Sting that is ailing Bihar

For the past two weeks the situation at Sri Krishna Medical College and Hospital (SKMCH), which is a well-known hospital in Muzaffarpur, is simmering with tension.

It is a hospital where the children from the district are being treated for acute encephalitis syndrome (AES). However, with the death of 127 children in Muzaffarpur from AES, the state government comes under increased scrutiny for its apparent failure to tackle the outbreak despite its best efforts.

Currently, the state is swarming with team of doctors from across India, but this does not end the struggle of patients who are grappling with issues like the insufficient number of beds, power cuts and unhygienic conditions at the hospital wards of SKMCH. A similar or more tough conditions are witnessed by the patients at the other hospitals in Muzaffarpur.

The sudden outbreak in Bihar from May and an increase in the number of children deaths have shocked the health department. Brain fever or AES is a syndrome and not a disease. It can be caused due to various factors. In five to 30% of the cases, AES is caused due to Japanese encephalitis virus (JE+ve). In Bihar, the Directorate of Health Services (DHS) has claimed that the JE virus had caused only two of the AES cases this year.

This year till April while there were zero cases and deaths due to the AES in Bihar, a sudden outbreak has seen an increase in the number of cases and around 165 deaths between May till June 22.

Also Read: Understanding what creates acute encephalitis syndrome

Heatwave not lychee

In AES cases, treatment should be started immediately after the admission of the patient related to headache, seizure, fever, and other health issues. While there are many factors which are taken into consideration for AES in children, the three major reasons include —heatwave, cultivation of lychee and other viruses causing AES.

AES is divided into two categories – AES known and AES unknown. AES known includes multi-factors through which AES can be caused. The primary report states that most of the death was related to hypoglycemia.

Dr Ragini Mishra, Bihar's state surveillance officer, said, "As per the recent finding, the major factor which we have found in the recent AES known cases happening in Bihar is hypoglycemia (low blood sugar level) and dyselectrolytemia."

Denying lychee to be the cause of AES death, Dr Mishra, added, "There are multiple papers' finding which states that lychee can be one of the factors. But consumption of lychee is not the only factor for the cause of AES death. Other factors through our surveillance findings include malnourishment in children, heat, and humidity are a few other factors involved."

The head of the paediatric department in SKMCH hospital, Dr Gopal Shankar Shahani has stated that the AES is not caused due to the consumption of. One of the major reason is the heat wave.

Lack of medical facilities

The high number of deaths have taken place due to the delay in the treatment. If the patient is stabilised for hypoglycemia and/or dyselectrolytemia at public health centre (PHC) level, then there is no need to shift them in the hospital. "AES cases which can not be managed at the PHC level are referred to the hospitals. Right now the cases are directly referred to the hospital as the situation is grim," said Dr Mishra.

Head of the SKMCH hospital, Dr Sunil Kumar Shahi has stated that the number of AES cases are increasing day by day. He said, "While the number of deaths is increasing, we are treating everyone. Due to the lack of bed facilities, two to three children are sharing a single bed. Once the monsoon starts, the number of patients will decrease"

Currently, there are 50 beds in the paediatric ICU ward of SKMCH and the patients' footfall is more than 100.

Speaking about the lack of medical facilities and what the government is doing, Dr Mishra, Bihar's state surveillance officer, said, "Overnight we can't upgrade the medical infrastructure in the medical college and hospital. AES cases are primarily treated at the PHC level. We are trying to stabilise the AES cases at the PHC level. We are strengthening the service by stocking medicines, other medical facilities and beds are made available at the PHCs."

Looking at the past data from Bihar state, the number of AES deaths had seen a decreasing trend from 2016 till 2018. In 2018, Bihar had recorded 124 cases and 33 deaths of brain fever. In the past five years, the highest number of deaths due to AES in the state of Bihar has reported in 2014 i.e 355 deaths.

Low awareness

According to the medical authority, less awareness about brain fever among the public is one of the reasons for the increase in the number of cases. Dr Rajiv Kumar, a senior doctor from Kejriwal Hospital in Muzaffarpur who has been treating the AES patients, said, "There is a lack of awareness level in the public. If children are given dinner every day and some sweet before going to bed, there is a possibility that they won't suffer from AES. Even if there is a proper guideline to inform the public and create awareness about the dos and don't, since the past two years, the government has failed to create awareness."

