Pakistan: Naegleria Fowleri Blamed For 10 Deaths

L & R: Trophozoites of N. fowleri in brain tissue, stained with H&E. Center: Ameboflagellate trophozoite of N. fowleri. Credit: DPDx

 

# 6619

 

 

Naegleria fowleri, commonly called the `brain eating amoeba’, has been blamed for 10 deaths in Karachi, Pakistan over the summer according to a Pakistani official with the World Health Organization.

 

The AP is reporting this morning that Musa Khan, the head of Pakistan’s DEWS (Disease Early Warning System), announced that the deaths occurred between March and September.

 

You may recall that I mentioned this outbreak, and the ongoing coverage by the newshounds on FluTrackers  (see this thread) back in July.

 

While it is exceedingly rare, we hear of a few fatal cases of PAM (Primary Amoebic Meningoencephalitis) each year caused by this water-borne organism.

 

It is usually acquired while swimming in warm lakes and streams, but last year we saw a couple of cases in Louisiana related to the use of Neti Pots for nasal irrigation (see FDA Advice On Safe Use Of Neti Pots).

 

Photo Credit FDA

 

Nasal irrigation is practiced daily by many in the Muslim community, and is suspected to be the route by which these Pakistani infections were acquired.

 

Several years ago nasal irrigation with N. fowleri contaminated tap water in Karachi, Pakistan was suspected to have caused 13 cases over 18 months. The CDC’s EID journal carried a dispatch on this outbreak in 2011:

 

 

Primary Amebic Meningoencephalitis Caused by Naegleria fowleri, Karachi, Pakistan

Sadia Shakoor, Mohammad Asim Beg, Syed Faisal Mahmood , Rebecca Bandea, Rama Sriram, Fatima Noman, Farheen Ali, Govinda S. Visvesvara, and Afia Zafar

Abstract

We report 13 cases of Naegleria fowleri primary amebic meningoencephalitis in persons in Karachi, Pakistan, who had no history of aquatic activities. Infection likely occurred through ablution with tap water. An increase in primary amebic meningoencephalitis cases may be attributed to rising temperatures, reduced levels of chlorine in potable water, or deteriorating water distribution systems.

 

 

This latest outbreak has inspired heated debate over the water quality in Pakistan’s largest city (pop 13 million).   This report from today’s Express Tribune:

 

Despite low chlorine level, KWSB insists there’s nothing fowl(eri)

By Saad Hasan / Samia Malik

Published: October 9, 2012

KARACHI:

As more cases of the deadly illness caused by the amoeba Naegleria fowleri continue to surface, officials have started wrangling with one another over the quality of water that runs through the city’s pipelines.

 

<SNIP>

 

The managing director of KWSB, Misbahuddin Fareed, said on Monday that the results showed that the level of chlorine was indeed low – it was 0.15 (parts per million) ppm when it should have been at least 0.5 ppm.

 

Despite this, the manager refused to believe that the water was contaminated and asked Aga Khan University to conduct research to determine whether the water did indeed carry the organism. “Our water is running water anyway. It does not stagnate and allow germs to multiply.” He said that the organisation checks the quantity of water every three hours.

(Continue . . .)

 

Since millions of people swim in waters where this amoeba naturally occur (or are otherwise exposed) and only a small handful of infections result, the odds of acquiring this infection are extraordinarily low.

 

Still, as this infection is almost always fatal, that makes the advice of using distilled, sterile or previously boiled water in your neti pot a reasonable enough precaution.

 

The Florida Department of Health has some common sense safety advice on how to avoid this parasite.

Photo Credit – Florida DOH

 

For more information on the Naegleria parasite, you can visit the CDC’s Naegleria webpage.

»» Read More

FDA Advice On Safe Use Of Neti Pots

 

Photo Credit FDA

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Regular readers of this blog are no doubt aware that we saw two fatal cases of PAM (Primary Amoebic Meningoencephalitis) in Louisiana attributed to sinus irrigation using tap water (see Neti Pots & Naegleria Fowleri) last fall.

 

While rare, most Naegleria fowleri parasite infections occur in young children or teens exposed while swimming along the bottom of warm, often stagnant fresh water lakes or streams. 

