MEMORANDUM: Japanese Encephalitis in Nepal

TO: Dr. Setiloane, Professor of Global Health

FROM: Brooke Wershaw, Amanda OKeeffe, Maggie Wilson, and Beatriz Gomez

Executive Summary
Japanese encephalitis remains prevalent within Nepal and continues to affect the daily
lives of citizens within the country. Through the transmission of infected mosquitoes of the
Flaviviridae family, the Japanese encephalitis virus spreads from pigs and birds to humans
through the bite of an infected mosquito (1). This results in either minor or no apparent
symptoms or symptoms such as inflammation of the brain, headache, fever, vomiting, high fever,
disorientation, coma, tremors, and convulsions (2). As a result, approximately 20-30% of the
cases will result in fatality (3). The infection affects mainly children in Asian and western Pacific
countries, with approximately 200 to 300 deaths per year (4). Several international resources are
available for both financial and moral support to assist the country with fighting the continued
prevalence of this disease. Nepal has taken vigorous measures to combat this endemic by
enacting public health approaches; such as partnering with global networks to provide
vaccination clinics, instituting information centers, and delivering resources (12).
Although still common among citizens in Nepal, the prevalence of Japanese encephalitis can be
reduced through rigorous action and vaccination.

Nature of Disease
Japanese encephalitis is a disease caused by the Japanese encephalitis virus, a vector-
borne virus belonging to the Flaviviridae family. The virus is transmitted through infected
mosquitoes of the genus Culex. Japanese encephalitis is spread from pigs and birds, who are the
natural hosts of this virus, to humans, by the infected bite of a mosquito (1). The Japanese
Encephalitis virus typically presents itself as symptomatic or as having mild symptoms. Less
than 1% of the time does the JE virus present develop into clinical disease. Although it is
uncommon, in symptomatic cases of Japanese Encephalitis, symptoms include inflammation of
the brain, sudden onset of headache, high fever, and vomiting, disorientation, coma, tremors, and
convulsions (2). There is a high fatality rate of symptomatic Japanese Encephalitis, with
approximately 20-30% of these cases resulting in fatality. Among the survivors, approximately
30-50% will have severe neurological defects (3). Japanese Encephalitis is typically a disease
among children due to the majority of adults natural development of immunity to the JE virus
due to exposure to the disease in their childhood (1).

Burden of Disease
Japanese Encephalitis is mostly found in rural and suburban areas of Asia and the western
Pacific near pig and rice farms. Some Japanese Encephalitis endemic areas include, China,
Nepal, India, Japan, Laos, Thailand, Cambodia, and Vietnam, all countries which fall within the
Asian and western Pacific region. The JE virus has never been detected in Europe, Africa or the
Americas (2). Due to the poor intensity and quality of Japanese Encephalitis surveillance, the
global burden of disease is unknown.
The global incidence of Japanese Encephalitis, however, is known among the presently
24 JE endemic countries. During recent years, from 2006 to 2009, WHO received reports from
JE endemic countries of 27,059 cases, an annual range of 45029459 cases. Approximately
33,900 cases, or 50% of the total cases occurred in China alone. Of the total Japanese
Encephalitis cases world wide, 55,000 or 81% of these cases occurred in areas with well
established or developing JE vaccination programs and 12,900 or 19% of the cases occurred in
areas with minimal or no JE vaccination programs. These figures display the lack of vaccination
among people in these widely JE endemic areas. In addition, 51,000 or 75% of the total cases
occurred in children aged 0-14 years old, displaying an annual incidence of 5.4 per 100,000 cases
within this age specific group (1).
Japanese Encephalitis widely affects the country, Nepal, located in southeast Asia.
Approximately 12.5 million people in Nepal live in Japanese Encephalitis risk areas. From 1978
to 2003, almost 27,000 people were infected with JE and 5,000 Nepalese people died. Each year,
approximately 3,000 to 4,000 people are at risk of death and 200 to 300 people die from
complications associated with JE in Nepal. Japanese Encephalitis is known as a seasonal disease,
with majority of deaths occurring in July and August (4).
Japanese Encephalitis causes many social and economic consequences on the Nepalese
people. Due to the nature of the disease, affecting mostly school aged children, Japanese
Encephalitis affects childrens academic performance and school attendance. In addition, parents
who are caring for their sick children experience a loss in productivity and wages. In attempt to
end the spread of Japanese Encephalitis from its hosts, pigs and birds, the killing of pigs and
ducks, bans on pig farming, and a request to cease providing loans for pig farmers was in effect
in Nepal. People who depended on pigs and ducks for their livelihood suffered immensely (4).

