An outbreak of diarrhoea in the eastern Indian state of Orissa has claimed 26 lives, a state minister has said.

The deaths have been reported in several villages in Kalahandi district, Health Minister Prasanna Acharya said.

Local newspapers put the death toll at 38. Health officials say 237 people suffering from the disease have been admitted to hospitals.

Diarrhoea is a major killer in the world and is thought to be responsible for around 4% of all deaths.

Remote villages

A team of doctors from the federal National Institute of Communicable Diseases (NICD) has travelled to the affected villages and begun an investigation into the causes of the outbreak.

DIARRHOEA
Diarrhoea is the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual
Usually a symptom of gastrointestinal infection, caused by a variety of bacterial, viral and parasitic organisms
Infection spread through contaminated food or drinking-water, or from person to person due to poor hygiene
Severe diarrhoea leads to fluid loss, and may be life-threatening

Consumption of contaminated water and rotting food by local people may have led to the deaths, health officials say.

Doctors and paramedics are struggling to reach the remote villages, often having to walk five to seven kilometres in the absence of any roads.

Health Minister Prasanna Acharya said 100 doctors travelling in mobile medical vans had been deployed to fight the outbreak.

There is an acute shortage of doctors in Kalahandi district - against the government-sanctioned 173 doctors in local hospitals, only 101 have been employed.

Many doctors are unwilling to serve in remote areas in India.

Kalahandi is one of the poorest parts of India and hunger and starvation deaths have been reported from this district in the past.

Drinking water here often comes from waterfalls and drains, which are usually contaminated.

More than 100 people died in a major outbreak of cholera two years ago in the Kalahandi, Bolangir and Koraput districts of Orissa.

Infective endocarditis (IE) is a severe form of valve disease characterized by infection located in the valves of the heart. It is still associated with a high mortality (10-26% in-hospital mortality). IE is a rare disease, with reported incidences ranging from 3 to 10 episodes/100,000 people per year.

Previous guidelines were published in 2004. Current revision was needed because of changes in the epidemiological profile, and significant advances in diagnostic and therapeutic strategies in these patients. The new guidelines will serve as a guide to help physicians to choose the best diagnostic and therapeutic strategy for their patients.

Two important points to underline:

1. A multidisciplinary approach is mandatory for the treatment of patients with infective endocarditis, including cardiologists, cardiac surgeons, and specialists of infectious diseases. They must be treated in highly specialized centers with surgical facilities. A recent work from our center showed that this multidisciplinary approach was responsible for a dramatic reduction in mortality in IE.

2. A second important conclusion of our study- reflected in the current guidelines- is that surgery must be performed much earlier than initially proposed, with good results. This point will be outlined by the current guidelines, which, for the first time, give information about optimal timing of surgery in patients with IE.

The main news in the current guidelines is:

* a. Epidemiology of endocarditis is changing:
From an epidemiological point of view, IE has changed over the last few years, with newer predisposing factors - valve prostheses, degenerative valve sclerosis, intravenous drug abuse (IVDA), associated with the increased use of invasive procedures at risk for bacteremia, while rheumatic disease has nearly disappeared. Health care-associated IE (meaning IE caused by in-hospital contamination) represents up to 30% cases of IE, justifying aseptic measures during venous catheters manipulation and during any invasive procedures

* b. Endocarditis prophylaxis is reduced: favor PREVENTION rather than PROPHYLAXIS
One of the main changes in the new ESC Guidelines is the proposed reduction of prophylaxis, because there is no real scientific proof of its efficacy, and it may be potentially dangerous. Thus, antibiotic prophylaxis is now recommended only for patients with the highest risk of IE undergoing the highest risk dental procedures (slide). Good oral hygiene and regular dental review have a very important role in reducing the risk of IE.

* c. Echocardiography is the key of diagnosis, prognosis, and management of patients with endocarditis
Diagnosis of IE is frequently difficult, particularly in some subgroups (prosthetic valve IE [PVE], intracardiac device and blood-culture negative IE [BCNIE]). The key value of echocardiography is underlined (slide), as well as its value in predicting embolic events

* d. Half patients with IE are operated on in Europe
The treatment of IE relies on the combination of prolonged antimicrobial therapy and - in about half patients - surgical eradication of the infected tissues. The 3 main complications of IE indicating early surgery are heart failure (HF), uncontrolled infection, and prevention of embolic events. The new guidelines will focus on these 3 main indications

* e. Early surgery is safe and is recommended
One of the most controversial issues is the indication of surgery. It is very difficult to say in which case and at which time surgery must be performed. Particularly, the risk of embolism is very difficult to assess. The new guidelines will focus for the first time on the optimal timing of surgery.

With 100 deaths in 3,987 laboratory confirmed positive H1N1 cases, India has registered a mortality rate of 2.3 per cent — much above the 0.9 per cent mortality rate for the rest of the world.

According to the World Health Organization (WHO), as on August 21, there have been 1,799 deaths in total 182,000 laboratory confirmed cases across the world, which makes 0.9 per cent the mortality rate across the world.

“The 2.3 per cent mortality rate is higher compared to the rest of the world, but we are the only country which is looking at laboratory confirmed cases as positive. Other countries are not testing and have included people with flu-like symptoms as positive,” said Dr S K Srivastava, Director General of Health Services.

With 584 deaths, Brazil tops the list of countries reporting fatalities due to the H1N1 virus. The mortality rate in Brazil is 0.29 per cent. However, if one takes into consideration the 5,206 laboratory confirmed cases, the mortality rate is 10 per cent — much higher than India’s. Brazil is followed by the US with 525 deaths, Argentina with 439 and Mexico with 179 deaths, according to the WHO. India is at the eighth position as far as the number of swine flu deaths is concerned.

Argentina has a mortality rate of 1.08 per cent. However, if one takes into account the 7,173 laboratory confirmed cases, the mortality rate from 439 deaths is 6.1 per cent.

The US has stopped posting figures pertaining to positive cases on its official website and has the figures for hospitalisation, instead. As of August 21, 7,983 hospitalisations were reported in the US. “If we take hospitalisation as the denominator, the death percentage is much higher,” said Srivastava.

The ministry has held informal meetings with several public health experts and the Public Health Foundation of India.

"Next week we will be able to finalise a group of experts for this purpose," said Dr V M Katoch, DG of ICMR, and Secretary, Health Research, Ministry of Health.