Encephalitis deaths in Bihar: Lack of trained doctors, drinking water woes pose challenges in preventing spread of virus

According to media reports, till 15 June, over a hundred deaths of children have taken place due to acute encephalitis syndrome and heat stroke in Muzaffarpur. In Muzaffarpur’s Sri Krishna Medical College and a private hospital, Kejriwal Matri Sadan, children suffering from encephalitis (locally known as chamki bukhar) are being admitted in large numbers. The district of Muzaffarpur is witnessing the same situation that it did in 2014. In that year too, ‘chamki bukhar’ had taken a large toll. According to the National Vector-Borne Diseases Control Programme (NVBDCP), 355 people died in 2014 due to AES and two due to Japanese Encephalitis (JE). In the wake of the recent outbreak, health minister Harsh Vardhan has visited Bihar . Before leaving for the state, he was quoted as saying that the deaths due to AES appear to be gradually reducing now. But the ground reality is somewhat different. Local newspapers are flooded with the news of a “mysterious fever” claiming the lives of children in Uttar Pradesh and Bihar. In this context, it may be relevant to recall that in August-September 2018, this “mysterious fever” had claimed the lives of 75 children in Uttar Pradesh’s Bahraich. Symptoms of this disease were well within the periphery of AES, as defined by the government. However, the government did not consider it as AES. The media, as well as government hospitals, described the disease as a “mysterious” fever. When Dr Kafeel Khan, who had earlier been in the news following the deaths of children suffering from encephalitis in Gorakhpur, sought to counter these claims, he was detained. [caption id=“attachment_6834151” align=“alignleft” width=“380”]  Children suffering from Acute Encephalitis Syndrome (AES) being treated at a hospital in Muzaffarpur on Monday. PTI[/caption] In a high-level meeting in November 2016, it was decided not to count dengue, malaria, scrub typhus and tuberculosis as AES-related diseases. This is despite the fact that scrub typhus infection is considered as a major cause of AES in and around Gorakhpur district of Uttar Pradesh. AES in Bihar Acute encephalitis syndrome is characterised by a sudden drop in blood sugar levels. Research has found that some chemicals in the litchi fruit may be the cause of this disease. This perception has become stronger as most cases in Bihar are reported in the litchi season (April to June), and the number of cases reduces after the onset of the monsoon. Guidelines issued by Bihar’s health department state that children should avoid eating unripe litchi, and should eat a full-fledged dinner. Although deaths due to AES in Bihar have been hitting the national headlines in recent days, cases of the disease have been reported throughout the year from Siwan, Gopalganj, East Champaran, Barauni and Gaya districts. Every year, hundreds of patients from Bihar are admitted to the BRD Medical College in Uttar Pradesh’s Gorakhpur. This year, till 7 June, there were 81 AES patients in the medical college, out of which eight were from Bihar. These patients hail from the districts of Siwan, Gopalganj and West Champaran. One patient was also diagnosed with Japanese encephalitis. In the year 2018, 1,073 encephalitis patients were admitted to the BRD Medical College, out of which over a hundred were from Bihar. This led Uttar Pradesh chief minister Yogi Adityanath to say that his state reported a higher number of cases of the disease due to the patients who come to the state from Bihar. Japanese Encephalitis/AES IN Uttar Pradesh In Uttar Pradesh, government figures suggest that there has been a reduction in deaths due to AES/JE in the past two years. According to the NVBDCP, in 2017, 4,724 AES cases and 621 deaths in Uttar Pradesh were reported. In the same period, 693 JE cases and 93 deaths were reported. In 2018, 3,080 AES cases and 230 deaths due to the disease were reported. In the same year, 323 JE cases, and 25 deaths due to the disease, were reported. Thirty-eight districts in Uttar Pradesh are affected by encephalitis, the worst-affected being Gorakhpur, Deoria, Kushinagar, Maharajganj, Siddharth Nagar, Sant Kabeer Nagar, Basti, Balrampur, Bahraich, Ballia, Azamgarh and Mau. The additional director-health of the Gorakhpur zone, Pushkar Anand, says that there has been a decline of approximately 60 percent in both cases and deaths due to encephalitis. The four districts in the Gorakhpur zone (Gorakhpur, Kushinagar, Deoria and Maharajganj) witnessed 130 cases and 13 deaths due to encephalitis till 12 June this year. In 2018, there were 1,279 cases and 125 deaths, while in 2017, there were 2,998 cases and 337 deaths. Ganesh Kumar, the principal of the BRD Medical College, has also claimed that cases of AES and JE have declined. The Uttar Pradesh government gives the credit for this achievement to the Dastak campaign , which was started in the year 2018. Under this mission, health workers of the state government went door-to-door and gave information about this disease. They informed people about the need to keep their homes and nearby areas clean, vaccination, using safe drinking water and visiting the nearby hospital if they find any symptoms of the disease. After the deaths of nearly sixty children in the college, allegedly due to a shortage of oxygen, the pediatric intensive care unit capacity of the BRD Medical College has been increased to 400 beds. Similarly, in the encephalitis-affected districts, the ICU capacity in district hospitals has been increased from 10 to 15. In all the four districts of Gorakhpur division, in eight community health centres and public health centres, mini-PICUs with three beds have been prepared. However, AES and JE continue to pose problems due to the scarcity of doctors, slow progress in drinking water projects in encephalitis-affected areas and difficulties in the identification of the causes of the diseases. In recent research conducted in Gorakhpur and nearby districts, the most common cause identified for AES is scrub typhus infection. In 2018, out of 1,073 AES patients admitted to BRD Medical College, 52 percent cases were due to scrub typhus infection. A cause for worry is that in Uttar Pradesh and Bihar, despite successful vaccination missions, cases of Japanese encephalitis constitute 7 to 10 percent of the total encephalitis cases. The number of cases of disabilities due to scrub typhus have decreased, but cases of mental illness have increased. Rehabilitation programmes for such patients are not in a good condition in Uttar Pradesh and Bihar. Malnutrition in children Encephalitis in children is directly related to malnutrition. In Bihar and Uttar Pradesh, most patients hail from poor rural families. Many of them are children of labourers, including landless labourers, and some of them have left their villages and migrated to cities to earn a living. Malnutrition among children is more prevalent in districts affected by AES in these two states. The state governments, therefore, need to take urgent steps to tackle malnutrition.