Japanese encephalitis (JE)

Lina Purnamasari
 Japanese encephalitis (JE)
• = a vector-borne disease
caused by JE virus  single-
stranded RNA virus  genus
Flavivirus (Flaviviridae family)
• transmitted by mosquitoes
(Culex tritaeniorhyncus)
• vertebrate hosts: birds,
mammals (pigs)
• Humans, animals (cattle,
horses) = dead-end hosts of
JEV, as they cannot develop a
sufficient level of viremia to
re-infect other mosquitoes.

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 Epidemiology
• Culex lives throughout South-East Asia and tropical areas.
• Culex mosquito, specifically, which lives and breeds in water pools and
flooded rice fields. This type of mosquito bites during night, with two
peaks in biting time: a few hours after sunset and around midnight.
• 30,000- 50,000 global cases per year, approximately 20-30% of patients
die and 30-50% permanent neurologic or psychiatric sequelae
• Most cases of JE  asymptomatic  estimated 1 in 50 to 1 in 1000 cases
showing clinical signs of infection.
• Children being the most affected

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 Indonesia
• Kemenkes 2017  326 cases in Indonesia in 2016
• ↑ rainy season
• most cases in Bali : 226 cases (69.3%)  associated with rice
fields, pig farms, irrigation areas

1 Kemenkes RI, 2017

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 Pathogenesis
Virus enter the body through the bite of insect (mosquitoes)
↓
After multiplication in RE system, viremia of varying duration ensues
↓
Virus is transported to target organ (brain) via blood
↓
Virus proliferate and damage the neuronal tissue thereby elicits nervous
manifestations

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 Clinical features
• Incubation time : 5 -15 days.
• Most infections are asymptomatic or cause non-specific febrile symptoms

1. Prodromal stage (1-6 days): fever, coryza, rigor, GI disturbances

(diarrhea), headache,nausea, vomiting, lethargy
2. Acute encephalitis stage : begin 3-5th day, high grade fever, altered
consciousness and seizures (convulsions occur in 75% of children), sign
increased ICP, mental status changes, focal neurological deficits
(weakness and, movement disorders)
3. Late stage (when active inflammation reduced): temperature N, CNS
involvement, mental impairment, epilepsy

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Clinical features
• The classic description of JE:
a dull flat mask-like facies
with wide unblinking eyes
(fig 3), tremor, generalised
hypertonia, and cogwheel
rigidity.
• Opisthotonus and rigidity
spasms, particularly on
stimulation (15% of patients)
• extrapyramidal features
• UMN signs
• acute flaccid paralysis

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 Diagnostic test
• it is difficult to distinguish JE from other cases of encephalitis
• Blood tests reveal neutrophilia, hyponatremia, elevated liver enzymes.
• Cerebrospinal fluid (CSF): pleocytosis, with lymphocytic predominance.
• JE is most commonly diagnosed by testing for JEV IgM in CSF, which is
reliably positive if the CSF sample is taken at least one week into illness.
• Other laboratory tests are molecular methods.

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 Treatment
• no specific antiviral therapies  Supportive care : controlling convulsions,
raised intracranial pressure, etc
• The case fatality rate is high  1/3 patients admitted to hospital die.
• JE-related deaths are due to raised intracranial pressure, hypoglycemia
and seizures. JE disease also causes serious brain damage in about 25-50%
of survivors, the highest rate of sequelae being reported in children.
• Moreover, in pregnant women, the infection can cause harm to the fetus.
• Even though JE is rare, it is potentially a severe life changing illness and
requires prevention.

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 Prevention
• Travelers to JE-endemic areas can reduce their exposure to
vectors by adopting personal protective measures:
• using mosquito-repellent agents, wearing appropriate
clothing, avoiding outdoor activities in the evening, using
permethrin-impregnated mosquito nets and staying in rooms
with air conditioning.
• vaccination against JEV infection

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 References
1. Amicizia D, et al. Overview of Japanese encephalitis disease and its prevention.
Focus on IC51 vaccine (IXIARO). Prev Med Hyg 2018; 59: E99-E107.
2. Pearce JC, et al. Japanese encephalitis: the vectors, ecology and potential for
expansion. Journal of Travel Medicine, 2018, Vol. 25, Suppl 1.
3. Solomon T. Japanese encephalitis. J Neurol Neurosurg Psychiatry 2000;68:405–
415.
4. Dutta K, et al. Japanese encephalitis: pathogenesis, prophylactics and
therapeutics. Current Science 2010, vol. 98, no. 3.
5. Kulkarni R, et al. Japanese Encephalitis: A Brief Review on Indian Perspectives.
The Open Virology Journal, 2018, Volume 12.

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TERIMA KASIH