Symptoms normally associated with Acute Encephalitis Syndrome (AES) have claimed the lives of 125 children in and around Muzaffarpur, Bihar, just days after CNN linked the mysterious deaths of 47 children to the inflammation of the brain caused by lychee toxins.
This year, the ongoing heatwave seems to have acted as a catalyst in the massive outbreak.
According to official data, more than 300 children have been admitted with complaints of AES since June 1. Close to 90 children died in Sri Krishna Medical College and Hospital (SKMCH), while 18 lost their lives in Kejriwal Maternity Clinic in the district, with the death toll still rising.
AES and its causes
AES is an umbrella term for myriad infections that can be bacterial, fungal or viral in nature. Parasites, toxins, and chemicals may also lead to the symptoms usually clubbed together as encephalitis.
Besides brain inflammation caused by virus, meningitis (swelling of the protective membranes covering the brain and spinal cord), encephalopathy (a broad term for any brain disease that alters brain function or structure) or cerebral malaria (severe neurological complication of infection with malaria) also come under AES.
In India, the most common manifestation of AES is attributed to the virus that causes Japanese Encephalitis (JE). Doctors have not yet established whether JE is the primary reason this year.
As per extensive studies by the National Centre for Disease Control, New Delhi, and the Center for Disease Control (US), the two competing theories give heat stroke and excessive lychee consumption as the primary causes of AES.
A Lancet report based on a study of a similar pandemic five years back backed the lychee theory in 2015.
Most medical professionals think humidity, malnourishment, late monsoons, and exposure to pesticides—together with lychee toxins and heat—comprise the combination of contributing factors to a mixed illness in Bihar.
According to CNN, the pandemic of AES and related symptoms has taken over the town of Muzaffarpur and its adjoining areas every year since 1995. Eastern Uttar Pradesh, too, sees frequent outbreaks. There is no fixed pattern, but a year with high temperature and scanty rain usually witnesses higher number of cases.
Hundreds of children were admitted to hospital in 2014, exhibiting symptoms of this illness, branded locally as “chamki ki bimari”, or “tinsel disease”. Of the 390 admitted for treatment, 125 have died.
In 2013, at least 355 people died of encephalitis in UP. “This year, the number [of cases] has gone up a bit. The heatwave has been too intense, and it has gone on for too long,” said Sanjay Kumar, a senior state health official to CNN.
Since January 1, 2019, 358 children with AES have been admitted to SKMCH and Kejriwal Matrisadan with AES.
Symptoms noticeable mostly in ages 1-10 begin with the onset of fever exceeding 104°F, accompanied by headache, disorientation, tremors, convulsions, and paralysis. These lead to delirium and, eventually, coma in most cases. If the symptoms are not treated within hours of the first few appearing, 30% of those affected usually die.
Doctors noted that malnourished children who played near the lychee orchards in the evening returned home “uninterested” in eating a proper meal. Skipping dinners and going to sleep may have caused night-time hypoglycaemia (extremely low blood sugar). One of the expert teams that identified the epidemic noted that these children fell ill in the pre-monsoon period between 4 am and 7 am, and were found unconscious in the morning.
Dr Gopal Shankar, acting HoD at SKMCH, however, claimed that the outbreak occurred due to “acclimatisation failure in children” and “environmental factors”, such as heatwave and poor rainfall. He even said that rainfall is the only remedy to this outbreak, drawing massive criticism for missing the link between low blood sugar and AES.
Paediatricians at SKMCH also noted an electrolyte imbalance. Besides, a test of their spinal fluids revealed a presence of pesticides and insecticides, making it difficult to dismiss the connection to lychee cultivation.
The combination of AES with hypoglycaemia is unique to Muzaffarpur, Vietnam, and Bangladesh, where malnourishment and a lack of proper diet abounds. As a sign of AES, hypoglycaemia causes convulsions in children, which can be stopped with a dose of intravenous glucose.
Dr Arun Shah, who was part of the consultative task force to understand the epidemic, told News18, “The human angle has always been ignored. It is criminal to say that the deaths are not a case of AES.”
