Encephalitis epidemic: Why India’s response is falling apart

by Oct 11, 2012

Earlier this month, the National Commission for Protection of Child Rights lambasted the Uttar Pradesh government for its ‘casual’ response to the rising death toll from Japanese Encephalitis (JE) and acute encephalitis (AES) in the eastern districts of the state.

This season alone, nearly 400 people have lost their lives to the disease.

The encephalitis outbreak occurs with frightening regularity in India. For decades now, thousands of children from some of the poorest regions of Uttar Pradesh, Bihar and Assam, have succumbed to the disease, although it is preventable.

Why has India failed so miserably to control the epidemic?

Firspost spoke to Manish Kakkar, senior public health specialist at the Public Health Foundation of India (PHFI), on what he makes of the government’s response to the health crisis and what the way forward should be.

Kakkar is part of a team that is conducting a study on acute encephalitis and Japanese encephalitis in Uttar Pradesh’s Kushinagar district. The findings from the study could provide insights into more effective interventions by the government in the region.

Excerpts from the interview:

How grave is the situation of Japanese Encephalitis (JE) in India?

Well, it is an important cause of child mortality in the endemic areas where the disease breaks out every year with high fatality rates. Typically, of every 10 children that suffer from acute encephalitis syndrome (AES), 2-3 will die. And amongst those who survive, another 2-3 will end up with significant neurological damage.
Another point of concern is that the disease seems to be spreading to newer areas. It is a significant problem, especially in these areas. From a public health perspective, there are interventions possible to make it a preventable disease.

Pic used for representational purposes only.

India has faced this epidemic for decades. Over the years, has the situation gotten worse, better or has it been status-quo? How would you assess India’s response to this crisis?

In the larger sense, it is status-quo. There were years when there was a major spike in the number of cases. And then, those cases came down in subsequent years. In 2005, for example, there was a large outbreak. There were interventions put in place, vaccinations rolled out, clinical management improved, inputs given. But again, the cases have started increasing.

What is more troubling is that earlier we were we focusing on JE as the most common specific etiology (cause of the disease) of acute encephalitis. While the ‘reported’ positivity for JE in AES cases has gone down in recent years following JE specific intervention, AES incidence continues to be unresponsive. In other words, the problem now also is that there are more and more cases reported as “unknown etiology AES.”

Unless you know the etiology—whether it is some other vector-borne virus or whether it is a water-borne disease— you cannot guide your intervention.
This has made the situation really complex.

Is the phenomenon of increasing cases of acute encephalitis from unknown causes across states or restricted to parts of eastern Uttar Pradesh?

It is a mainly problem in the Gorakhpur belt, although similar reports of unknown etiology have been received from other endemic areas also. The point is also whether this is the reality or not. We need to look into that. Whether it is a case of unknown etiology or whether there is some problem in the way we are collecting and testing samples needs to be ascertained.
South East Asian countries also face the problem of JE. Very specific local conditions such as expansion of rice fields and the resulting water-logging have been identified as contributing to the outbreak of JE.

In India, what are the specific local conditions that are causing the epidemic?

That is what our study is looking into. The classical local factors— paddy fields, presence of pigs (which is an amplifier host), susceptible population and disease transmitting vector— are all present but they only partly explain the epidemiology of JE in India.

For example, apart from paddy fields, you also require pigs as an amplifier host. What we have observed in our study, from some of our initial enquiries is that there are villages which have pigs but have not reported AES/JE for years, and, at the same, there are villages where there are no pigs but have reported AES/JE cases. It is an intriguing case.

That is what we are trying to investigate in our ongoing study.

It raises questions in terms of what could be some of the other transmission cycles which are maintaining the JE virus. And if these are not JE cases, then what are these due to.
On the other hand, one cannot be oblivious to the health system challenges —both delivery and accessibility—that are unique to these very backward areas. These local factors make a huge difference to the incidence of disease and clinical outcomes.

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