 

According to the CDC’s FAQ on Naegleria, we average 2 to 4 infections each year in the United States with this parasite. .

 

But a few years ago nasal irrigation with N. fowleri contaminated tap water in Karachi, Pakistan was suspected to have caused 13 cases over 18 months. Earlier this summer (see this FluTrackers Thread) a number of new cases were reported in Pakistan, once again with suspicions cast towards contaminated tap water.

 

In the wake of the first two cases of N. fowleri in the United States associated with use of neti pots, the FDA has released some safety guidelines to reduce (and hopefully) eliminate the risks.

 

Is Rinsing Your Sinuses Safe?

Little teapots with long spouts have become a fixture in many homes for reasons that have nothing to do with tea.

 

Called neti pots, they are used to rinse the nasal passages with a saline (salt-based) solution, and have become popular as a treatment for congested sinuses, colds and allergies, and for moistening nasal passages exposed to dry indoor air.

 

However, the Food and Drug Administration (FDA) has concerns about the risk of infection tied to the improper use of neti pots and other nasal rinsing devices. The agency is informing consumers, manufacturers and health care professionals about safe practices for using all nasal rinsing devices, which include bulb syringes, squeeze bottles, and battery-operated pulsed water devices.

 

These devices are generally safe and useful products, says Steven Osborne, M.D., a medical officer in FDA’s Center for Devices and Radiological Health (CDRH). But they must be used and cleaned properly.

 

Most important is the source of water that is used with nasal rinsing devices. Tap water that is not filtered, treated, or processed in specific ways is not safe for use as a nasal rinse.

 

Some tap water contains low levels of organisms, such as bacteria and protozoa, including amoebas, which may be safe to swallow because stomach acid kills them.  But these “bugs” can stay alive in nasal passages and cause potentially serious infections, according to the Centers for Disease Control and Prevention (CDC).

 

Improper use of neti pots may have caused two deaths in 2011 in Louisiana from a rare brain infection that the state health department linked to tap water contaminated with an amoeba called Naegleria fowleri.

<SNIP>

What types of water are safe to use in nasal rinsing devices?

• Distilled or sterile water, which you can buy in stores.  The label will state “distilled” or “sterile.” 
• Boiled and cooled tap water—boiled for 3-5 minutes, then cooled until it is lukewarm. Previously boiled water can be stored in a clean, closed container for use within 24 hours.
• Water passed through a filter with an absolute pore size of 1 micron or smaller, which traps potentially infectious organisms. CDC has information on selecting these filters, which you can buy from some hardware and discount stores, or online.

How do I use and care for my device?

• Wash and dry hands.
• Check that the device is clean and completely dry.
• Use the appropriate water as recommended above to prepare the saline rinse, either with the prepared mixture supplied with the device, or one you make yourself.
• Follow the manufacturer’s directions for use.
• Wash the device with distilled, sterile, or boiled and cooled tap water, and then dry the inside with a paper towel or let it air dry between uses.

(Continue . . . )

 

For more on this rare, but generally fatal parasitic infection, you may wish to visit the CDC’s webpage:

 

Naegleria fowleri - Primary Amebic Meningoencephalitis (PAM)

Photo Credit CDC

Naegleria fowleri (commonly referred to as the "brain-eating ameba or amoeba"), is a free-living microscopic ameba*, (single-celled living organism). It can cause a very rare, but severe, infection of the brain called primary amebic meningoencephalitis (PAM). The ameba is commonly found in warm freshwater (e.g. lakes, rivers, and hot springs) and soil. Naegleria fowleri usually infects people when contaminated water enters the body through the nose. Once the ameba enters the nose, it travels to the brain where it causes PAM, which is usually fatal. Infection typically occurs when people go swimming or diving in warm freshwater places, like lakes and rivers. In very rare instances, Naegleria infections may also occur when contaminated water from other sources (such as inadequately chlorinated swimming pool water or heated and contaminated tapwater) enters the nose.

