Posts Tagged ‘India’

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UK Epidemiologists Disclose Spread of Superbug: WHO Rings Alarm

Friday, April 8th, 2011 by

New research published this week in the prestigious medical journal The Lancet has disclosed the presence of super bacterium NDM-1 in the drinking and ground water in Delhi, India. NDM-1 resists treatment by the most powerful antibiotics available and could spark a worldwide spread of untreatable infections. NDM-1 has already been carried from India to Europe by “medical tourists” who contracted the infection during a hospital stay.

Upon learning this news, the World Health Organization (WHO) sounded an alarm asking medical researchers around the globe to take up an urgent collective effort to combat NDM-1. The WHO is particularly concerned because

  • The population density of India suggests that millions of people may already be carriers
  • The NDM-1 gene has spread to bacteria that cause dysentery and cholera, which are easily passed among humans who drink sewage-contaminated water
  • 650 million people in India do not have access to toilets served by sewers

WHO Regional Director Zsuzsanna Jakab said “Given the growth of travel and trade in Europe and across the world, people should be aware that until all countries tackle this, no country alone can be safe.”

Photo by SAsqrd.

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Traveling to Eat Well: Culinary Tourism Takes Off

Wednesday, March 9th, 2011 by

If encountering KFC signs abroad makes you wonder why you booked the trip, you’re ready to join the vanguard of the culinary tourism movement. Discovering local foods has always been a cool travel experience, but now the public’s enthusiasm for organic and “slow” food is putting gustatory experiences at the top of many itineraries. According to the International Culinary Tourism Association (ICTA), purveyors of local delicacies all around the world successfully started to reach significant numbers of culinary tourists about four years ago, and now an “industry” is starting to emerge.

The ICTA is promoting culinary tourism to the traveling public through http://www.foodtrekker.com/, which is in soft launch mode. It aspires to be a community of eaters and eateries that spans the planet. Keep an eye on this site to see how it develops. In the meantime, The International Ecotourism Society (TIES) is joining the party and promoting culinary tours put together by its members.  Itineraries featuring local dining and cooking adventures await you in Peru, Chile, New Zealand, India, Costa Rica and Ethiopia. I can’t think of a better way to travel and stay healthy.  Take the time to make plans to eat well and literally savor the local culture.

Photo by Andy Orr.

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Road Safety Targeted in Ten Countries Over Five Years

Thursday, January 27th, 2011 by

What’s on track to become a bigger killer than malaria? Vehicular traffic. Unless trends are reversed, cars and trucks will kill 1.9 million people worldwide annually by 2020. To combat this deadly threat, Bloomberg Philanthropies has funded a five-year initiative in Brazil, Cambodia, China, Egypt, India, Kenya, Mexico, Russia, Turkey and Viet Nam where statistics are increasingly grim. A consortium that includes the World Health Organization, Johns Hopkins University and the Association for Safe International Road Travel (ASIRT) is charged with engaging governments and NGOs to promote more responsible driver behavior, trauma care and data collection in each of these countries. Efforts are just getting underway and will continue through 2014. We’ll dig deeper into this topic by  taking a closer look at ASIRT and its activities in one of our next posts.

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Rabies Alert: CDC Highlights Threat to Travelers

Friday, October 15th, 2010 by

Though it may be far from many travelers’ minds, rabies poses a lethal threat in most parts of the world.  Today’s travel bulletin addressed the 100th rabies related death in Indonesia.  Earlier this month the Centers for Disease Control (CDC) reported on a fatal case of rabies acquired by a Virginia man in India in 2009. Rabies is rare in the U.S.– since 2000, only 31 cases have been reported but seven were acquired abroad. Cases were contracted by Americans traveling in India, the Philippines, Mexico, Ghana, El Salvador and Haiti. Rabies is transmitted by animal bites—most commonly by dogs but also wild animals, including bats.

The biggest threat is posed by dogs in Asia and Africa, but very few countries are free of rabies (see chart below). And many rabies cases are likely treated abroad and not reported. According to the CDC, the actual rate of rabies exposure in tourists has not been calculated with accuracy; however, studies have found a range of roughly 16 to 200 infections per 100,000 travelers.

