March 2011
Over the last few months, at least six people have died in unexplained circumstances in the city of Chiang Mai. Thai authorities are still investigating whether the deaths are the result of a viral or bacterial infection (see bottom of page for the full statement from Thailand’s Ministry of Public Health). It is difficult to establish the full facts of each case as there are conflicting reports in the Thai and overseas media. It has been suggested that at least four of the victims used the facilities at one particular Chiang Mai hotel, the Downtown Inn close to the central Night Bazaar area. It should be pointed out that Thai authorities have inspected the Downtown Inn and the hotel remains open for business*.
Update June 2012:
The Downtown Inn in Chiang Mai is in the process of being demolished.
Five of the victims were overseas tourists and one was a Thai tour guide. One of those who died was a young New Zealand woman and the nature of her death has prompted the New Zealand government to write this as a travel advisory:
“We are aware of 6 recent unexplained deaths in Chiang Mai, including of one New Zealander. The cause of death is unknown, and the results to date are inconclusive although there has been speculative media comment linking the deaths to local food markets.
It is recommended that travellers take general preventative health measures including paying attention to personal hygiene, eating only hot food and drinking clean water. Those who experience severe sudden multiple vomiting with or without diarrhoea, should seek medical attention immediately.
The Governor and authorities in Chiang Mai have asserted that Chiang Mai is safe for tourists. However, in light of the lack of any clear explanation of the recent deaths, it is up to individual travellers themselves to determine the risks of travelling there.”
In addition to this, the Thai Ministry of Public Health have issued a very detailed statement. In case the link doesn’t work, here is the full statement from that website which was updated today:
Progress on epidemiologic investigation of myocarditis cases in Chiangmai
(Updated 22 March 2011)The Department of Disease Control, Ministry of Public Health, Thailand is continuing its investigation of cases of myocarditis and unexplained deaths in Chiang Mai. To date, this investigation has involved the following organizations, institutions and persons: the Department of Disease Control and Bureau of Epidemiology, Ministry of Public Health, Thailand; the Provincial Public Health Office, Chiang Mai; Ramathibodi Poisons Centre, Bangkok; WHO Thailand; the WHO Regional offices of the Americas, Europe, South East Asia and the Western Pacific; WHO Headquarters; the United States Centers for Disease Control; and the International Health Regulations (IHR) Focal Points of France and New Zealand. In the meantime, staff of the New Zealand Embassy in Bangkok are periodically consulted and updated.
After the first update on 11 March 2011, no further new cases of myocarditis or unexplained deaths have been identified. Therefore, it remains the case that since the deaths of the husband and wife from the UK on 19 February 2011, no further new cases have been reported despite the institution of active surveillance (case finding) in all 25 hospitals in the Province of Chiang Mai. Reports of an additional death in a 59-year old Canadian male who died on 26 January and may have visited a hotel where other deaths have been reported are being actively investigated, but at present, the details of this case remain unverified. The Department of Disease Control is sending an investigation team to review the details of this case and determine whether there is any linkage to the cases described in the first update.
The investigation and reporting of these events has been complex and subject to a number of important constraints. Deaths that occur outside of a hospital or in unexplained circumstances are the primary responsibility of the police, resulting in parallel forensic and public health investigations, but the full integration of all such efforts is now in progress. Active case finding therefore currently include examination of relevant police records and forensic pathology reports, as well as reports appearing in the media. In addition, all hotels and guesthouses in the city of Chiang Mai are currently required to report episodes of severe vomiting in guests.
The different owners of the hotels and guesthouses that have been associated with deaths are all giving their cooperation to the investigation including reporting possibly new suspect cases. To date, no common link has been found between cases with respect to restaurants, water, food and travel.
Although many cases appear to have suffered similar illnesses, a detailed examination of clinical case records shows important differences that place significant constraints on establishing a common cause. In addition, one case developed symptoms before arriving in Chiang Mai and several other cases developed symptoms, and in one case died, less than 24 hours after arrival in the city. All the cases of confirmed myocarditis and the other cases (travelling companions) directly associated with them were identified and clinically investigated at Chiang Mai Ram Hospital which is an international standard healthcare facility accredited by the Joint Commission International Accreditation USA. All the cases of clinically confirmed myocarditis were diagnosed based on the findings of echocardiography (cardiac ultrasound) and raised levels of cardiac (heart muscle) enzymes. However, the clinical details of these cases also show some significant differences, for example only one had a high fever, and the histopathology of the heart muscle specimens of the two cases on which autopsies were performed show different findings. The significance of these findings is currently unclear, but they may point to different underlying causes.
On 15 March, the Department of Disease Control has held a VDO Conference with WHO Thailand and US CDC, Atlanta about the cases. Specimens of blood, heart muscle and urine available from some of the deceased case are being shipped for further testing in US CDC. Blood and stool specimens from the two surviving cases in New Zealand nationals are also being sent to Japan for further testing
Based on available scientific evidence so far and the absence of new cases in travelers or local population despite vigilant surveillance, threats to the general public remain low or minimal. The general public and tourists in Chiangmai are not recommended to take any specific precautions, but should continue to observe general preventive health measures as described in the previous update. Any persons who may have specific medical or public heath concerns about this event are invited to report them or make queries using the following email address: outbreak@health.moph.go.th.
We wish to highlight that in the absence to date of any clearly defined and specific threat to public health, and following specific requests from grieving family members to show sensitivity and respect confidentiality, information on some of the cases whose names have already appeared in media reports is not being made public until a preliminary investigation has been completed. Furthermore, detailed personal information of cases will not be made available even after completion of all enquiries.”