“These deaths have had the same symptoms since the last two decades. Poor, malnourished children stay hungry and pick up anything they find in the gardens, like lychees, to eat. The government in Bihar is trying to divert the issue of malnutrition instead of taking it up seriously.”
What’s Nitish Kumar doing?
Having announced an ex-gratia compensation of ₹4 lakh each to families of deceased children, Chief Minister Nitish Kumar on Monday chaired a high-level meeting to take stock of the situation. A day later, he announced that the state government would bear the cost of treatment and also reimburse transport charges incurred in ferrying patients referred by primary health centres (PHCs).
Kumar visited the patients at SKMCH on Tuesday, facing flak from the Opposition for the fragile health and awareness systems in the state, and protests from local children and relatives of patients and the deceased demanding effective response to the outbreak. Flanked by Deputy CM Sushil Kumar Modi and local MLA Suresh Sharma, he held an impromptu meeting with the hospital authorities.
Kumar also convened a review meeting of health, disaster, and education departments in Patna, reportedly to look into the possibility of providing necessary medical care in remote areas, to conserve time spent in travelling to cities. He issued instructions to equip PHCs with AES-specific facilities.
The Centre issued a statement last week advising children to, henceforth, “minimise lychee fruit consumption” in affected areas, and eat an evening meal during the “outbreak period”.
Union Health Minister Harsh Vardhan on Monday directed a high-level multi-disciplinary team of experts to be sent to Bihar to establish the cause of the disease. He also directed the state government to set up a 100-bed paediatric intensive care unit at SKMCH and virological units across the state by year-end. Vardhan promised to set up a “multi-disciplinary institute” to “identify the reason behind the disease”.
The National Human Rights Commission Monday issued notices to the Union Health Ministry and Bihar government and took suo motu cognisance of media reports about the rising number of deaths of children due to AES.
A complaint has been filed against Vardhan and his Bihar counterpart Mangal Pandey with the chief judicial magistrate, for negligence, flawed implementation of vaccination programmes, and apathy in launching awareness campaigns.
The apex rights body also sought a report on all precautionary measures the state has taken till date, including the maintenance of hygiene and cleanliness, absence of which further exacerbates chances of a contagion.
Why this matters
With leprosy staging a comeback a decade after India was declared free of it, the cyclical return of AES in one of India’s poorest and most malnourished states is indicative of the major flaws in our healthcare delivery system, especially in the rural and underdeveloped regions. In fact, opposition party RJD has accused the government of taking a backseat because most of the affected children hail from Dalit families.
Medical professionals have pointed to the time it takes for parents in remote areas to reach the nearest health centre, which reduces the chances of their child’s survival. Those who do survive are so poor, they continue to live with neurological or physiological deficits as they cannot afford rehabilitative treatment.
The fact that the outbreak occurred despite the government being advised to ensure children don’t venture out in the heat, increase fluid intake, have a meal before they sleep, and to prepare PHCs with supply and training to provide intravenous glucose in case of an attack, speaks volumes about the state of children’s development in Bihar.
Ministry of Health and Family Welfare data shows that Bihar along with UP accounts for over 35% of child deaths in the country. National Family Health Survey-4 data shows that, in 2015-16, 48% of children aged less than five in Bihar were stunted—the highest in India. According to the state government, vaccines are free for all and yet the coverage is restricted to 70%.
Neighbouring states Jharkhand and West Bengal are on high alert.
Muzaffarpur is one of India’s most prominent lychee-growing spots with Bihar accounting for 40% of all lychee cultivation, exporting the fruits all over the country. Coupled with the heatwave, the perils of such an outbreak are wide-ranging, assuming these are the primary reasons behind the pandemic.
Even if heat and lychee played the aetiological role, lack of awareness, poor access to clean drinking water and trained doctors, malnutrition, and unhygienic living conditions have collectively led to the rising death toll in Bihar, and it’s time the government acknowledged it.
Prarthana Mitra is a Staff Writer at Qrius.