Rabies immunization is widely available and is a good idea if you are traveling to the developing world. Unless treated early, rabies is usually fatal. Travelers are advised to avoid contact with unattended dogs, and spelunkers should seek treatment if they come into physical contact with a cave-dwelling bat that produces a scratch or cut.

Countries reporting no indigenous cases of rabies during 20051

Source: Centers for Disease Control   

Region Countries
Africa  Cape Verde, Libya, Mauritius, Réunion, São Tome and Principe, and Seychelles
Americas North: Bermuda, St. Pierre and Miquelon Caribbean: Antigua and Barbuda, Aruba, Bahamas, Barbados, Cayman Islands, Dominica, Guadeloupe, Jamaica, Martinique, Montserrat, Netherlands Antilles, Saint Kitts (Saint Christopher) and Nevis, Saint Lucia, Saint Martin, Saint Vincent and Grenadines, Turks and Caicos, and Virgin Islands (UK and US)South: Uruguay
Asia Hong Kong, Japan, Kuwait, Lebanon, Malaysia (Sabah), Qatar, Singapore, United Arab Emirates
Europe Austria, Belgium, Cyprus, Czech Republic2, Denmark2, Finland, France2, Gibraltar, Greece, Iceland, Ireland, Isle of Man, Italy, Luxemburg, Netherlands2, Norway, Portugal, Spain2 (except Ceuta/ Melilla), Sweden, Switzerland, and United Kingdom2
Oceania3 Australia2, Northern Mariana Islands, Cook Islands, Fiji, French Polynesia, Guam, Hawaii, Kiribati, Micronesia, New Caledonia, New Zealand, Palau, Papua New Guinea, Samoa, and Vanuatu

1Bat rabies may exist in some areas that are reportedly free of rabies in other animals.

2Bat lyssa viruses are known to exist in these areas that are reportedly free of rabies in other animals.

3Most of Pacific Oceania is reportedly rabies-free.

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Cholera: Still a big killer, no effective vaccine

Thursday, September 16th, 2010 by

On the quiet London street corner of Broadwick and Lexington stands the John Snow pub with a commemorative plaque honoring the medical detective work of Mr. Snow, who identified the Broad Street water pump as being responsible for an outbreak of cholera that ravaged thousands in 1855.  Today, all patrons of the John Snow can enjoy a pint of local ale, and even more importantly, a refreshing glass of crystal clear, pathogen-free water. It was John Snow who first discovered that cholera, the most feared diarrhea-associated illness in the world, was conveyed by water.

Cholera is caused by the bacteria Vibrio cholera, a powerful pathogen. Untreated cases can lead to dehydration and death within hours of infection.  Cholera is most commonly acquired from drinking water in which the bacteria is found naturally or into which it has been introduced from the feces of an infected person.  The disease can also be acquired from contaminated fish, shellfish or vegetables that have been rinsed with contaminated water.

Cholera outbreaks occur yearly in developing countries.  In 2007, 53 countries reported 177,963 cholera cases and over 4,000 deaths to the World Health Organization Last month, the worst cholera epidemic in almost twenty years broke out in Nigeria.  Nearly 800 people have died, and the epidemic is now spreading to the neighboring countries of Cameroon, Chad and Niger where hundreds of others have succumbed to the illness.

Further east, monsoon flooding that has displaced 18 million people in Pakistan has raised fears of a massive cholera outbreak. Next door, India reports almost seven hundred patients from the state of Orissa have been treated for cholera. Thirty nine patients have been reported dead, and local official N.B. Jawala reports that over 50 new patients are being seen daily with severe symptoms.  ‘We are struggling to prevent the disease from spreading,” he added, “but the patients do not come to the hospital for treatment.”  Indeed, since cholera infection is most often asymptomatic or results in only mild symptoms, the management of a cholera outbreak can be an epidemiologist’s nightmare.  

Travelers who follow tourist itineraries and who observe food safety recommendations are at very low risk. The risk, however, is real for those who drink untreated water or eat poorly cooked or raw seafood in cholera-endemic areas, primarily sub-Saharan Africa, India and China.  Those travelling to developing countries where access to good medical care (intravenous fluid and electrolytes) is limited are at the greatest risk of acquiring and succumbing to the illness. There is no vaccine for cholera available in the United States, and the CDC does not recommend either of the two vaccines available outside the United States because of the low risk of cholera to U.S. travelers and the brief and incomplete immunity that the vaccines confer. Without any medical silver bullets at hand, it appears that this ancient illness is not going away anytime in the near future.

