Japanese Encephalitis

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Japanese Encephalitis

• Epidemiology and Vaccination in India

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Disease Burden

• Leading cause of viral encephalitis in Asia
• 35,000-50,000 cases annually
• (SourceCDC,2004)

3
Death and disability from JE

• Up to 30 of all patients with JE die.
• For those that survive the illness, more than 30
  cases are left with disability.
• Disability is both physical and cognitive.

4
JE Virus

• Belongs to the flavivirus family
• Antigenically related to several other flavivirus
  including St. Louis encephalitis and West Nile
  fever
• Vector-borne
• Transmitted by biting Culex mosquitoes that breed
  in rice paddies, ditches, and ground pools
• Zoonotic
• Pigs Amplifying Hosts
• Birds - Reservoirs.
• Humans are not infectious reservoirs.
• There is no human to human transmission.

Culex tritaeniorhynchus (Cx vishnui group)
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JE Virus Transmission Cycle
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Population at risk

• People living in rural areas have the highest
  risk of disease because the mosquitoes that
  spread JE breed in rice paddies and pools of
  water.
• Cases in urban areas also occur.

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A typical JE case in India

• An unvaccinated child below 15 years living in
  the rural rice growing regions of India. Close
  proximity to pig farming increases the risk of
  infection.

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JE Control
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Different approaches

• Control programs for JE have focused on three
  major areas
• Mosquito control
• Amplifying host (Pig) control
• Vaccination

• Neither mosquito control nor pig control have
  proven to be reliably effective public health
  measures to control JE in human

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Role of vaccination in JE control

• With the availability of safe, effective and
  affordable vaccines, JE control is now possible,
  as an integrated part of the public health
  system. Vaccination now provides an effective and
  reliable public health intervention
• (WHO/SEARO/2006)
• "Vaccination is the single most important control
  measure JE vaccination should be extended to all
  areas where JE is a demonstrated public health
  problem." (WHO JE position paper, 2006)

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JE vaccination strategy

• A proven immunization strategy for JE control
  seems to be to initiate a preventive campaign in
  high risk areas and age groups followed by
  introduction of vaccine into the routine EPI
  programme
• (Bi-regional JE Meeting, 2005 WHO/PATH)

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JE vaccination in India - 2006
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Triggering Factor (s)

• Massive outbreak of JE in districts of Eastern
  Uttar Pradesh and adjoining Bihar in 2005
  adjoining Terai Region of Nepal
• In 2005, More than 1600 deaths and more than 6000
  cases were reported from eastern Uttar Pradesh
  alone

• Evidence of JE transmission since 1950s
• Outbreak of JE reported since 1970s
• Over the past decade repeated cyclical outbreaks
  causing large number of deaths and disabilities
  reported from 12 States

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Target population

• Almost 95 of cases reported are below 15 years
  of age

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At risk districts- Prioritization

• Total number of cases reported over the past
  decade
• Disease incidence
• Recent outbreak
• Serological evidence
• Epidemiological continuity

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Vaccine availability

• Currently, there are three types of JE vaccines
  in large-scale use
• Mouse brain-derived, purified and inactivated
  vaccine
• Cell culture-derived, inactivated JE vaccine
  based on the Beijing P-3 strain (only available
  in China and being replaced by live attenuated
  vaccine).
• Cell culture-derived, live attenuated vaccine
  based on the SA 14-14-2 strain of the JE virus.

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JE Vaccines Today
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In Pipeline
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M-b derived inactivated vaccine

• Has been used globally successfully to control JE
• Safe, efficacious
• Manufactured in India and used in many states
  since 70s

• Multiple doses ( 3 Primary Booster)
• High cost
• Low availability
• Production stopped by major manufacturers
  globally
• CRI may also close down the production

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Cell culture-derived, inactivated JE vaccine

• Used in China for domestic purpose
• Not available in Global market
• Being replaced by SA14-14-2 live attenuated
  vaccine

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SA14-14-2 Live attenuated JE Vaccine

• Has been used since 1988 in China
• Over 200 million children vaccinated
• Safe and efficacious (GACVS)
• High immunogenicity following single dose
• Nepal campaign study ( Lancet GACVS)
• Licensed in Nepal and South Korea and Thailand
• Following this the vaccine has been licensed in
  India for use in public health programs and is
  in the final stages of licensing in Sri Lanka
• Special cost of vaccine for public program in
  GAVI eligible countries
• Approximately 13 children could be vaccinated
  with the SA14-14-2 vaccine with the cost of
  vaccinating one child with the inactivated m-b
  derived vaccine

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JE Vaccination Strategy for India

• Vaccinate all children between the age group of
  1-15 years with a single dose of live attenuated
  SA14-14-2 JE vaccine in a one time campaign
• Integration into the routine immunization in the
  district to cover the new cohort of 1-2 years

• Pre introduction and concurrent clinical studies
  specific for the Indian population (ICMR
  recommendation)
• Animal Toxicity Test
• Immunogenicity Studies
• Post marketing surveillance
• Adult Viraemia
• Post Introduction - Effectiveness of vaccine
  (NTAGI recommendation)
• Vaccine Effectiveness Case Control Study

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Key Operational Strategies

• To cover entire district
• Village to village campaign
• Vaccination cards as record
• Only AD syringes to be used
• Injection safety measures
• Intensified surveillance for AEFI

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2006 2007 Campaigns
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Reported Coverage - 2006
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Reported Coverage - 2007
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Advocacy
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(No Transcript)
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Posters and Banners
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Social Mobilization
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Community Participation
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IEC
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Queue for vaccination
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Recording Pre-vaccination
Photo Courtesy UNICEF
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Promising a healthier life
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Post vaccination
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Recording Post Vaccination
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Emergency drugs
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Waste Disposal
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AEFI - Adverse Events Following Immunization
9.3 million children were immunized in 2006
18.5 in 2007
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Committee - 2006

• Following report of AEF mass campaigns with the
  SA14-14-2 JE vaccine, GOI set up an expert
  committee to investigate all cases of reported
  AEFIs
• Members
• Dr T Jacob John ( Team leader)
• Dr Ramteke, DCGI
• Dr Dipali Mukherjee, ICMR
• Dr Shah Hossain, NICD
• Dr Pradeep Haldar, GOI

• The Objective of the committee was to review
  State Investigation reports and to investigate
  the AEFI with live attenuated SA14-14-2 vaccine
  against JE in high risk districts covering 4
  States in the country

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Summary Statement

• No direct causality has been established
  between the reported illnesses and the live
  attenuated SA14-14-2 JE vaccine.
• No stricture on the further use of the vaccine
  is warranted

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JE Vaccination Plan India
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Future Plan
Source Immunization Division, MoHFW, GOI
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Dr Pritu DhalariaProgram ManagerJE
ProjectIndiaPATHpdhalaria_at_path.org

• www.path.org
• www.path.org/je