 

And for previous blogs on this fascinating parasite, you may wish to revisit:

 

The Return Of Naegleria fowleri

Neti Pots & Naegleria Fowleri

Sometimes It’s Zebras

»» Read More

Neti Pots & Naegleria Fowleri

 

Photo Credit – Wikipedia Commons

 

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Last August in Sometimes It’s Zebras I wrote about a rare, but nearly always fatal, type of meningitis caused by infection with the Naegleria fowleri parasite.

 

First described in 1965 by Fowler & Cutler of Australia, more than 140 cases have since been diagnosed worldwide.

 

Most occur in young children or teens exposed while swimming along the bottom of warm, often stagnant fresh water lakes or streams. Earlier this year, we saw two cases (one in Florida, one in Virginia) - of PAM (Primary Amoebic Meningoencephalitis) attributed to this parasite.

 

Both were acquired while swimming in freshwater lakes.

 

Several years ago N. fowleri contaminated tap water in Karachi, Pakistan was believed to have caused 13 cases over 18 months. All but one of these Pakistani cases denied recent freshwater swimming activities, but all routinely performed ritual ablution, which included taking tap water into the nostrils.

 

In recent years the use of Neti Pots – used for nasal saline irrigation – has become more common in the western world. I have one myself, and during allergy season I use it every day.

 

But today we’ve a cautionary note from the Louisiana Department of Health, after a second case of N. fowleri infection has turned up this year associated with the use of tap water and and nasal irrigation.

 

This press release is from the Louisiana Department of Health and Hospitals.

 

Public Health

North Louisiana Woman Dies from Rare Ameba Infection

DHH warns residents about improper neti pot use

Tuesday, December 6, 2011  |  Contact: Bureau of Media & Communications (225) 342-7913 or (225) 252-3579 (cell)

Baton Rouge—The Louisiana Department of Health and Hospitals is warning residents about the dangers of the improper use of neti pots. The warning follows the state's second death this year caused by Naegleria fowleri, the so-called brain-eating ameba. A 51-year-old DeSoto Parish woman died recently after using tap water in a neti pot to irrigate her sinuses and becoming infected with the deadly ameba. In June, a 20-year-old St. Bernard Parish man died under the same circumstances. Naegleria fowleri infects people by entering the body through the nose. A neti pot is commonly used to irrigate sinuses, and looks like a genie's lamp.

 

"If you are irrigating, flushing, or rinsing your sinuses, for example, by using a neti pot, use distilled, sterile or previously boiled water to make up the irrigation solution," said Louisiana State Epidemiologist, Dr. Raoult Ratard.  "Tap water is safe for drinking, but not for irrigating your nose."  It's also important to rinse the irrigation device after each use and leave open to air dry.

 

Naegleria fowleri infection typically occurs when people go swimming or diving in warm freshwater lakes and rivers. In very rare instances, Naegleria fowleri infections may also occur when contaminated water from other sources (such as inadequately chlorinated swimming pool water or heated tap water less than 116.6 degrees Fahrenheit) enters the nose when people submerge their heads or when people irrigate their sinuses with devices such as a neti pot. You cannot be infected with Naegleria fowleri by drinking water.

 

Naegleria fowleri causes the disease primary amebic meningoencephalitis (PAM), a brain infection that leads to the destruction of brain tissue. In its early stages, symptoms of PAM may be similar to symptoms of bacterial meningitis.

 

Initial symptoms of PAM start one to seven days after infection. The initial symptoms include headache, fever, nausea, vomiting, and stiff neck. Later symptoms include confusion, lack of attention to people and surroundings, loss of balance, seizures, and hallucinations. After the start of symptoms, the disease progresses rapidly and usually causes death within one to 12 days.

 

Naegleria fowleri infections are very rare. In the 10 years from 2001 to 2010, 32 infections were reported in the U.S. Of those cases, 30 people were infected by contaminated recreational water and two people were infected by water from a geothermal drinking water supply.

(Continue . . . )

 

 

While the odds of contracting an amoebic infection of the brain this way are undoubtedly miniscule, these two recent reports out of Louisiana show they are not zero.

 

As this infection is almost always fatal, that makes the advice of using distilled, sterile or previously boiled water in your neti pot a reasonable enough precaution.

»» Read More