Rickettsia tsutsugamushi is one of seven Rickettsia and Rickettsia-like organisms which have been associated with human infection in India (the others are Rickettsia sibirica, Rickettsia conorii subsp. indica, Candidatus Rickettsia kellyi, Rickettsia typhi, Rickettsia prowazekii and Coxiella burnetii)

Epidemics of scrub typhus were previously reported among troops stationed in the north and east.

Risk factors include living close to bushes and wood piles, work on farms, observation of rodents at home and at work, and raising domestic animals (Darjeeling, West Bengal, 2009 publication)

Exported cases:
- Three cases of imported scrub typhus were reported in the United States during 1983 to 1988 – all originating in India.
- In 2002, a Belgian traveler developed scrub typhus following a trip to India.

17 fatal cases were reported in Himachal during 2001 to 2002.
- 21 cases (3 fatal) were reported in Himchal Pradesh during 2004.
- Nine cases were confirmed in Uttarakhand (2010 publication)
- 29 cases were reported from a hospital in Manipal, Karnataka during 2009.

Prevalence surveys:
24.1% of febrile hospitalized patients in Vellore (2006 publication)
15% of children below age 14 hospitalized for fever in Tamil Nadu (2003 to 2004)
14.3% of children hospitalized with fever and at least one suggestive feature of rickettsial infection (central India, 2011 publication)
37.5% of febrile malaria-negative patients in Tamil Nadu in 2004, and 9.2% in 2005
47.5% of patients hospitalized for acute undifferentiated febrile illness in Vellore, Tamil Nadu (2010 publication)

The principal vector is Leptotrombidium deliense.
- Schoengastiella ligula mites infesting shrews (Suncus murinus) were identified as vectors during an outbreak in Kurseong, Darjeeling.
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Notable outbreaks:
2001 to 2002 – An outbreak (28 cases, 3 fatal) was reported in Tamil Nadu.
2003 – An outbreak (225 cases, 19 fatal) was reported in Himachal Pradesh.
2006 to 2008 – An outbreak (50 cases) was reported in Pondicherry.
2007 – An outbreak (38 cases) was reported in Bishnupur district, Manipur.
2009 to 2010 – An outbreak (80 cases, 5 fatal) was reported in Meghalaya.
2011 – Outbreaks were reported in Himachal Pradesh (200 cases, 13 fatal) and Nagaland (9 cases, 3 fatal).

References:
1. Berger SA. Infectious Diseases of India, 2011. 480 pp, 65 graphs, 3503 references. Gideon e-books, http://www.gideononline.com/ebooks/country/infectious-diseases-of-india/

Reproduced on ProMED

Graph generation system outlined in [1])

Note that a precipitous decline in mumps in the Czech Republic followed the introuction of widespread MMR vaccination in 1987. [2,3]

1. Gideon Graphs module tutorial Gideon Graphs
2. Berger SA. Infectious Diseases of the Czech Republic, 2011. 424 pp, 139 graphs, 1192 references. Gideon e-books, http://www.gideononline.com/ebooks/country/infectious-diseases-of-the-czech-republic/
3. Berger SA. Mumps: Global Status, 2011. 157 pp, 187 graphs, 390 references. Gideon e-books, http://www.gideononline.com/ebooks/disease/mumps-global-status/

Reproduced by ProMED

References:
1. Berger SA. Infectious Diseases of Mexico, 2011. 446 pp, 128 graphs, 1655 references. Gideon e-books, http://www.gideononline.com/ebooks/country/infectious-diseases-of-mexico/
2. Berger SA. Rabies: Global Status, 2011. 366 pages, 546 graphs, 1056 references. Gideon e-books, http://www.gideononline.com/ebooks/disease/rabies-global-status/

References:
1. Berger SA. Infectious Diseases of the World, 2011. 987 pp, 383 graphs, 12,492 references. Gideon e-books, http://www.gideononline.com/ebooks/country/infectious-diseases-of-the-world/

Mike was one of my senior managers at Netscape, who I always held in high regard. I’m saddened by this event and hope this will help accelerate research into a cure for the disease.

On December 31, the Media will once again recount all of the wars, earthquakes, divorces, births, rapes, sporting records …. Inevitably, a long list of famous persons will have passed on: most “after a long illness,” “suddenly” or “of natural causes.” 427 famous folk died of specified misfortunes in 2008. For the purpose of this research, “famous” is defined as “well recognized by the general public at large.”

Cancer was recorded as the reason for death in 38.9% of notable deaths, while heart attack or stroke accounted for 16.7%. 7.1% died of pneumonia and 6.2% vehicular accidents (half of these related to automobiles). 3.1% were murdered and 3.3% committed suicide. An additional 9.4% succumbed when their liver, lungs, kidneys or heart “failed”; while 6.6% died because their brains did likewise (Alzheimer’s, Parkinson’s, etc).

During the past two decades, a small number of fatal conditions have continued to account for most deaths among the famous and infamous; however, the relative ranking of some diseases appears to be changing. A cause of death was specified for 4,652 VIP’s during 1990 to 2008.

The most obvious change has been the fact that people rarely die of AIDS any more. 287 famous persons are known to have contracted AIDS. 172 have died of the disease since 1989, but only 20 since 1999. In contrast, the contribution of cancer to famous death increased significantly during the same period. Cancer accounted for 25.7% of VIP obits in 1990, and 35.8% in 2008. In fact, throughout all of history, 2,708 famous persons have died of cancer. 91% of these deaths have occurred since 1900, 87% since 1950, 56% since 1990 … and 5.8% during the single year, 2008 !