Identify the risk factors and those segments of the population most affected and why
The risk factors of obtaining Japanese Encephalitis involve the location of where one
lives. Transmission of the disease generally occurs in rural agricultural locations where flooding
irrigation is practicedsome of which may maybe near or within urban centers (5). The
transmission of the disease is mainly related to the rainy season but may take place at any time of
the year, especially in tropical climate zones (5). Individuals who are located in areas in which
rice culture and pig farming coexist may also face higher risks factors of obtaining the disease
(6). This is because the transmission cycle involves Culex tritaeniorhynchus mosquitoes and
similar species that lay eggs in rice paddies and other open water sources, with pigs and aquatic
birds as principal vertebrate amplifying hosts (6). In addition, cases of acute Japanese
encephalitis have also occurred in the hill and mountain areas of Nepal (7). For example,
between the years of 2004 and 2006, there were 108 laboratory-confirmed cases from the
mountain and hill districts of Nepal (7). In some endemic areas some adults may have acquired
immunity through natural infection and thus the disease is primarily among children (7).

International Resources
There are some international resources that have been and are willing to further support
Nepal in research of the disease and with implementation of policies helping to end the
eradication of the disease. The World Health Organization (WHO) has assisted Nepal with
conducting surveillance of acute encephalitis syndrome (11). WHO provided and supported a
national sentinel surveillance network that allowed for Nepals government to conduct the
surveillance (11).
The National Borne Disease Control Program has preventive measures [that] are
directed at reducing the vector density and in taking personal protection against mosquito bites
using insecticide treated mosquito nets (8). This program also has access to the limited
quantities of the JE vaccine, produced by the Central Research Institute in Kasuali, India (8).
Furthermore, this program provides technical support for outbreak investigations and control, on
request of the state health authorities (8).
The Encephalitis Societys vision states as, To live in a world where Encephalitis is as
rare as it possibly can be given its eradication is unlikely, and that those affected and their
families, have access to early diagnosis, excellent management of their condition, timely access
to rehabilitation and other forms of support (10). This particular society may be extremely
beneficial in supporting and implementing projects and policies in Nepal because it truly is
looking to end this disease. The society seeks to support all adults and children affected by the
disease by providing advice and information and working at a national and international level to
improve services (10). Additionally, the society produces evidence-based quality information on
the disease, raises awareness about the condition and problems of the disease, and conducts
research in partnerships with other establishments to find a solution (10).
Encephalitis Global functions as a support community for individuals and populations
affected by Japanese Encephalitis (9). Although this group does not have many resources to
directly assist Nepal, the support and information it can provide may vastly help the country.

Approach: National Sentinel Surveillances Network

The government of Nepal alongside with the help of the World Health Organization
(WHO) has paired up to introduce the National Sentinel Surveillance Network. This network has
been able to strategically diagnose and record over 108 confirmed cases from remote areas (13).
This surveillance network not only tracks possible cases and confirmed cases it also shares
information with other neighboring countries affected by the disease. This aggressive tracking
has provided the country with information on how the disease has been transmitted and what
areas would be considered high-risk areas.

