Thursday, Sep 29, 2022

That annual affliction

Between Centre and state,why hasn’t anyone cracked UP’s encephalitis?

Large numbers of children die every year during autumn months in and around Gorakhpur in eastern Uttar Pradesh,from a disease popularly called brain-fever,now labelled acute encephalitis syndrome (AES). Local hospitals get overwhelmed with cases in bad years like this one.

Unfortunately,this disease has not been diagnosed exactly yet — we do not even know if the outbreak is a single disease or a combination. Japanese encephalitis is endemic to the area,but without a spinal tap it is difficult to distinguish viral encephalaitis from other brain diseases like encephalopathy in which the pathology is not in the brain,but biochemical changes affect brain functions. For all the talk about “enteroviruses” in Gorakhpur,that is common all over India and is unlikely to cause such annually recurrent encephalitis. Systematic investigations are needed to unravel the real cause of these outbreaks.

There was a huge outbreak of AES in 2005,and the dominant diagnosis was Japanese encephalitis (JE). In 2006,there was a mass campaign to give JE vaccines to all children below 15 years of age,and since then vaccination has been available to children through the national immunisation programme (NIP). However the coverage is low for a variety of reasons including the low functional efficiency of NIP,occasional vaccine shortfalls,disputes about the vaccine’s quality,and so on. Reliable information is not available in the public domain. However,it appears as though JE is not as widespread these days.

On the ground,there are several problems. The exclusive dependence on the media for information illustrates the lack of an official source of authentic information on health events and outbreaks. The government does not take the public into confidence. This absence of a definitive diagnosis illustrates the sub-optimal performance of our public health system. Every disease has a name and a code number in modern medicine — brain-fever and AES are only colloquial terms,not accepted diagnoses. Every disease-causing microbe has also been identified and diagnostic tests defined. That large numbers of children die annually without a precise diagnosis tell us that either technical expertise is not available or there is a lack of leadership in the health system to assume responsibilities and obtain available expertise. Neither the Central nor state governments have taken charge.

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Modern medicine has advanced on two fronts — healthcare and public health. Doctors and hospitals,in the public sector or private,provide individual healthcare after an illness has occurred. The initiative is taken by the person or the family,and the cost borne out of pocket or covered by the government through hospital budgets. There is no equity promised,or quality assured,in either sector. Public health,on the other hand,is not concerned with specific individuals but the whole community. Public health staff must work within the community to intercept the outbreak,for which three pieces of information are essential. What is the identity or nature of the disease-causing microbe? Most cases of encephalitis are caused by viruses,such as the JE virus.

Second,where do the causative microbes multiply? Is it in mosquitoes,animals or only in humans? Third,what is the exact transmission channel? Is it mosquito bites,or water-supply contaminated with human excreta,or is it directly transmitted between persons? Only with these three pieces of information can public health officials take appropriate action to stop the multiplication or cut the transmission chain of the disease-causing microbe. Obviously,all three remain unanswered in eastern UP,as indicated by uncontrolled annual outbreaks of the same disease.

It is not difficult to get a team to dedicate itself to understanding the recurrent outbreaks. In western UP,there used to be a disease called “Saharanpur encephalitis” that killed hundreds of children in the post-monsoon months every year,over two decades. The Indian Academy of Paediatrics put a team together to investigate the outbreaks,which revealed that it was not “brain fever” or AES,but plant poisoning of young children who ate the seeds of a common weed,Cassia occidentalis. Once public education was undertaken,the outbreak disappeared.


Who is accountable for outbreak control? Healthcare and public health are concurrent subjects,shared by the Centre and the state. That is a certain part of the problem,with both deflecting blame. India must reorganise its public health system so that diseases are diagnosed more effectively and information is shared through official alerts,which requires better coordination between the Centre and the state.

The writer is former head of the department of clinical virology,Christian Medical College,Vellore

First published on: 17-09-2010 at 02:26:33 am
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