Recently, some of us doctors sat together in Gorakhpur when the Indian Council for Medical Research and Pune-based National Institute of Virology (NIV) held a meeting. A report on it has not been made public, but sources later indicated that research submitted to the government revealed that a majority of the cases of acute encephalitis syndrome (AES) were caused by scrub typhus, which manifests as fever, headache and rashes. Why then did over a 100 children in Gorakhpur die from AES under a single roof in just the beginning of what is the ‘season of death’? That too, when scrub typhus can easily be treated through affordable drugs like azithromycin and doxycycline that are widely available!
The two main causes of AES, before this revelation, were deemed to be Japanese encephalitis (JE) and the entero-viral. Both of these were untreatable and had an average mortality of 25 to 30 per cent. Can a causative organism change its pattern in eastern Uttar Pradesh alone? After several visits and studies, a joint team of the Centre for Disease Control and Prevention (CDC) from Atlanta in the US and NIV assumed that AES was probably caused mainly by JE and entero-viral encephalitis.
Earlier, continuous campaigning and advocacy since 2005 led the central government to import a JE vaccine from Japan. It was mass-administered (to 65 lakh approximately) and then in 2010 to 75 lakh in Gorakhpur and three neighbouring UP districts. The JE cases came down to 6-8 per cent of total AES cases from 2007 onwards. After that, there was no significant drop in AES cases and deaths. So, it dawned on all that entero-viral encephalitis was the main culprit for a majority of AES cases. If the burden now shifts to scrub typhus, without conclusive studies and research, as the main cause of nearly two-third of AES cases, why haven’t deaths come down drastically, since low-cost antibiotics are easily available?
Research is essential, but it cannot be perpetual. The correct preventive steps must be implemented after determining the actual culprit for AES cases and deaths. Since 1977, AES has been killing children in thousands every year in 19 states of country, with UP’s Poorvanchal being the worst affected.
I suspect entero-viral encephalitis causes around three-fourth of the AES cases. The CDC teams have confirmed this, too. There is neither vaccine nor cure for entero-viral encephalitis, which is passed through human and animal excreta.
Half of India’s 120 crore people still defecate in the open. The rainwater washes this into the fields and it eventually seeps into the water table. As preventive measures, there has to be provision of safe drinking water and at least one sanitary toilet after every 10 houses initially. The CM has said he will ensure that every house in the UP area has a toilet by 2018. Fulfilling a substantial part of this promise by next year will greatly reduce the health risk.
Our self-funded campaign against AES began in 2005. We realised that this problem could only be tackled through a national programme. Accordingly, we had drafted a 75-page National Encephalitis Eradication Programme and sent it to the UPA government in 2006. There was a lack of response; so we implemented the scheme in a pilot form by using our own resources. That was in 2010 in Bholiya village on the Nepal border between Kushina-gar and Gorakhpur. The media had dubbed it as the Dandi March of Poorvanchal.
Nation-wide deaths from dengue over the past 40 years will probably be less than the average number of annual AES casualties in eastern UP.
In 2012, the UPA-II government finally implemented a scheme—with a different name (National Programme for Prevention and Control of Encephalitis and AES). A separate relief fund of Rs 4,000 crore was allotted to tackle AES. Since this is an incurable disease, the government could have deployed more people on the ground to work on preventive measures and awareness. Instead, they chose to pay most (around Rs 2,500 crore) of these funds to pharma companies to manufacture vaccines and making ICUs and other infrastructure in treatment centres. No pilferage seemed to have happened, but the idea implementation was poor. Eventually, the programme was a non-starter.
Apart from the above, there are many other causes of AES, but they are rare. The three mentioned here are the chief causes. One theory that gained popularity was that consuming litchis caused encephalitis—there is no proof of this till now.
In Delhi, dengue deaths always lead to a high alert. But, the total dengue deaths over the last 40 years all over the country would probably be less than the average number of deaths each year due to AES in eastern UP alone. The mosquito in Delhi lives in coolers. The cases have a maximum mortality rate of five per cent or so, an average mortality rate of 1-2 per cent. Encephalitis has had a killing rate of 30 per cent for the last 40 years.
There has to be some amount of parity in the way people have been provided healthcare in Gorakhpur. The Centre has not made any consistent effort over the years. Is this because the affected are young children and that too of poor farmers? The only step taken by the WHO was to send the CDC team a few times. The lone solution is a dedicated and accountable national programme—similar to that which eradicated polio and small pox.
The recent child deaths in Gorakhpur have triggered a national outcry, probably because it has happened in the CM’s constituency. There have also been discussions on the lack of oxygen supply, which is a repeat of what happened in 2005 when a child had died every hour. I have requested the state government to provide each ward with two oxygen separator devices, which can concentrate and store the oxygen in the room itself. There can be many other reasons for stoppage in supply of oxygen and this will take care of that.
The Three Kinds Of Encephalitis
The virus is found in pigs, in which it multiplies but doesn’t affect the host. When a mosquito bites the pig, it carries the virus and infects humans that it bites. Spread mostly in those with weaker constitutions; maximum vulnerability amongst young children of age group 2-3 years.
- Symptoms: Spasms, high-grade (between 104-106) fever, headache, vomiting, body-ache, and seizures/ convulsions and going into a coma. Sets in within a day or two.
- Treatment: Nil
- Vaccination: Available
- Prevention: Children are advised to stay away (especially during dawn and dusk) from rice fields, where these mosquitoes breed
One of many types of virus present in human excreta that contaminates drinking water and easily communicates the disease
- Symptoms: Low-grade fever for four-five days which escalates followed by same symptoms as JE, along with chances of passing out
- Treatment: Nil
- Vaccination: Nil
- Prevention: Safe drinking water; hygienic toilets for each house; prevent contamination of ground water caused by heavy irrigation carrying human excreta from open defecation
Possibly caused by a parasite passed through the bite of a bug that inhabits shrubs
- Symptoms: Similar to JE; with a cough and rash added and other varying symptoms depending on strength of virus
- Treatment: Antibiotics: Azithromycin and Doxycycline
- Vaccination: Nil
- Prevention: Doctors are only recently learning of it
(The writer is chief campaigner, Encephalitis Eradication Movement, started in 2005 as a self-aided collective of citizens from seven UP districts.)