in an epidemic situation. However, implementation can pose problems. No new cases have been reported in Perak so there is hope that the control measures are effective.

10. Will the disease spread to other parts of the country?

We hope not. Strict measures are taken to prevent the movement of pigs and vector control is being stepped up in areas where the disease has not appeared. In addition, vaccination of humans and pigs are on-going.

Prof. Lam S.K

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Subject: RE: Thoughts on the JE outbreak
From:
Sri Ranga
Date: 11-Mar-99

Prof. Alan mentioned " Vast majority of patients are IgM negative in blood and csf". Instead of using serology are there facilities here for PCR tech. to detect the viral RNA?

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 11-Mar-99

On Thu, 11 Mar 1999 05:15:55 -0800, dobbs@shoppe.com.my wrote:

>Muruga Vadivale has posted a new message to DOBBS General BBS.

>Message>Here are some FAQ and answers by Prof.Lam S.K.

Thanks, that was good.

I have one question.

According to WHO report, the mosquito bites the viremic host &, after an incubation period of 9 to 12 days, can transmit the disease to the other hosts.

I saw an exhibition by the health authorities in my club today, it says that the infected mosquito can pass on the virus in its eggs and hatch a new batch of infected mosquitos without going through an intermediate host.

Is that correct ? If so, then the destruction of all those pigs would be in vain, wouldn't it ?

BUSHIDO [hwang@pc.jaring.my]

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 12-Mar-99

In reply to Sri Ranga, yes there are locally available facilities to detect the virus by PCR but these are not so readily available as the IgM serological test. I do not know the PCR results of those tested negative for IgM. Will check with Prof Ken Lam

Alan Teh

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Subject: RE: Thoughts on the JE outbreak
From:
Muruga Vadivale
Date: 12-Mar-99

There are now updates on JE at MOH site at http://dph.gov.my/press/press2/japan_e.htm

At last! Good work MOH!

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Subject: RE: Thoughts on the JE outbreak
From:
Muruga Vadivale
Date: 16-Mar-99

Very interesting article :- Diagnosis and Management Of Viral Encephalitis by James F. Bale, Jr., MD, Alan R. Seay, MD; Infect Med 15(8):547-548,550-556, 1998...from Infections in Medicine Journal see http://www.medscape.com/SCP/IIM/1998/v15.n08/m3128.bale/pnt-m3128.bale.html

Latest updates at http://www.vadscorner.com/je.html

M.Vadivale

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Subject: RE: Encephalitis outbreak - a new virus?
From:
Dobbs Admin
Date: 16-Mar-99

Hot off the press - my notes from morning symposium on the current outbreak held in UH on 0800 17 March 1999 These are unedited notes taken on my PalmPilot and hotsynched. Pls note there is only a _suspicion_ of a new virus and this is not yet confirmed but quite possible...

JE Symposium 3/17/99

27m 3f mean age 33.9 (13-52)yrs bkt pelanduk 73% sg nipah

vaccination doses

nil - 20%

1 - 3.3%

2 - 36.7%

3- 33.3%

don't know - 6%

14/30 ventilated

unusual features:

clinical: does not affect pyramidal system if recovers - very well rapid onset coma ? Brain stem involvement

epidemiological: direct pig handlers rather than only staying in area adults affected, few children pigs dying

lab features:

diagnostic tests used inhouse IgM Elisa panbio eia from austra haemagg inhib pcr with je primer virus isolation - vero, ps, c6/36 suckling mice

only 51.7% confirmed to be je by 1 or more tests as above expect 100% seropos in pair samples but 50% seroneg pts with paired samples

isolation of new virus from 5 csf in vero cells - caused paralysis in mice

The new virus:

syncytial cpe in 24hrs

size & morph in em - 140-160nm unlike je (smaller)

isoln in vero kills mice in 2 days

presence of Ab to ciinical isolates

member of paramyxovirus rather than flavivirus (eg measles, hendra, australian bat lyssa + other zoonotic virus)

awaiting confirmation from cdc

possibility of use of ribavarin as for enveloped rna viruses


Subject: RE: Thoughts on the JE outbreak
From:
Muruga Vadivale
Date: 17-Mar-99

Interesting....need to update my page on info on paramyxoviruses.

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Subject: RE: Thoughts on the JE outbreak
From:
Dr. Chan Sook Ching
Date: 17-Mar-99

In view of latest at JE symposium, if patients / members of our own family who stay within 2 km of pig farm but are not pig handlers, ask for advice on JE vaccine, what do we tell them? 33.3% with 3 doses still get infected from data given.