Of course, “cancer” is not a single disease. The nature of fatal tumors was specified in 65% of cancer obits. During 1990 to 2008, the relative proportion of fatal lung and brain cancers has remained fairly constant. The contribution of breast and hematological malignancy (leukemia and lymphoma) has declined, while prostate and colon tumors have increased accordingly. Cancer of the pancreas, a relatively unfamiliar tumor, is actually more common than breast, prostate or colon cancer as a cause of death in this population.

We should not assume that VIP-death reflects mortality trends among the general population. Indeed, famous persons are “not like the rest of us.” Many follow a life style which might invite medical misfortune, while enjoying access to excellent medical facilities. Thus, an analysis of mortality in this group might not represent the incidence of nonfatal diseases. In any case, diagnoses which we read in obituaries are often based on speculation or tend to stress the more sensational misfortunes of famous people.

Summary:

Specific causes of death – 427 famous persons in 2008

• Cancer 38.9%
• Heart attack or stroke 16.7%
• Pneumonia  7.1%
• Vehicular accidents 6.2% (half of these related to automobiles)
• Murder  3.1%
• Suicide 3.3% committed suicide
• Liver, lung, heart or kidney failure 9.4%
• 6.6% Alzheimer’s or Parkinson’s diseases

Trends in death -  4,652 famous persons during 1990 to 2008

• 172 AIDS deaths; but only 20 since 1999
• Cancer accounted for 25.7% of VIP deaths in 1990, and 35.8% in 2008.
• 2,708 famous persons have died of cancer throughout history.   91% since 1900, 87% since 1950, 56% since 1990 … and 5.8% during the single year, 2008 !
• The relative proportion of fatal lung and brain cancers has remained fairly constant.
• The contribution of breast and hematological malignancy (leukemia and lymphoma) has declined
• Prostate and colon tumors have increased accordingly.
• Cancer of the pancreas, a relatively unfamiliar tumor, is actually more common than breast, prostate or colon cancer as a cause of death in this population.

Although the current outbreak of Avian influenza (“bird flu”) began in 2003, and has continued well into 2008, the numbers of reported cases and deaths has actually been decreasing since, 2006. A total of only 387 cases, and 245 deaths, from this infection have been reported to date. In other words, the chance of dying from a lightning bolt or scorpion sting in one of the infected countries is far greater than the chance of acquiring bird flu.

During the past year, cases of human disease were reported in only 5 countries – while infection of birds occurred in 23 countries.

Note that the cases appear to occur in waves – first involving Vietnam, then Indonesia and finally Egypt.

Speaking of Egypt, few realize that a classic disease associated with that country continues to affect many parts of the world. Four countries reported plague outbreaks during 2008: China, Madagascar, Uganda and the Democratic Republic of Congo.

Does anybody still remember ‘Ebola.’ ? Ebola became a house-hold word in 1995, when cases in Africa appeared on the backdrop of one or more Hollywood movies about lethal bugs carried to America by villains, monkeys and other primates. The good news is that no Ebola outbreaks occurred in 2008; though few realize that more cases were reported in Africa during ’07 than during the panic-year of ’95.

The next panic-year in America was 2001, when anthrax evolved into a mail-order disease. In 2008, a man in London died of anthrax acquired from African animal skins used to make drums. Similar cases were reported in Scotland and in New York City in 2006. No fewer than twenty countries reported outbreaks of human (11 countries) or animal anthrax in 2008. As is often the case, these outbreaks occurred in areas of misery and upheaval – Iraq and Zimbabwe.

In fact, Zimbabwe has become a paradigm for epidemics in recent months. As we move into 2009, a massive outbreak of cholera is spreading through the country, with many cases in the capital city and infected refugees spreading the disease into neighboring South Africa. Outbreaks of cholera were officially reported by 37 countries in 2008, while many others reported “severe diarrhea” – a euphemism for cholera, often used by nations which would rather not scare of tourists with the “C” word.

For diseases, 2008 was a matter of “business as usual.” Dysentery, salmonellosis, influenza, conjunctivitis, Legionnaire’s disease, Norovirus gastroenteritis, Lyme disease, plague, rabies … simply plague humanity.

The Health establishment once promised us that at least two diseases would be eliminated by the 21st century: Poliomyelitis and Measles. Sadly, outbreaks of both were still reported in 2008. In both cases, safe and effective vaccines are simply not being used in some populations. In contrast, other diseases for which vaccines do not exist will continue to worry us all into 2009 – AIDS, Malaria, Dengue, Hepatitis C, West Nile fever…

Inevitably, each new year heralds the discovery of new diseases and pathogens. Sadly, new antibiotics and vaccines appear at a slower pace. One of the more interesting outbreaks of 2008 involved over 1 million cases of Chikungunya in India, Malaysia and nearby countries. Chikungunya is caused by a virus spread by mosquitoes, and is characterized by fever, rash and severe inflammation of joints. Inevitably, the disease began to be reported among tourists returning from affected countries (approximately 50 to the United States, and almost 1,000 to France) and ultimately 337 cases acquired in Italy in 2007, as local mosquitoes began to transmit the virus. These events remind us of the entry of West Nile fever into the United States in 1999, and to forebode similar events in years to come.

The good news is that some diseases are disappearing. Cases of leprosy are on the decline, with fewer than 500,000 lepers estimated for the entire planet as of this year. A rather nasty parasite, Dracunculus, incapacitated over 720,000 Africans in 20 countries as recently as 1988; fewer than 10,000 in 9 countries as of 2008. SARS has simply disappeared as a disease, with no cases reported since the outbreak of 2003. Active mass treatment and prevention campaigns continue to reduce the incidence of river blindness, childhood meningitis, tetanus, diphtheria and some forms of hepatitis.

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