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NDM-1 (Antibiotic-Resistant Suberbug): Q&A with a Specialist in Infectious Diseases and Microbiology

Wednesday, August 18th, 2010 by

The antibiotic-resistant enzyme, the carbapenemase NDM-1, has been appearing in recent headlines across the globe. For that reason, the Healthy Travel Blog requested some perspective on the situation from Dr. Vanya Gant, a Specialist in Infectious Diseases and Microbiology in London.  Here are his thoughts on the background, risk and future of this “superbug.”  

NDM-1 is one of several enzymes which destroy carbapenem antibiotics such as meropenem, imipenem, doripenem and ertapenem and are therefore called carbapenemases. By breaking down the carbapenem groups of antibiotics, these can no longer be relied on to treat infections. NDM-1 stands for New Delhi metallo-beta-lactamase 1.

The carbapenem group of antibiotics are powerful antibiotics for treating Gram negative bacteria (coliform bacteria such as E.coli and Klebsiella species) which can cause urinary tract infections, and are responsible for a considerable proportion of Hospital Acquired Infections.

The genetic material that leads to the production of the carbapenemase enzyme is found on a small mobile element (referred to as a plasmid – a sort of virus within a bacterium) that can easily pass from one bacterium to another. This ability to transmit from one bacterium to another implies that there is an alarming potential for it to spread among many other bacterial populations.

Q: Is this the first time that a carbapenemase has been described?

No. Other carbapenemases called VIM, KPC and OXA have been identified in Klebsiella species. These have caused problems in Greece, Turkey, USA and Israel.

Q: Where do these come from?

The rise of another antibiotic resistance enzyme, ESBL (extended spectrum β lactamase), which made Gram negative bacteria resistant to the cephalosporins, has led to an increase in the use of the carbapenems. This in turn has provided a selection pressure for carbapenem resistance to emerge, and is yet another example of the remarkable ability of bacteria to adapt and eventually become resistant to new antibiotics. This is made much easier by the existence of these “bacterial viruses” called plasmids, which can transmit easily from bacterium to bacterium.

Q: What is the risk of this enzyme?

It means that a very effective class of antibiotics may no longer be used for treatment of infection.

What’s more, it would appear that the plasmid carrying this resistance also carries resistance to other antibiotics. This means that once predictably powerful and active antibiotics such as the modern penicillins and cephalosporins, and other antibiotic classes such as the quinolones (such as ciprofloxacin), and the aminoglycosides (such as gentamicin – a hospital antibiotic) may not always work.

Q: Can NDM-1 still be treated?

The bacteria carrying the NDM-1 resistance enzyme remain sensitive to individual aminoglycosides and aztreonam, and many, if not most, isolates remained susceptible to colistin and tigecycline. Combinations of antibiotics are used to treat it.

Q: Are there new antibiotics that could help?

While there is large investment in research to find new antibiotics, currently there are no plans to approve or license one that could provide a single solution.

Q: How is it spread?

NDM-1 can spread from person to person in hospitals, hence the importance of environmental cleaning and hygiene as well as individual personal hygiene. In India it has spread outside hospitals through contaminated water in which people bathe, wash clothes and also defecate.

Q: Why is it a problem?

Ultimately, NDM-1 strains could produce dangerous infections that would spread rapidly from person to person and be almost impossible to treat.

Human air travel and migration allow bacteria and their plasmids to be transported rapidly between countries and continents. Much of this dissemination is undetected with resistant clones carried in the normal human flora (in their intestines mostly) and only becoming evident when they are the source of endogenous infections.

NDM-1 is widespread in India and Pakistan and has arrived in several distant countries as a result of global travel. While a particular issue for the UK, medical tourism for procedures such as transplants, pregnancy care and cosmetic surgery, has been a contributing factor for other developed nations.

The potential for wider international spread of NDM-1 plasmids and other similar novel antibiotic resistance genes to become endemic worldwide is clear and frightening.

