New Delhi: The death toll of children fighting Acute Encephalitis Syndrome (AES) in Bihar crossed 140 on Sunday. The government-run Sri Krishna Medical College and Hospital (SKMCH) in Muzaffarpur district is going through an epidemic-type situation similar to what was witnessed at the Baba Raghav Das (BRD) Medical College and Hospital in Uttar Pradesh's Gorakhpur district in August 2017. Since January 1, over 400 children suffering from AES have been admitted to SKMCH and Kejriwal Matrisadan, a private hospital, in Muzaffarpur.
The SKMCH management has opened two more wards in addition to the existing paediatric wards to tackle the emergency situation. Sanjay Kumar, Principal Secretary for Health, said the disease had affected 222 blocks in 12 districts of the state, including Muzaffarpur, Vaishali, Sheohar and East Champaran.
According to the state health department, over 600 children were affected by the disease across 16 districts in June. As protests over the large number of deaths erupted across the nation, Chief Minister Nitish Kumar recently called a meeting of health department officials, directing them to take necessary measures to fight the disease. He also announced an ex-gratia of Rs 4 lakh each to the families of the deceased children. The state government has also ordered a socio-economic survey of over 450 people whose children have either been affected by or have died of the disease.
Union Health Minister Harsh Vardhan and his state counterpart Mangal Pandey have visited SKMCH and assured the affected families of appropriate measures to save children’s lives. “We are trying everything and anything that can save children’s lives. From doctors to medicines, everything is being made available," Pandey said.
During his visit, Vardhan announced a 100-bed paediatric intensive care unit (ICU) to be set up at SKMCH and 10-bed paediatric ICUs at hospitals in adjoining districts. He also announced setting up of five virological diagnostic laboratories in the state at Gaya, Bhagalpur, Bettiah, Pavapuri, and Nalanda. However, Vardhan has faced much criticism with his promises that sounded similar to the ones he made five years ago as health minister when Muzaffarpur was in the grip of another encephalitis outbreak and 355 children had lost their lives.
NHRC takes note
Pointing to a deep political apathy towards public health care, the National Human Rights Commission (NHRC) last week sent notices to the Union Health Ministry and Bihar government. “The state appears to have failed to protect the young innocents’ lives," the rights body wrote.
Taking suo motu cognisance of a series of media reports about the loss of human lives all over the country, the council has expressed serious concerns over the deplorable public health infrastructure. Through another notice served to the Centre and all the states, the NHRC directed its teams, comprising doctors and officers, to visit hospitals in “vulnerable" states to conduct a fact-finding probe.
AES and its causes
Medically, encephalitis is an umbrella disease. AES is an acute inflammation of the brain usually resulting from either a viral infection or due to the body's own immune system attacking the brain tissue. Encephalitis is more common among children and young adults and can lead to considerable morbidity and mortality. Viruses are the main causative agents in AES cases, although other sources such as bacteria, fungus, parasites, spirochetes, chemicals, toxins and noninfectious agents have also been reported over the past few decades.
Encephalitis generally begins with fever and headache. The most common symptoms are headache, seizures, drowsiness, fever, vomiting, a stiff neck, muscle trembling, confusion, loss of consciousness and extreme weakness. Among infants and children, signs and symptoms might also include bulging in the soft spots (fontanel) of an infant’s skull, vomiting, body stiffness, not waking up for food and irritability.
Japanese encephalitis (JE) is a major cause of AES in India (ranging from 5%-35%). It is a mosquito-borne viral infection that involves inflammation of the brain. It is endemic with seasonal distribution in parts of China, south-eastern Russia and south and south-east Asia. The start and end of summer and monsoon months in India witness a peak in AES and JE, respectively.
Alarming situation
AES has been a serious public health problem in India for years. Bihar, particularly the district of Muzaffarpur, has reported cases of acute encephalitis among children since 1995. It has only increased since 2009. According to a research paper titled ‘Status and trend of AES and JE in Bihar, India’ published in the National Medical Journal of India, from 2009 to 2014, a total of 4,400 cases (733 cases each year) with an average case fatality rate (CFR) of 30% for AES was reported. A total of 396 cases of JE was also reported, with approximately 14% CFR.
Of the 2,697 cases registered between 2013 and 2018 in Bihar, on an average, 130 deaths have been reported annually, according to the 2018 National Health Profile under the National Vector Borne Disease Control Programme (NVBDCP) of the Ministry of Health and Family Welfare. This means the mortality rate is 130 out of an average 450 cases each year due to AES, with a 29% fatality rate. For the same period, a total of 348 cases of JE was reported in Bihar, claiming 61 lives, or at least 10 deaths each year.
In the last six years, the five top states majorly affected by AES/Encephalitis are Uttar Pradesh (3,220 deaths out of 21,042 cases), West Bengal (1,496 deaths out of 11,400 cases), Assam (1,440 deaths out of 10,273 cases), Bihar (777 deaths out of 2,696 cases) and Odisha (142 deaths out of 4,704 cases). Since 2013 to April 2019, total 66,926 AES cases and 7,254 deaths have been reported from 22 states, according to NVBDCP data. This means fatality rate due to AES in India is 11 per cent (1,206 deaths each year). In case of JE, the fatality rate was 5 per cent with 626 deaths.