Approach: Public Health Education

The Ministry of Health has addressed one of the largest encephalitis outbreaks in the
world by engaging the population of Nepal in public health awareness campaigns. Because the
country lacks the socioeconomic status to foster massive vaccine clinics, this approach has
proved to be the most cost-efficient way to combat the outbreak. Community education
campaigns serve to increase awareness of the high-risk areas of the country. This campaign also
has increased community participation allowing there to be a united front in combating Japanese
Encephalitis (JE)
The first round of campaign awareness started by distributing surveys and collecting
information on the number of people that have a high risk of contracting the disease and those
that have already been infected by the diseases. Nepal looked at different demographics when
interviewing high-risk areas or what the ministry would call JE areas. Those demographics
included socioeconomic status, age, and work occupation, literacy, ethnicity and diseases
awareness. The socio-behavioral survey revealed that those working in pig farms or living in
close proximity were at high risk. The study also revealed that a high 89% of the population
knew that JE was associated with pig farming and pig raising practices but only 14% knew
anything about JE vaccines(12). Those of low literacy and socioeconomic status lacked the
resources needed to understand prevention or obtain vaccines.
The second round of the campaign was geared towards addressing the lack of resources
that the JE areas needed. The affected communities lacked proper insecticide-treated mosquito
nets (ITMNs) nets for each individual family member. The study concluded that 52% of all
householders had at least one member unprotected to the disease (12). Instruction on how to
properly use the ITMNs was also given to the JE area population. Health clinics were created
to administer JE vaccines. According to the health report these preventative strategies have aided
in reducing the number of people infected each year.

Effective Global Practices

The best practices for fighting Japanese Encephalitis (JE) are through education and
prevention initiatives. Some effective global initiatives include Global TravEpiNet (GTEN), the
Japanese Encephalitis Vaccine, and overall education regarding preventative methods. Each of
these practices serves as a vital component for protecting the world against this detrimental
infection.
Global TravEpiNet (GTEN) is sponsored by the Centers for Disease Control and
Prevention (CDC), and is a consortium of US clinical practices that provide pre-travel care to
international travelers. Although this practice is in regards to travel health, implantation of such
in Nepal could be very beneficial. GTEN sites are distributed across the US and include
academic practices, healthcare consortia, health maintenance organizations, pharmacy-based
clinics, private practices, and public health clinics (14). Furthermore, these networks aim to
improve the health of those who travel internationally, by at the sites clinicians ask travelers to
provide details about their medical history, destination countries, purpose of travel, geographic
type of travel (urban, rural, or both), planned activities, planned accommodations, and duration
and dates of travel (14). With this information, clinicians then determine whether or not an
individual is at risk and needs a vaccination. In regards to the JE health crisis in Nepal, GTEN
could prove beneficial in providing healthcare locations for education, prevention techniques,
and treatment options for those already infected.
Another effective practice is through receiving the Japanese Encephalitis vaccination.
Now while the JE vaccination is available to some in Nepal, it is primarily used by U.S. and
European travelers visiting areas at high risk for the infection. This vaccine is recommended
for travelers who plan to spend a month or longer in JE-endemic areas during the JE virus
transmission season. The vaccine should be considered for short-term travelers (<1 month) if
they plan to travel outside of an urban area and have an itinerary or activities that will increase
the risk of JE virus exposure (15). Additionally, the JE vaccine is given as an injection and
requires two doses for full protection, with the second dose given 28 days after the first. The
second dose should ideally be completed at least a week before travelling. Also, if an individual
continues to be at risk of infection, a booster dose of the vaccine should be given between 12 and
24 months after you are first vaccinated (15). Since this vaccination has proven effective in
travelers, the people native to the areas with high risk, such as Nepal, should be more regularly
administered the vaccine, especially children.
Lastly, aside from vaccinations and health care clinics, education about preventive
practices is a key element to controlling Japanese Encephalitis. The most universal
recommendation is to avoid mosquito bites. Some of the best ways to do this include, using an
EPA-registered insect repellent, wearing long-sleeves, long pants and socks when outdoors, and
reducing exposure to mosquitoes during the peak biting hours, which are cooler hours from dusk
to dawn (16). All in all, it is through such healthcare practices, preventive measures, and
education awareness that will reduce the Japanese Encephalitis burden in Nepal, and around the
world.
Advocacy Action
A vital component of addressing the Japanese Encephalitis health crisis in Nepal is to
continue to spread awareness of the disease to remote areas of Nepal through education
campaigns. Such campaigns include, spreading control measures, increasing surveillance
practices, self-diagnosing methods, and involving community participation to promote JE
vaccinations. Another essential component of our advocacy plan includes large-scale
vaccinations. To make this possible, more government funding must be directed towards the
purchase and distribution of the JE vaccines.
Community participation in the promotion of the JE vaccination is necessary to ensure
that citizens become aware of the benefits of getting vaccinated. However, the promotion of the
JE vaccination is only possible if government funding is provided to assist in purchasing and
distributing the vaccination. If the government of Nepal is unable to provide such funds, the
government should turn to international resources to request funding from various countries. It is
vital that there is government and international funding to ensure that Nepals citizens are able to
obtain these crucial vaccines. Furthermore, it is critical that the JE vaccines are distributed in all
areas of the country, including remote areas. The training of health staff to properly educate local
community members about methods to prevent JE will be an essential component to addressing
this health crisis, as well. Such preventative measures include avoiding mosquito bites,
improving agricultural practices, and stressing the importance of being aware of high-risk areas.
Nepal would benefit from using outside aid from various global and local actors such as
the National Borne Disease Control Program, located in India, to gain access to vaccines, and the
Global TravEpiNet sponsored by the CDC, to provide US health care practices of JE prevention.
In addition, continued support from the WHO to track surveillance and further develop the
National Sentinel Surveillance Network.
If action such as vaccination and education is implemented throughout Nepal, the
detrimental effects of Japanese encephalitis could be significantly reduced, saving and improving
the lives of thousands of Nepals citizens.