The Bihar government has now planned to start an awareness drive in the villages located in Muzaffarpur district which is the epicentre of brain fever. According to the government, they will be covering around 7.7 lakh houses through the awareness drive.

Dr Ragini Mishra, further added, "State government is monitoring the groundwork and creating awareness. ORS and electrolyte powder is distributed in the affected areas where the AES cases are reported more. Additional manpower support and a team of UNICEF and state resource unit are sent to the four districts in Bihar which are adversely affected."

How other states fair

Apart from Bihar where the brain fever cases have been reported in India is Odisha, Uttar Pradesh and West Bengal. As per the National Vector Borne Diseases Control Programme (NVBDCP) data more than 250 cases of AES have been collectively reported in the above mentioned states. The data further points out of the 18 deaths due to AES this year, 16 deaths were reported in West Bengal. Assam and Uttar Pradesh reported one death each till April this year.

In Maharashtra, the number of cases as well as deaths is less in numbers. Looking at the NVBDCP data from 2013 till April 2019, there has been only two deaths due to AES and the number of cases is 312 out of which highest number of cases (143 cases) were reported in 2017.

According to Maharashtra's health department, good medical facilities and routine check have reduced the number of Japanese encephalitis (JE+ve) and Chandipura virus cases in the state which constitutes encephalitis illness.

Dr Pradeep Awte, state surveillance officer, Maharashtra, said, "In Maharashtra, only a handful of deaths are reported due to AES. Around nine districts in the Vidarbha region such as Nagpur, Akola to name a few, do get a handful of AES cases. But routine check-up, awareness level and surveillance help to control the spread of AES and JE+ve cases in Maharashtra."

Skipping of meal

In 2014, when Bihar had reported 1,358 cases and 355 deaths due to AES (second highest in the number of deaths that year) a research study was carried out by Researchers from the National Centre for Disease Control (India) and the National Center for Environmental Health, US Centers for Disease Control and Prevention.

Out of the 390 cases who came for treatment in two months, 122 patients died. As per the researchers, they found that an absence of an evening meal significantly modified the effect of eating litchees on the disease.

As per the study, the researchers concluded, that the recurring outbreak of acute encephalitis is associated with both hypoglycine A and MCPG toxicity from lychee consumption. It is also associated with the absence of an evening meal. To prevent illness and save lives in Muzaffarpur district, a recommendation to minimise lychee consumption among young children, ensuring children in the area receive an evening meal throughout the outbreak season and implementing rapid glucose correction for children with suspected illness.

How Deadly Encephalitis Spread Its Wings In 16 Districts Of Bihar 

• June 8, 2019: 14 children die due to Acute Encephalitis Syndrome (AES) in Muzaffarpur district, Bihar while over a dozen are admitted in Shri Krishna Medical College and Hospital (SKMCH) with high fever and other symptoms of the infection.
• June 9, 2019: Death toll reaches 19, goes to 31 on June 12 
• June 14, 2019: Death toll reaches 19, goes to 31 on June 12 
• June 16, 2019: Union Health Minister Harsh Vardhan visits the families of children suspected to be suffering from AES in Muzaffarpur, assuring them of help from the Centre. Bihar Chief Minister Nitish Kumar announces an ex-gratia of Rs 4 Lakh each to families of the children who died of the disease. Meanwhile death toll rises to 102
• June 17, 2019: Nitish Kumar calls an internal meeting of senior officials of the health department
• June 18, 2019: Nitish Kumar visits Shri Krishna Medical College and Hospital to review the situation where more than 300 children have been admitted with complaints of AES. He faces protests from angry people over the deaths
• Advocate Manohar Pratap files a plea in the Supreme Court (SC) seeking direction to the Centre to urgently constitute a team of medical experts for treatment of children
• June 19, 2019: Death toll reaches 112 including 93 children at Sri Krishna Medical College and Hospital (SKMCH) and 19 others at Kejriwal Hospital. 
• Dr. Harsh Vardhan reviews the ongoing public health measures, also directs five teams of senior pediatricians and para-medics to be sent to Muzaffarpur immediately 
• SC agrees to hear a plea seeking a direction to urgently constitute a team of medical experts for the treatment of children suffering from AES on June 24
• June 20, 2019: As per the statistics released by the state Health department, the total number of AES cases since June 1 stands at 626. Total number of deaths reaches to 136

—Compiled by DNA Research N Archives

With inputs from Zee Media Newsroom