A high-level team of specialists constituted by the Centre to review the surge in acute encephalitis syndrome (AES) cases in Bihar this year believes the heat wave was a factor behind the nearly 200 deaths, making it the first major AES outbreak in the state since 2014.
Dr Arun Singh, who led the central team, says the affected districts had temperatures of over 40 degrees for several days at a stretch. “We know that the children played outdoors in high heat… The combination of extreme heat, exhaustion and micro-nutritional deficiency can be lethal,” he says, calling for “more research on this triad”.
AES is an umbrella term for infections that cause swelling in the brain. Muzaffarpur, Vaishali, East Champaran, Sheohar and Sitamarhi were the worst-hit districts this time, with Shri Krishna Medical College and Hospital (SKMCH), Muzaffarpur, alone recording more than 60 per cent of the casualties.
“I have been observing AES outbreaks for several years now,” says Dr G S Sahni, who heads the SKMCH paediatric unit and has authored papers on the subject. “I had reservations with the litchi theory when it was postulated
after the 2014 outbreak. The toxins in litchi should show up in the liver-function tests of the affected children. But they don’t. My understanding is that this is a case of heat stroke affecting malnutritioned children.”
The heat in Bihar this year was unrelenting with no rainfall, points out Dr Shakeel, a Patna-based physician and Jan Swasthya Abhiyan activist. “Malnutritioned children are ill-adapted to deal with such heat. Their thermo-regulatory mechanism does not work well.”
Dr Singh says they found that research groups had “pre-set positions on the outbreak”. “Because of Muzaffarpur’s proximity to Gorakhpur (in Uttar Pradesh), some researchers talked about Japanese Encephalitis, while others repeated the now well-known litchi theory… We did not carry any baggage, and the ministry supported our open-mindedness. Our first task was to save lives and establish logistics for the purpose. And as far as the cause of the disease is concerned, we let the patient lead the way.”
He adds, “While treating the children, we found their liver was enlarged, muscle tone was low, and they had high heart rates… (We) were dealing with dysfunctioning of more than one organ. The muscle biopsies showed the mitochondria were affected… We sent blood samples to NIMHANS. They revealed the children had severe carnitine deficiency. The job of carnitine is to transport fatty acids to mitochondria, which produce the cell’s energy… We administered carnitine to two children, and their metabolic rates normalised.”
About the proponents of the litchi theory, Dr Singh says, “In stressing on the metabolic aspect, they were close to what we found. But it’s a simple fact that all fruits have toxins. A child needs to consume more than 1.5 kg of unripe litchi and 5 kg of the ripe fruit for the toxins to act. And besides, let’s not forget that litchi also has nutrients.”
Dr Arun Shah, a Muzaffarpur-based pediatrician and one of the authors of the litchi theory, says he is open to new research. “Look, we never said that litchis are the primary cause of AES. And we assert that malnutrition is the main reason. A healthy child who eats unripe litchis will never contract the disease.”
If heat stroke was the main reason, he adds, “Why is it that the disease affected only 12-15 districts of Bihar, when the entire state was reeling under a heat wave?… I do not say either that all children who contracted AES had litchis. But if they suffered a heat stroke, why is it that the symptoms manifested in the early hours of the day? The theory of metabolic malfunctioning in malnutritioned children due to consumption of unripe litchis has provenance in countries such as Bangladesh, Vietnam and Jamaica (whose staple fruit, ackee, is similar to litchi),” he says.
Noting the confusion over what really causes AES, Bihar Principal Secretary, Health, Sanjay Kumar says this is the major reason the state failed to check the outbreak this year.
Agrees Sushama, the first line of defence against the disease as as an auxiliary nurse mid-wife, posted at Sahpur in Muzaffarpur. “Researchers must tell us what causes AES,” she says.
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Over at the SKMCH, they are just relieved “the worst is over”. Says Superintendent Dr Sunil Kumar Shahi, “The onset of monsoon brings relief. Only a handful of children in the pediatric ward now are encephalitis patients.”
In the corridors of the hospital, relatives and caregivers are dealing with another matter: how to find space for patients yet to be assigned beds among the filth and grime left behind by wet footwear.