References

1. Estimated global incidence of Japanese encephalitis: a systematic review. [online].

Available at http://www.who.int/bulletin/volumes/89/10/10-085233/en/. Accessed
December 5, 2015.

2. Japanese Encephalitis. [online]. Available at

http://www.cdc.gov/japaneseencephalitis/. Accessed December 6, 2015.

3. National Institutes of Health. Use of Japanese Encephalitis Vaccine in US Travel

Medicine Practices in Global TravEpiNet. [online]. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4183389/. Accessed December 9, 2015.
4. Estimated global incidence of Japanese encephalitis: a systematic review. [online].
Available at http://www.who.int/bulletin/volumes/89/10/10-085233/en/. Accessed
December 5, 2015.

5. Japanese Encephalitis. [online]. Available at

http://www.who.int/ith/diseases/japanese_encephalitis/en/. Accessed December 1, 2015.

6. Estimated Global Incidence of Japanese Encephalitis: A Systematic Review. [online].

Available at http://www.who.int/bulletin/volumes/89/10/10-085233/en/. Accessed
December 1, 2015.

7. Japanese Encephalitis. [online]. Available at

http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-
travel/japanese-encephalitis. Accessed December 2, 2015.

8. Japanese Encephalitis. [online]. Available at

http://nvbdcp.gov.in/je9.html. Accessed December 2, 2015.

9. Encephalitis Global. [online]. Available at http://encephalitisglobal.org/?

gclid=CKnbx_j7uskCFVcTHwodE8QBBQ. Accessed December 1, 2015.

10. The Encephalitis Society. [online]. Available at http://www.encephalitis.info. Accessed

December 2, 2015.

11. Japanese Encephalitis in Hill and Mountain Districts, Nepal. [online]. Available at
http://wwwnc.cdc.gov/eid/article/15/10/08-1641_article. Accessed December 2, 2015.

12. The Nepal Survey on Malaria, Japanese Encephalitis and Kala-azar. [online]. Available at
http://www.ehproject.org/PDF/EHPBriefs/EHPB19.pdf. Accessed December 12. 2015.

13. Japanese Encephalitis. [online]. Available at

http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-
travel/japanese-encephalitis Accessed December 12, 2015.

14. National Institutes of Health. Use of Japanese Encephalitis Vaccine in US Travel

Medicine Practices in Global TravEpiNet. [online]. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4183389/. Accessed December 9, 2015.

15. Centers for Disease Control and Prevention. Morbidity and Morality Weekly Report:
Recommendations for Use of a Booster Dose of Inactivated Vero Cell Culture-Derived
Japanese Encephalitis Vaccine -Advisory Committee on Immunization Practices.
[online]. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6020a5.htm
Accessed December 9, 2015.
16. Centers for Disease Control and Prevention. Japanese encephalitis: Prevention.
[online]. Available at http://www.cdc.gov/japaneseencephalitis/prevention/index.html
accessed December 9, 2015.