Two of the authors of a seminal study in The Lancet (published in April, 2017) on Acute Encephalitis Syndrome (AES) say oxygen is a critical element needed in AES care. In fact, paediatric ICUs are public health requirement for AES-prone districts.
Disruption in oxygen supply in the encephalitis ward of Gorakhpur’s BRD Medical College Hospital is said to have proven fatal for several infants.
Uttar Pradesh Chief Minister Yogi Adityanath, however, insisted that oxygen shortage did not lead to the deaths.
Dr A C Dhariwal of the National Vector Borne Disease Control Programme, who is one of the authors of a study in The Lancet linking AES in Muzaffarpur to excessive litchi consumption, said: “Critical care is a crucial element of AES. Clinical set-up, availability of paediatricians, laboratory facilities, etc are important to ascertain the causal agent; it can be anything — virus, bacteria, protozoa. But critical care, which means monitoring of heart rate, respiratory rate, blood pressure, oxygen saturation, blood electrolytes, etc, and undisrupted oxygen supply is extremely important for AES care.”
All of these, Dr Dhariwal said, have been provided in the 60 paediatric ICUs set up in AES-prone districts of the country, including Gorakhpur.
Respiratory distress depends on the stage and severity of the disease, said Dr L S Chauhan, who retired from the National Centre for Disease Control and is one of Dr Dhariwal’s co-authors in The Lancet study. “Respiratory distress is a function of chest infection. It usually appears late in the disease but depends on the severity,” Dr Chauhan said.
“AES is basically not one disease but a syndrome with multiple manifestations, (and) the prognosis is different for different patients.”
The importance of oxygen in AES care — right from the primary health centre-level — is reflected in the operational guidelines for the National Programme for Prevention and Control of JE/AES, released in 2014.
The guidelines talk of oxygen and use of ambu-bags — handheld resuscitation device that can be used when a ventilator is not available — at the level of primary health centres (PHC), the first level of healthcare in India. The guidelines say: “All centres should be equipped with ambu bag and oxygen, in addition to other medicines and I/V (intravenous) cannula.”
One of the essential components of a paediatric ICU for JE/AES is “central gas pipeline (Oxygen, compressed air, vacuum) (2 pts. For O2 and 1 for vacuum and compressed air)”, the guidelines state. Oxygen is listed as an “essential equipment” even at the PHC level.
The BRD Hospital is a tertiary care centre (third level of health system, providing specialised care) in one of the most AES-prone districts of the country.
Gorakhpur is one of the 60 districts where the Centre has sanctioned paediatric ICUs for tackling AES, and oxygen supply is a crucial element of any ICU.
Yet, BRD Hospital, which has treated AES outbreaks in Gorakhpur since 1978, chose to ignore red flags about possible disruption in oxygen supply and even sat on the suppliers’ payment.
A review of AES cases in BRD Hospital — “AES: Clinical Presentation and Dilemmas in Critical Care Management”, published in 2014 in the Journal of Communicable Diseases titled — noted: “Nehru Hospital of Baba Raghav Das Medical College is the most approachable tertiary care hospital for a population of 50 million of eastern UP, parts of Bihar and adjoining Nepal, and has witnessed all epidemics right from 1978… The annual admission rate for AES is approximately 2,000-2,500 patients/year.”