Japanese Encephalitis

Background
o Japanese encephalitis virus (JEV) represents the most significant etiology of arboviral encephalitis worldwide and is a neurologic infection closely related to St. Louis encephalitis and West Nile encephalitis. It is the most important form of epidemic and sporadic encephalitis in the tropical regions of Asia including Japan, China, Taiwan, Korea, Philippines, all of the Southeast Asia and India. Countries with the proven epidemics of Japanese encephalitis (JE) are India, Pakistan, Nepal, Sri Lanka, Burma, Laos, Vietnam, Malaysia, Singapore, Philippines, Indonesia, China, maritime Siberia, Korea, and Japan (Vaughn and Hoke 1992). In the past 50 years however; geographic area affected by JE virus (JEV) has expanded. Epidemic activity in Northern India, Central India and Nepal has increased since the early 1970s. Since 1990s the virus has continued to spread in Pakistan (Igarashi et al 1994), Nepal (Zimmerman et al 1997), and Australia (Hanna et al 1996, 1999).

Japanese Encephalitis . Asim A Jani, Burke A Cunha, MD. Medsacpe Reference http://emedicine.medscape.com/article/233802-overview

Distribution
o o Based on endemicity, epidemics, isolation of virus from patients and vectors and general serological surveys, the virus has been shown to be widely prevalent in most parts of Southcentral, Northern and Northeast states of India. Apparently, part of Maharashtra and states like Gujarat, Rajasthan and Madhya Pradesh are free from JE.

Japanese Encephalitis . Asim A Jani, Burke A Cunha, MD. Medsacpe Reference http://emedicine.medscape.com/article/233802-overview

Clinical Spectrum
o o o JEV infections are mostly asymptomatic in about 90% of the cases and an estimated ratio of symptomatic to asymptomatic infection has been 1 to 251000 (average of 1:300). Meningo-encephalitis is the most important and serious form of JEV infection resulting in death in 535% cases. About 50-60% of the survivors suffer from serious long-term neurologic sequelae manifested as convulsions, tremors, paralysis, ataxia, memory loss, impaired cognition, behavioural disturbance and other such symptoms (Halstead and Jacobson 2003).

The clinical picture of this infection has four stages i. ii. Prodormal Stage Lasts 2-3 days. Acute Stage Lasts 3-4 days

iii. Subacute Stage Lasts 7-10 days. iv. Convalascent Stage Lasts 4-7 weeks.

Preventive strategies for frequent outbreaks of Japanese encephalitis in Northern India. Vandana Saxena and Tapan N Dhole. J. Biosci. 33(4), November 2008

Laboratory criteria for diagnosis: WHO surveillance guidelines for JE

Laboratory confirmation of a JE virus infection includes:
1.

Presence of JE virus-specific IgM antibody in a single sample of cerebrospinal fluid (CSF) or serum as detected by an IgM-capture ELISA specifically for JE virus; OR Detection of JE virus antigens in tissue by immunohistochemistry; OR Detection of JE virus genome in serum, plasma, blood, CSF, or tissue by reverse transcriptase PCR or an equally sensitive and specific nucleic acid amplification test; OR Isolation of JE virus in serum, plasma, blood, CSF, or tissue; OR A four-fold or greater rise in JE virus-specific antibody as measured by hemagglutination inhibition (HI) or plaque reduction neutralization assay (PRNT) in acute and convalescent-phase serum samples. The samples should be collected 14 days apart.

2.

3.

4.

5.

WHO Manual for the Laboratory Diagnosis of Japanese Encephalitis Virus Infection. March 2007

Options for Diagnostic tests in Humans

I. Isolation, amplification, or antigen detection? i. Viraemia in JE is low and short so the likelihood of a positive result is low. ii. High technology requirement and expensive. Antibody-based (serology) methods? i. High sensitivity (if properly timed samples). ii. Options include PRNT, ELISA, and HI.

II.

WHO Manual for the Laboratory Diagnosis of Japanese Encephalitis Virus Infection. March 2007

Antibody-based (Serology) Methods

1.

2.

3.

Plaque reduction neutralization assay (PRNT) o Least cross-reactivity; most specific. o Upto 14 days to complete test. o High biosafety level requirements. o Early acute phase specimen less likely to test positive with PRNT than ELISA o Requires acute & convalescent-phase serum. Haemagglutination Inhibition (HI) o High levels of cross-reactivity with other flaviviruses, low specificity. o Anamnestic response with secondary flavivirus infection. JE-specific IgM capture ELISA
o

Advantages Simple. Sensitivity of IgM detection good as competition by IgG molecules eliminated. Disadvantages Some cross-reactivity with other flaviruses.

ELISA is most feasible testing methodology

WHO Manual for the Laboratory Diagnosis of Japanese Encephalitis Virus Infection. March 2007

Molecular Diagnosis
o PCR assays are not recommended for routine diagnosis; however, PCR assays combined with sequencing can be useful for providing information about the molecular epidemiology and evolution of viruses.

JEV Diagnosis

Antigen Detection
Antigen capture ELISA Immunofluorescence test

Serological Tests
Haemagglutination Inhibition (HI) ELISA (IgM, IgG) Neutralisation

Genome Detection
PCR

WHO Manual for the Laboratory Diagnosis of Japanese Encephalitis Virus Infection. March 2007

Tests Offered at SRL

Sr. No. 1 2 Test Name Japanese Encephalitis Virus IgM antibodies Japanese Encephalitis Virus RNA Detection Sample Serum/Plasma CSF Method Immunochromatography Real Time PCR Test Code 7987 7595

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