Encephalitis deaths in Bihar

Encephalitis deaths in Bihar: Clinical ambiguity, delayed access to medical care raise questions about steps taken to prevent disease

• As Muzaffarpur and adjoining districts of Bihar continue to grapple with the deadly Encephalitis outbreak, questions arise as to whether adequate steps have been taken to identify the cause of the disease and prevent it from spreading further.

• So far, around 150 children have died due to acute Encephalitis syndrome (AES) in the past fortnight and several more are feared infected, even as the state government comes under increased scrutiny for its apparent failure to tackle the outbreak despite its best efforts.

What and how?

• Encephalitis is a disease that causes inflammation of the brain. It leads to fever and associated neurological afflictions like confusion, mental disorientation and delirium, and in some cases, even coma. The symptoms include high fever and convulsions, with blood sugar level going extremely low.

• Though it's essentially a vector-borne disease caused by mosquitoes, one of the factors considered to trigger the syndrome is malnutrition. Also, under considerable scrutiny is the alleged link to consumption of lychee, a fruit widely cultivated in Muzaffarpur and neighbouring districts. The fruit is said to contain a toxin that can cause a sudden drop in blood-sugar levels if consumed by the child, especially in an empty stomach.

Placing it in context

• This is not the first time that Bihar is faced with such a crisis, though. Contrarily, the state has a long tradition of being the epicentre of Encephalitis outbreaks, with the first instance recorded in 1995. Between 2008 and 2014, there have been 44,000 cases and nearly 6,000 deaths from encephalitis throughout the country. Most of the deaths were reported from Uttar Pradesh and Bihar. In 2016, around 125 children died in Gorakhpur. According to media reports, between 2016 and 2018, at least 228 cases were reported in Bihar alone, claiming 46 lives.

• So what ails the system? Is it faulty diagnosis or inadequate steps being taken to prevent recurring outbreaks?

• In this regard, an important factor to be noted is the nutritional status of children in Bihar. The National Family Health Survey (NFHS-4) data reveals worrying figures for the state. Around 48.3 percent children (under 5) are stunted (short for their height) and around 43.9 percent underweight (in proportion to their age) — a glaring sign of chronic malnutrition. Muzaffarpur, the ground zero of the latest outbreak, fares no better. Around 48.6 per cent of the children here are stunted, 17.5 per cent are wasted (too thin for their height) and 42.3 per cent are underweight.

• Further, according to NFHS-4 data only around 7.7 percent of children in Muzaffarpur, aged 6months-23 months, receive adequate diet (for breastfed children adequate diet means receiving 4 or more food groups and a minimum meal frequency, for non-breastfed children a minimum meal frequency that is receiving solid or semi-solid food at least twice a day); and to add to the woe, a whopping 58.5 per cent kids are anaemic, in the age group of 6-59 months.

Were we prepared enough?

• Even as debate rages over the consumption of lychees as one of the possible causes of the successive outbreaks, the chronic undernourishment among children in this and other poverty-ridden districts of the state probably makes them susceptible to this disease all the more.

• Post the outbreak in 2014, the Bihar government had introduced the Japanese Encephalitis vaccine in the Immunisation Schedule in 27 out of 38 districts in the state. Muzaffarpur was brought under the coverage of the campaign, but neighbouring districts of Sitamarhi and Sheohar were left out. In the latest outbreak, cases are being reported from these districts as well.

• For a state riddled with a history of Encephalitis outbreaks over the years, has enough been done to make people aware of the probable causes and symptoms of the disease? With clinical ambiguity about the exact cause widely prevalent even among top-level researchers, it comes as no surprise that the awareness campaign has not gained too much strength on the ground.

• While the state government claims that it has been organising door-to-door campaign among people in remote areas, one may ask if the effort matched the gravity of the situation, or it was too little too late. Communities in far-flung areas are not aware of what they need to immediately after the onset of symptoms. Widespread misconceptions and superstitions are adding to the confusion.

• Delayed access to medical care is one of the reasons that fatalities are rising sharply this time around. There are reasons to believe that many such deaths could have been avoided had the children in remote villages been provided with adequate medical attention closer home.

• For the record, Muzaffarpur has 1 Medical College and Hospital, 1 Sadar Hospital, 1 Referral Hospital, 16 Community Health Centres (CHC), 83 additional PHCs. There are 500 health sub-centres across the district and 3655 ASHA workers on the ground, as the state government data reveals.

• As it turns out, the machinery hasn't been able to cope with a rapidly worsening situation.