In 2018, 11,388 AES cases and 636 deaths were reported from 22 states with a case fatality rate of around 6 per cent. Among the various communicable diseases with high CFR (about 2% and above) reported by states/UTs during 2017, AES was 8 per cent. The total number of cases and deaths during the period due to AES was 13,672 and 1,097, respectively. While of the 2,181 JE cases, 252 deaths were reported with 12 per cent fatality rate. However, a year ago in 2016, as many as 1,301 lives were lost (highest till now) even as a total of 11,651 cases was reported.
Crucial Case of Uttar Pradesh
According to the NVBDCP data of the Union Health Ministry, in 2017, UP reported the maximum number of cases (4,724) and deaths (654) with the highest fatality rate 36 per cent, followed by Assam (178 deaths out of 2,077 cases) and West Bengal (169 deaths out of 1,514 cases). In August-September 2017, AES had claimed the lives of hundreds of children in BRD hospital in Gorakhpur, while a similar scenario was witnessed around the same period next year in Bahraich district. In 40 years, 25,000 children have died in Gorakhpur alone due to encephalitis.
However, the BRD Hospital data for 2017 said 1,527 deaths (mostly children) were recorded of the 6,264 afflicted patients admitted. Data further reveals that between 2005 and 2016, encephalitis claimed 6,431 deaths out of the 29,539 cases that were registered in the hospital. Most of the patients here came from different different districts of eastern UP. This means, there were 584 deaths with 22 per cent annual mortality rate. The year 2005 was the deadliest with 937 deaths out of 3,532 cases.
In July 2018, Lucknow reported 135 (maximum) cases of AES among 48 districts of the state. It was 15 times more than the number of such cases reported a year earlier in Lucknow.
A report by the United Nations Inter-agency Group for Child Mortality Estimation (UNIGME) released in September, 2018, stated that lack of access to water, sanitation, proper nutrition and basic health services resulted in 8,02,000 infant deaths in India in 2017, despite the government’s programmes on sanitation, health and nutrition. That means approximately 2,200 children died in the country every day.
Inadequate Infrastructure and Human Resource
National president of Indian Medical Association (IMA) Ranjan Sharma said IMA should be roped in by the government to suggest remedies for encephalitis. “Every year, it is being said that everything has been done to contain it but it still occurs. It is not the doctors who can be blamed. Infrastructural support, basic cleanliness and involvement of various communities are key," Sharma told news agency ANI.
According to the Directorate of State Health Services and National Health Profile, one government doctor serves 28,391 people in Bihar. Uttar Pradesh ranked second with 19,962 patients per doctor, followed by Jharkhand (18,518 patients per doctor), Madhya Pradesh (16,996), Chhattisgarh (15,916) and Karnataka (13,556). In India, on an average, a government doctor attends to 11,082 people, more than 10 times the recommendations of the World Health Organisation (WHO).
Pediatrician Dr Kafeel Khan told News18, “Ten per cent of the encephalitis cases are bacterial that can be treated by medicines, but 70 to 90% cases are viral for which we don’t have medicines. This led to the huge number of deaths. All over the world, doctors use some anti-viral therapy but it is under trial and it has not been accepted as the defined treatment. Out of this 90 per cent we know 20 % are JE or Nipah encephalitis etc. But in 70% cases it is unknown whether which viral is causing the disease."
Citing his own team’s research at BRD Hospital, Gorakhpur, he said that it was found that encephalitis or AES was very common in north India because of poor hygiene, lack of safe drinking water, poor sanitation and most importantly, malnutrition. “Mostly poor people are affected by encephalitis," he said. According to the Assocham-EY report, India is home to the largest number of malnourished children in the world.
Dr Kafeel said, “WHO has been providing free vaccination as preventive measure to AES and JE for the last 25 years. But there is not enough monitoring of the vaccination programme run by government agencies. Also, there is a lack of doctors, nurses, infrastructure and equipment." Dr Kafeel and some doctors are holding a medical camp in Gorakhpur this week to provide free treatment to encephalitis patients.
“I visited SKMCH in Muzaffarpur where only four doctors (one senior resident doctor and three juniors) and five nurse were available for 200 children admitted there. According to the ICU guideline in India, there should be one doctor for four critical patients and one nurse for two critical patients. “How can these few staff take care of such a large number of patients there," he said.
Dr Kafeel and three other doctors were suspended for alleged negligence when shortage of oxygen cylinders in the children’s ward at BRD hospital, Gorakhpur, led to 70 infant deaths in three days in August 2017. After spending more than eight months in jail, the Allahabad High Court granted him bail in April this year. The high court found “no material on record, which may establish medical negligence against" him individually in connection with the deaths. Dr Kafeel is still awaiting reinstatement at BRD hospital.
He rebutted UP Chief Minister Yogi Adityanath’s claims on curbing the spread of encephalitis. “Now, the number of cases in encephalitis has declined in Gorakhpur because patients neighbouring districts are being referred to either Lucknow or Varanasi. That’s why Lucknow recorded such a high death rate in 2018," he said.
A new diagnostic term “Acute Febrile Illness" or “Acute Viral Fever" is being used for encephalitis-affected patients in UP and the data for these patients is not being released by state health department, Dr Kafeel said.
Meanwhile, the Centre has initiated a probe into the large number of deaths among children in Muzaffarpur. Also, the health ministry has alerted the Indian Council of Medical Research adding that there were no reports of the spread of this virus from other parts of the country.
(Graphics by Pooja Dantewadia)
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