During the course of the last week, a terrible and enormous human tragedy that unfolded in this country went unheeded and unnoticed in the heat of the countrywide doctors’ strike, triggered by an assault on two junior doctors at NRS Hospital in Kolkata.
It took this event to subside and disappear from the headlines before the country noticed that, in the interim, more than a hundred children had lost their fight with Acute Encephalitis Syndrome (AES) in Bihar’s Muzaffarpur district. The children mostly belonged to the age group between one and ten. What they shared, apart from age, was abject poverty that did not even permit grief.
WHAT IS ACUTE ENCEPHALITIS SYNDROME (AES)?
- Acute encephalitis syndrome (AES) is characterized by an acute onset of fever and clinical neurological manifestation that includes mental confusion, disorientation, delirium, or coma
- Viruses have been mainly attributed to be the cause of AES in India although other sources such as bacteria, fungus, parasites, spirochetes, chemical, and toxins have been reported over the past few decades
- The causative agent of AES varies with season and geographical location, and predominantly affects population below 15 years.
- Keeping in mind the wide range of causal agents and the rapid rate of neurological impairment due to pathogenesis, clinicians face the challenge of a small window period between diagnosis and treatment.
- In India, the most common cause is the virus that causes Japanese encephalitis (JE).
- Health Ministry estimates attribute 5-35% of AES cases to the JE virus.
- In Bihar, the Directorate of Health Services claimed that the JE virus had caused only two of the total 342 AES cases this year.
- The syndrome is also caused by infections such as scrub typhus, dengue, mumps, measles, and even Nipah or Zika virus.
- In the latest outbreak in Muzaffarpur, the cause is yet to be clinically identified in most of the children.
HOW IS HYPOGLYCAEMIA LINKED TO AES?
- Hypoglycaemia (low blood sugar) is a commonly seen sign among AES patients, and the link has been the subject of research for long.
- The combination of AES with hypoglycaemia is unique to Muzaffarpur, Vietnam and Bangladesh.
- A 2014 study in Muzaffarpur suggested that hypoglycaemia was the trigger that led to diagnosis of encephalitis.
- With 98% of AES patients in Bihar also suffering hypoglycaemia, doctors are attributing deaths to the latter.
- In Bihar, convulsions in children (which is AES) are found in combination with hypoglycaemia.
LITCHI AND AES?
- Early researches have drawn parallel between cases in Bihar’s Muzaffarpur and in Vietnam’s Bac Giang province.
- In both places, there were litchi orchards in the neighbourhood.
- Methylene cyclopropyl glycine (MCPG), also known as hypoglycin A, is known to be a content of litchi fruit.
- Undernourished children who ate litchi during the day and went to bed on an empty stomach presented with serious illness early the next morning.
- When litchi harvesting starts in May, several workers spend time in the fields.
- There, it is common for children to feed on fallen litchis and sleep without food.
- The toxin in litchi (MPCG) lowers blood sugar level during night, and these children are found unconscious in the morning.
- Blood glucose falls sharply causing severe brain malfunction (encephalopathy), leading to seizures and coma, and death in many cases.
- However, this remains a subject of debate, and the possible association needs to be documented.
WHAT ROLE DOES MALNUTRITION PLAY?
- If toxins from litchi were causing hypoglycaemia, then these cases should have remained consistent each year.
- Also, it should have affected children of all socio-economic strata.
- But in contrast, this year, all deaths have been recorded in the lower income groups.
- While well-nourished children eating litchi remain unaffected even if they go to bed on an empty stomach, the under-nourished ones were at grave risk.
- This is because under-nourished children lack sufficient glucose reserve in the form of glycogen.
- Also, the production of glucose from non-carbohydrate source is unsafe as it is unsustainable and thus stopped midway.
- This leads to low blood sugar level, giving way for further health complications.
- In all, even if litchi is a triggering factor, the real cause for adverse effects is said to be malnutrition.
- So, while the cause of AES is still being researched, hypoglycaemic AES may be caused by malnutrition, heat, lack of rain, and entero-virus.
WHAT MAKES BIHAR AND UP VULNERABLE?
- Malnutrition is high in both states, and malnourished children are prone to infection.
- As per Health Ministry data, UP and Bihar together account for over 35% of child deaths in the country.
- National Family Health Survey-4 data show that in 2015-16, 48% children aged less than 5 in Bihar were stunted, which is the highest in India.
- Also, heat, humidity, unhygienic conditions and malnutrition which are unique to these areas, together contribute to the rise in AES.
- Incidence is higher in litchi fields around which malnourished children live.
WHAT MEASURES HAVE BEEN TAKEN?
- In 2014, 74% of sick children were saved through a simple intervention by infusing 10% dextrose within 4 hours of the onset of illness. [Infusing dextrose is necessary to completely stop the attempt by the body to produce glucose from non-carbohydrate source.]
- Also, the prevention strategy of ensuring that no child goes to bed without eating a meal was adopted from 2015.
- This ensured a sharp drop in the number of children falling sick.
- The Bihar government introduced free vaccines at all primary health centres. The current coverage is 70%.
- The central and state governments have also conducted awareness campaign asking people not to expose their children to sun.
- Also, ensuring a proper diet and increased fluid intake were insisted.
- Besides these, early hospital referral and standard treatment for convulsions, high fever and vomiting can save lives.
Although Muzaffarpur is in a remote part of the state, it is not inaccessible. The district headquarters is a mere 72 kms away from the state capital Patna and can be reached by road in less than two hours. However, the casualness with which the state authorities approached the matter forced a conscientious petitioner to escalate the matter up to the Supreme Court seeking a direction to the Centre to immediately constitute a team of medical experts to go into the causes of the disease — the AES — and for providing all necessary medical equipment and support for the effective treatment of children.
What saddens Indians is that these deaths were not a sudden 2019 occurrence. Deaths on account of AES have taken place since 2008 in the state and particularly since 2014 — the year that witnessed 139 deaths — and now total around a thousand over a decade. Several attempts at pinpointing the cause of the disease have been made but no agreed diagnosis has been established.
However, what is not denied is that malnutrition makes the children particularly vulnerable to the disease. Health surveys clearly reveal that in Bihar, a very high number of children do suffer from malnutrition. In 2015-16, National Family Health Survey-4 revealed that 48% of children aged less than five were stunted and this was the highest in India. However, state authorities have sought to underplay the issue of malnutrition. Any such attempt smacks of insensitivity and a clear denial of governmental accountability. It is for this reason that the National Human Rights Commission (NHRC) has been driven to send notices to the Ministry of Health and Government of Bihar over the continued deaths of children in Muzaffarpur. It has also sought a report on “not only vaccination, but all precautionary measures such as cleanliness and hygiene.” The NHRC was categorical in stating that the state appeared “to have failed to protect the young innocent lives.”
Bihar will not come out of its terminal crisis unless the Government of India puts its heart into the job. The task is much too large to be handled by the state alone, given its proven ineptness. GoI needs to set up a high-level task force to develop a strategy for the state, equip it with a committed and dedicated team for implementation, provide the team with adequate resources and set targets of development indices to be achieved in the next five and ten years that bring the state and its people on par with the rest of the country. Without such an effort, the state will continue to pull back the nation’s development and impact its standing as a developed nation. The abandoned state must be reclaimed and revived.
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