Q: What can be done to stop it?

Individuals must be aware of the possibility that they may pick these strains up if they receive medical care in India and Pakistan.

It is currently extremely unlikely that they will pick these strains up in other countries — even though they have been found, they continue to be very rare.

It remains axiomatic that the best way to protect oneself against these resistant organisms is to be very aware of one’s own personal hygiene, and to make sure that wherever possible any healthcare received is from accredited units offering the very best levels of infection control and antibiotic stewardship.

Author: Dr. Vanya Gant
Dr. Vanya Gant, PhD, FRCP FRCPath is a specialist in Infectious Diseases and Microbiology.  He is Divisional Clinical Director for Infection at University College London Hospitals Trust in London, England.  In addition to patient care and clinical service redesign, Dr. Gant develops new techniques and materials for combating infection. He has appeared in several Public service and independent programs on matters of infection and microbiology, some of which he co-wrote.  In his free time, he enjoys and plays music, rides fast motorcycles, pilots paragliders, cooks and is an aspiring dance music DJ.

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New Antibiotic-Resistant Superbug Appears in Medical Tourists

Wednesday, August 18th, 2010 by

Last week the British Medical Journal The Lancet reported that a new bacterium resistant to almost all antibiotics, coined  New Delhi metallo-lactamase-1 or NDM-1 has emerged from India and Pakistan, and infected patients in Canada, the United States, Australia, Sweden, and a number of other countries.

Labeled “superbugs” by medical authorities, these bacteria resist strong antibiotics that are administered only when more common ones have failed. The NDM-1 gene mutation has been identified on plasmids- small fragments of DNA that easily move from one bacteria strain to another.  The gene spreads primarily among bacteria that frequently cause respiratory and urinary tract diseases.

The vast majority of NDM-1 infections have occurred in “medical tourists” who traveled to South Asia for elective surgeries such as face lifts, dental implants, hip replacements and even organ transplants. The Lancet researchers found that 37 Britons who had been treated in India and Pakistan carried NDM-1 bacteria when they returned to the United Kingdom.  They also reported that dozens of bacteria samples with the NDM-1 gene had been discovered in two Indian cities, speculating that local hospitals probably were overusing antibiotics.

Indian health authorities have been quick to retort, claiming that the Lancet report was seriously flawed and underwritten by foreign pharmaceutical companies who stood to gain from a global panic.    “It’s all hype and not as bad as it sounds,” said Karthikeyan Kumarasamy, lead author of a March report in the Journal of the Association of Physicians in India outlining the risks posed by NDM-1. “The threat of the NDM-1 is not that big as, say, H1NI (swine flu).”  He added “”The conclusion that the bacteria were transmitted from India is hypothetical. Unless we analyze samples from across the globe to trace its origin, we can only speculate.” 

Whether or not the new drug resistant strains can be traced back exclusively to South Asia, the possibility alone should remind us that obtaining health care in other countries, does have its risks.  Many of the medical facilities in India and other developing countries are first class, and staffed by well trained physicians. They are able to provide the same level of care as can be found in the United States.  Nonetheless, the globalization of medical care may inadvertently permit “superbugs” such as the NDM-1 bacteria to emerge and rapidly spread across the globe.

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India: H1N1 Endures

Tuesday, August 17th, 2010 by

The pronouncement last week by WHO Director General Margaret Chan that the H1N1 pandemic is officially over apparently ignores the latest reports from India.  Health officials in the world’s second most populous nation say that the number of new H1N1 cases for the week of August 2-8 reached a new peak for the current season with 942 cases resulting in 83 deaths.

One of India’s leading health officials stated “Many would say the virus has now settled down to replace the seasonal influenza strain. But there is no doubt that H1N1 continues to infect Indians in large numbers. A majority of those who died were pregnant women and the elderly — the vulnerable group.”  The state of Maharashtra saw the most victims, recording 400 confirmed cases and 51 deaths. Karnataka was second with 200 cases and 12 casualties, while Andhra Pradesh, with 105 cases and six deaths, was third. Overall, India has been one of the countries hit hardest by the H1N1 virus, with nearly 37,000 cases and 1,833 deaths since the outbreak began in May of last year. To put these numbers into perspective, seasonal flu historically has a death rate of 1 per 1,000. Worldwide the H1N1 virus has killed nearly 1 in 100. In India, H1N1 has killed about 1 in 50.

