Last week, Indian news channels were full of stories and ground reports about child deaths caused due to Acute Encephalitis Syndrome (AES) in Bihar’s Muzaffarpur district. A week earlier, the news was all about the doctors’ strike in West Bengal. Both these incidents show India’s broken public healthcare system.
Over 100 children may have died due to AES in Muzaffarpur district alone -- epicentre of the disease’s latest outbreak.
Japanese encephalitis virus (JEV) is a major cause of AES in India. However, other sources such as bacteria, fungus, parasites, chemicals, toxins and non-infectious agents cannot be ruled out. Symptoms include headache, fever, confusion and vomiting. AES is said to be caused due to inflammation of the membranes around the brain. It mostly affects children below 15 years of age, as they are most vulnerable.
In the latest outbreak, it was reported that the encephalopathy is associated with hypoglycaemia, or, a condition caused by very low level of blood sugar.
The case-fatality rate of AES can be as high as 30 percent among those with the disease’s symptoms. Of those who survive, 20–30 percent suffer permanent intellectual, behavioural or neurological sequelae such as paralysis, recurrent seizures or the inability to speak.
Lack of understanding
The biggest worry about AES is the lack of understanding of what exactly causes the disease. There are several causative theories. While JEV was widely seen as a cause, patient case reports suggest that it was not.
One theory, though contentious but gaining ground, is the litchi toxins.
Most children who are falling ill come from families that work in Bihar’s litchi orchards. The April-July period, which is the harvest season for litchis, is where children work to collect the fruits fallen on the ground. These children, who are poor and malnourished, eat litchis on empty stomach, exposing them to a toxin called methylene cyclopropyl glycine (MCPG). The toxin interferes with the natural mechanism to correct low blood glucose levels affecting fuel supply to the brain.
The other theories are malnutrition, and the heat wave.
Union Health Minister Harsh Vardhan promised to set up a “multi-disciplinary institute” to “identify the reason behind the disease”.
But, what AES underlines is the dismal state of outbreak investigation in Muzaffarpur. Dr Vipin Vashishtha, a member of the team that studied the epidemic in Muzaffarpur along with NCDC and CDC from 2011 to 2013, speaking to News18, described the investigation as “five blind people describing an elephant”.
“The problem is, each team starts with a fixed mindset and looks for the some infective pathology behind every outbreak. There is lack of coordination and synchronisation of efforts, and ultimately they waste their energy either duplicating the efforts of other or pursuing a different approach unmindful of other’s accomplishments,” Vashishtha said.