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 17-Mar-99

On Tue, 16 Mar 1999 18:13:26 -0800, dobbs@shoppe.com.my wrote:

>vaccination doses >nil - 20% >1 - 3.3% >2 - 36.7% >3- 33.3% >don't know - 6%

This is scary ! It appears that we were vaccinating against the wrong virus !

Thanks for the update.

BUSHIDO [hwang@pc.jaring.my]

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 17-Mar-99

On Tue, 16 Mar 1999 18:13:26 -0800, dobbs@shoppe.com.my wrote:

>JE Symposium 3/17/99

>epidemiological: >direct pig handlers rather than only staying in area >adults affected, few children >pigs dying

If I remember correctly, there were 2 deaths of abbatoir workers ?

If so, and the recent cases were direct pig handlers, would you consider a direct contact route other than via mosquitos ?

Perhaps, saliva, blood or other bodily fluids ? Or even mites or ticks ?

BUSHIDO [hwang@pc.jaring.my]

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 17-Mar-99

Hwang wrote:

>If I remember correctly, >there were 2 deaths of abbatoir workers ?

>If so, and the recent cases were direct pig >handlers, >would you consider a direct contact route other >than via mosquitos ?

That would seem to be the case. If it were mosquitoes, surely others staying in the vicinity but not handling the pigs directly would have been affected.... As it is, those affected handled the pigs directly. We can only speculate on the actual route of transmission for now...

So far no evidence of human-human transmission for this virus but it would be prudent for all hospital health care workers with such patients admitted to undertake universal precautions

Alan Teh

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Subject: RE: Thoughts on the JE outbreak
From:
Muruga Vadivale
Date: 17-Mar-99

Information on paramyxoviruses and related "new viruses" at http://www.vadscorner.com/paramyxo.html No mention is made to the present outbreak until confirmation or announcement by MOH.

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Subject: RE: Thoughts on the JE outbreak
From:
Dobbs Admin
Date: 17-Mar-99

I've just discovered there's a pig farm not far from my clinic, and intend to vaccinate myself and my staff.

Could anybody kindly suggest 1. what vaccine I should use, and 2. where I can obtain such vaccine?

also, would anyone be able to hazard a guess on how much immunity one could actually expect from such vaccination?

raghbir (already mad with work, could i be immune to enchaphalitis?)

** wiser men do not make enemies with mosquitos

Raghbir Singh [raghbir@pc.jaring.my]

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Subject: RE: Thoughts on the JE outbreak
From:
Dr Hon Peck Lim
Date: 19-Mar-99

Care to imagine what is the actual situation at groung zero ? I practice in Seremban (~40 km from Bukiy Pelandok)and have the opportunity to speak with some residents and patients from there.

1) Bukit pelandok town, once a thriving town lined with Mercs and Accords is now a ghost town.

2) Initially residents moved out because of the stench of rotting unattended carcasses and later when neighbours, friends and relatives start falling ill and dying ther was a mass exodus.

3) Squealing hungry pigs were left unattended.

4) Some brave farmers were killing pigs by clobbering them to death with planks!. 1 squealing hungry pig can give you nightmares. Can you imagine thousands of them being killed in this way? 5)Imagine the psycho-sosial and economic impact. - families forced to abandoned their bussinesses and become unemployed. - house rental in surroung towns (eg Lukut) have skyrocketed - huge financial loss for those directly involved in pig farming. - widespread depression and anxiety . There was at least 1 case of suicide.

It was indeed heart-wrenching to hear some of these stories first-hand. It baffles me why something like this was allowed to happen. It is not because we do not have the knowledge , technology , laws and guidelines that govern pig farming.

It is my hope that the powers that are responsible for implementation, inspection, enforcement in the Ministry of Health, Veterinary services and Local Authorities would buckle up and take their responsibilities more professionally otherwise you can bet your last dollar that something like this will occur again even with chicken, horses and cattle!

Have to get this off my chest.

regards from P L HON.

[further discussions/threads deleted for the sake of brevity but are available for reading on Dobbs http://shoppe.com.my/dobbs]

 

Conclusions

An online forum like Dobbs allows information to be disseminated rapidly within the community. Doctors like all Internet users should also be wary that misinformation or inaccuracies could easily as well be rapidly disseminated in this manner. Nevertheless, I feel that it is a powerful tool for the medical community and as an experiment in online medical discussion for the Malaysian medical community, I believe Dobbs has only just begun to show its potential. Some discussions in particular may be deemed "sensitive" and not suitable if readily accessible in a public electronic forum but Dobbs is a closed forum confined to the Malaysian medical community. All Malaysian doctors who have Internet access are invited to join Dobbs at http://dobbs.com.my/

Alan Teh

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Last Updated 9th May 2005.