The brain-fever or Acute Encephalitis Syndrome (AES) outbreak in Bihar’s Muzaffarpur district, which has killed more than 60 children below the age of 10 in the last two weeks, is not new to this region. For over four decades, the wards of government hospitals in over 12 districts of Bihar and eastern Uttar Pradesh brim with unconscious kids suffering from high fever and convulsions each year, the actual cause of which remains unknown.
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In Muzaffarpur, over 250 children are still in two hospitals — government-run Sri Krishna Medical College and Hospital (SKMCH) and private-run Krishnadevi Deviprasad Kejriwal Maternity Hospital. Many of them may not live more than a few days.
As the news of the spike in cases and deaths spread, Bihar health minister Mangal Pandey visited SKMCH and, in a populist move, announced six ambulances for the institute and enhancing its ward capacity to 100. The Union government sent a team to Muzaffarpur to assess the cause of the deaths and advised the hospital to set up a research wing and preserve serum samples for rechecking, Down To Earth reported.
But these moves are neither going to contain the disease nor prevent the children from dying.
In 2017, Baba Raghav Das Medical College, the lone public tertiary hospital in Uttar Pradesh’s Gorakhpur district, made news due to the alleged insufficient backup of liquid oxygen that killed children. The kids who were in the hospital, ill with the disease, allegedly died due to medical negligence. Last year, the hospital was in the news again for poor management of the brain-fever outbreak, lack of funds, resources and manpower.
Two issues emerge out of these concurrent flare-ups. First, despite this region being endemic to brain fever, there is a dearth of reliable research-based evidence on what kills so many children each year. Secondly, the serious lack of health infrastructure in Bihar and Uttar Pradesh makes handling of such outbreaks and disease epidemics more challenging.
The doctors in Muzaffarpur had first claimed that the deaths are due to hypoglycaemia, a condition where the blood sugar levels fall. By 14 June, the health minister said that given the symptoms the deaths could be clubbed under Acute Encephalitis Syndrome (AES). Under AES, children develop an acute fever with disorientation, confusion and inability to talk. It is not a disease. According to the government manual, AES is a group of clinically similar neurologic manifestations caused by several different viruses, bacteria, fungi, parasites, spirochetes, chemicals/ toxins, etc. It includes Japanese Encephalitis (JE).
The first JE case in India was reported in 1955 from Tamil Nadu and the first outbreak happened in 1973 in West Bengal. By 1978, it had 18 states in its grip, including Uttar Pradesh and Bihar. So far, 24 states have reported suspected JE cases.
In Muzaffarpur, there have been outbreaks almost every year between April and July since 1995. The doctors have since linked these to extreme heat and humidity of the region, but this theory is contested by many experts. Another link to the disease was made with toxicity in lychee seeds. While a 2017 Lancet paper links the outbreak to excessive lychee consumption, experts from Muzaffarpur-based National Research Centre on Litchi have refuted the claims based on toxicology tests.
The brain-fever crisis spiralled in Gorakhpur when in 2005 a particularly virulent form of JE affected over 6,000 people, killing 89 percent of those infected. After the mayhem, the infection was largely contained with two JE vaccination drives, in 2006 and 2010.
Yet, children were being brought in with acute brain fever, vomiting, suffering unconsciousness and seizures that left doctors in the region baffled. Numerous studies and research have shown that the infections have perhaps mutated.
A doctor retired from BRD Medical College explained that the laboratory tests for JE were negative after the vaccination rounds. The suspicion was then on a different breed of viral infections called enterovirus, a family of a hundred similar strains.
JE could be prevented because a vaccine for it was available. But for enterovirus, doctors were not sure which strain was causing the disease. So, no vaccine or drug could be used to thwart or treat it.
In 2011, BRD Medical College doctors sent samples for tests to renowned healthcare centres and labs in Lucknow and Gwalior, and confirmed enterovirus. But experts at the National Institute of Virology (NIV) in Gorakhpur were not convinced.
In 2011, a scientist at NIV explained to this reporter that for three years, the Institute tested the cerebrospinal fluid (CSF), or the liquid in the spinal cord, as the virus reaches the brain via that route. It also tested the rectal swabs that show the virus present in the gut. The rectal swab tests were positive for enterovirus but the CSF tests were not. The scientists were unsure if the virus present in the gastro tract was penetrating through multiple protective layers and reaching the brain. NIV flagged that it could be a different virus that’s affecting the brain.
Till a consensus was reached, all brain-fever cases in BRD Medical College started getting clubbed as AES.
In 2011-12, the cause of almost 42 percent of AES was unknown, according to a study published in Centers for Disease Control and Prevention, or CDC, Atlanta. It went up to about 60 percent in 2013-14. In 2016, the Indian Council of Medical Research (ICMR) tested 3,402 specimens and found only 9 percent of these to be JE. In the same year, mortality because of AES was 27 percent: this was two percentage point higher than in 2015.
By then, scientists had started working on other theories. In August 2017, CDC published a study conducted by Indian doctors from BRD Medical College and NIV in Gorakhpur, National Institute of Epidemiology in Chennai, Christian Medical College in Vellore and ICMR in Delhi, which gave a completely new direction to the research in identifying the strain causing AES in Gorakhpur.
The team found that the high proportion of AES cases was because of Orientia Tsutsugamushi. This meant scrub typhus, a bacterial infection transmitted to humans through mites, was causing AES. The study was conducted on 46 AES-affected children admitted at BRD Medical College along with 151 healthy children. It found scrub typhus in more than 60 percent of the children suffering from AES. Surveys were also done in lean and peak seasons of AES in Gorakhpur that confirmed “endemicity of scrub typhus infection” especially during the peak period.
The follow-up studies threw up a gamut of infections clubbed under AES, such as dengue, human herpesvirus, enterovirus and rickettsia of the spotted fever group.
These studies are, however, contested. The 2017 examination, for instance, was done on children from the same village and they were exposed to the same environmental risks. Researchers in Gorakhpur also claim that since last year the hospital has stopped sharing data on the cases, deaths and treatment, leaving little space to analyse if children are being treated for scrub typhus and if they are getting cured.
What compounds the outbreaks in this region each year is the poor health infrastructure in Uttar Pradesh and Bihar, along with the overall health and sanitation statistics in the region.
There is enough evidence to show that malnourished children are more prone to the infection. In Bihar, 48 percent of the children are stunted, 20.8 percent are wasted and 44 percent children are underweight. For Uttar Pradesh, these numbers stand at 46 percent, 18 percent and 39.5 percent, respectively. More than 63 percent children in both the states are anaemic. Only 25 percent households in Bihar and 35 percent in Uttar Pradesh have access to sanitation facilities.
In terms of healthcare resources, each doctor in Bihar serves an average population of 28,391, and in Uttar Pradesh, the average is about 20,000 per doctor. To put this in context, each doctor in Tamil Nadu serves about 9,544 people. Bihar has one hospital bed per 8,645 people and Uttar Pradesh has 2,904 people per bed. Tamil Nadu has 899 people per bed.
Despite such skewed numbers, only 3.94 percent of Bihar’s total expenditure is for health, the second lowest after Haryana. Uttar Pradesh spends 5.07 percent. Per capita expenditure on health is the lowest in Bihar at Rs 491. Uttar Pradesh spends Rs 733, the third lowest in the country.
Given how limited resources these states allot to healthcare, the inflow of patients at the time of outbreaks and epidemics will make the management of diseases worse, leading to higher casualties. The mystery will remain even as the deaths continue. Till the time we know what’s killing children in this region, prevention and efficient disease management is the key to reducing the bulging patient load.