WHO’s Chan has responded to criticism that her announcement was premature, saying “Based on experience with past pandemics, we expect the H1N1 virus to take on the behavior of a seasonal influenza virus and continue to circulate for some years to come.” She added that isolated outbreaks are likely to occur, given the extreme virulence of the virus.  Others have pointed out that the H1N1 virus may not have finished mutating, and could become even more deadly over the next several years.

As HTB reported earlier, millions of H1N1 vaccine doses have expired and already been destroyed, with millions more set to expire over the next few months.  The reports from India should remind us that although the pandemic may have faded, the virus has not.  The Centers for Disease Control indicates that the 2010-2011 seasonal flu vaccine scheduled for shipment next month will include immunization to the 2009 strain of the H1N1 virus. Anyone travelling overseas not previously immunized against H1N1 should avail themselves of the seasonal flu vaccine.

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H1N1 (Swine) Flu: Should we still be concerned?

Thursday, July 8th, 2010 by

A recent article  in the Washington Post detailing criticism of the World Health Organization’s handling of the H1N1 (swine) flu pandemic, suggests that “much ado was made about nothing” and that the WHO was unduly influenced by drug manufacturers who stood to gain from widespread panic over the spread of the novel H1N1 virus.

Yet in a separate, sparsely circulated news article released last week, India reported that the number of swine flu cases jumped dramatically in June.  During the week of June 8-14, the country recorded 168 H1N1 cases with 14 deaths.  In comparison, from June 21-27, there were 345 new cases of H1N1 flu with 17 deaths. Somewhat alarmingly, the virus appeared in parts of India that were minimally affected last year. 

The news from India came at a time when over 25% of the H1N1 vaccine produced last year for the United States, a staggering 40 million doses worth over $250 million, was destroyed because it had expired.  An additional 30 million doses will likely also expire without being used.  If added to the 40 million doses slated for destruction this week, it means that almost half of the vaccine produced for the U.S. will have gone to waste. 

Despite unprecedented publicity by the World Health Organization, and an international campaign to encourage immunization against the novel H1N1 virus, a vast number of people remain unimmunized against H1N1.  Should we be concerned?  If the recent news out of India is any indication, H1N1 has not gone away and may become front page news once again in the coming flu season, typically late November thru March.

Scientists cognizant of the Spanish flu timeline from early 1918 until 1920, during which time three separate strains of the influenza virus emerged – with the second being the most deadly – are quick to point out that the novel H1N1 virus from last year could easily mutate and cause widespread devastation in an unimmunized population. Should this occur, the waste of millions of unused vaccine, and the consequential reluctance of manufacturers to mass produce any more doses, could have catastrophic consequences in the months ahead.

Travelers should keep in mind that it is flu season in many parts of the world, and that those travelling to the Southern hemisphere in particular should pay close attention to regions reporting increased H1N1 activity.  Ask your physician about obtaining the H1N1 vaccine, particularly if you are pregnant or have a chronic illness such as asthma or HIV/AIDs.  Criticism of the World Health Organization notwithstanding, it is still premature and historically unjustifiable to write off the novel H1N1 pandemic as a fabrication for the benefit of vaccine manufacturers.

Photo by Jeremy Brooks

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Traveling to India? Be Careful on the Roadways

Wednesday, June 30th, 2010 by

Last summer we analyzed the World Health Organizations (WHO) comprehensive study of road hazards across the world.   The report showed that the differences in fatalities in the analyzed countries were a result of road safety laws and the resources necessary to support them.  Some countries don’t have the road and traffic patterns necessary to manage the large volume of travelers.  The New York Times shows that the road death statistics in India are increasing dramatically while other countries, such as China, are seeing their numbers decline.

Improvements can be made in the form of more strictly enforced safety laws, better roadways, and paths for pedestrians and bikers that will keep them from having to share the already congested roads with careless drivers in unsafe vehicles. 

Before you hit the road this summer, find out what to expect on the roads in your host country.

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