The mys­tery deep­ens

There is no sci­en­tific con­sen­sus on the cause of en­cephali­tis that has been claim­ing lives ev­ery year in the Go­rakh­pur re­gion since 1978. But an un­pre­pared gov­ern­ment along with med­i­cal mis­man­age­ment made mat­ters worse this year.


Med­i­cal mis­man­age­ment leads to a tragedy in Go­rakh­pur, even as the cause of en­cephali­tis re­mains an un­re­solved mys­tery

MORE THAN 9,950 chil­dren have died of en­cephali­tis in a sin­gle hospi­tal in Go­rakh­pur in the past 40 years. But the health sys­tem con­tin­ues to be un­pre­pared to deal with the disease. On Au­gust 10 this year, a news por­tal ran a story about short­age of liq­uid oxy­gen in the Baba Raghav Das Med­i­cal Col­lege (brd), and warned of an im­pend­ing cri­sis. Since Jan­uary, the disease had al­ready claimed 160 lives. But oxy­gen was not made avail­able and that night 23 chil­dren died. Chil­dren con­tin­ued to die, and by Au­gust 21, the death toll rose to 260 for the year. Though it was clear that the chil­dren died due to lack of oxy­gen in brd on Au­gust 10-11, the state gov­ern­ment de­nied un­der­pre­pared­ness, even as it sus­pended the prin­ci­pal of the col­lege and vowed to take ac­tion against the sup­plier.

So was the hospi­tal man­age­ment aware about the short­age? The jour­nal­ist who wrote the story, Manoj Ku­mar Singh, says every­one was aware about the loom­ing cri­sis and the gov­ern­ment is now just pass­ing the buck. It seems Ra­jiv Mishra, the prin­ci­pal of brd, re­minded the au­thor­i­ties in sev­eral let­ters about sanc­tion­ing the pend­ing pay­ment to the sup­plier. Ac­cord­ing to me­dia re­ports, Mishra wrote the first let­ter on March 22 to se­nior of­fi­cials in the state’s health min­istry. On Au­gust 1, Mishra copied this let­ter to the Med­i­cal Ed­u­ca­tion Min­is­ter Ashutosh Tan­don. Re­ports also sug­gest that the sup­plier too had in­formed the col­lege and higher au­thor­i­ties that un­less his dues of 68.65 lakh were cleared, the com­pany would stop de­liv­ery.

This is not the only case of mis­man­age­ment in gov­ern­ment hospi­tals across the coun­try as far as short­age of oxy­gen sup­ply is con­cerned. Ac­cord­ing to Amulya Nidhi, an In­dore-based ac­tivist, in July, 17 peo­ple, in­clud­ing two chil­dren, died at the Ma­haraja Yesh­wantrao Hospi­tal in In­dore due to lack of oxy­gen sup­ply. The Mad­hya Pradesh gov­ern­ment has con­sti­tuted a “com­mit­tee” to in­ves­ti­gate the mat­ter (see ‘In cold blood’).

K P Kush­waha, who was the former head of the pae­di­atrics de­part­ment at the brd Med­i­cal Col­lege, says cor­rup­tion is the big­gest rea­son for th­ese deaths. From sanc­tion­ing to trans­fer­ring money, a share of the money has to be given to gov­ern­ment au­thor­i­ties, he says. Amit Sen­gupta, a Delhi-based public health ex­pert, says it is ev­i­dent that the Ut­tar Pradesh gov­ern­ment did not sanc­tion the pay­ment de­spite re­peated re­minders. It is likely that this was a re­sult of cor­rupt prac­tices, and thus, needs to be in­ves­ti­gated.

Need for guide­lines

The Go­rakh­pur tragedy is an ex­am­ple of the de­plorable state of In­dia’s public health sys­tem. brd caters to pa­tients from 15 dis­tricts of eastern Ut­tar Pradesh and also from a few dis­tricts in Bi­har. Pa­tients from Nepal too come here for treat­ment. At any given point in time, the pae­di­atric de­part­ment is treat­ing 300 chil­dren, but there are only 210 beds.

So the hospi­tal is not only over­crowded, but it also faces a re­source and fi­nan­cial crunch. A Comptroller and Au­di­tor Gen­eral re­port in June this year had warned that there was a 27.21 per cent short­age of clin­i­cal equip­ment and 56.33 per cent short­age of non-clin­i­cal equip­ment in this hospi­tal. The sup­ply of oxy­gen is part of non-clin­i­cal equip­ments.

Sri­nath Reddy, pres­i­dent, Public Health Foun­da­tion of In­dia, a pol­icy think tank, says that to en­sure ac­count­abil­ity, In­dia needs to en­force stan­dard man­age­ment guide­lines for doc­tors, nurses and hospi­tal staff for ef­fec­tive treat­ment meth­ods as well as to pro­cure equip­ments. Yet most states have not even adopted the Clin­i­cal Es­tab­lish­ment Act, 2010, which pre­scribes a min­i­mum stan­dard of ser­vices and fa­cil­i­ties for clin­i­cal es­tab­lish­ments, he says.

Ex­perts say there is a need to de­cen­tralise the public health man­age­ment sys­tem to en­sure ac­count­abil­ity. At present, the in­ef­fi­ciency is partly due to the lengthy bu­reau­cratic pro­cesses.

Reddy says to en­sure ac­count­abil­ity, the Right to Health is es­sen­tial. In­dia’s Na­tional Health Pol­icy, 2017, how­ever, says that the coun­try can­not yet in­clude this in the Con­sti­tu­tion. Sen­gupta says that in many coun­tries such as Brazil and South Africa, the Right to Health is part of their Con­sti­tu­tions, which means that the gov­ern­ment can be held re­spon­si­ble in cases of lax­ity and neg­li­gence. Worse, loop­holes in In­dia’s health­care sys­tem al­low the ac­cused to eas­ily evade the law, adds Sen­gupta.

Grap­pling with the mys­tery

Acute En­cephali­tis Syn­drome (aes) has been hound­ing chil­dren in Ut­tar Pradesh’s Go­rakh­pur re­gion for many decades. Most cases and deaths are re­ported in Au­gust and Sep­tem­ber each year. The lack of oxy­gen in brd hospi­tal may have made the head­lines this Au­gust, but the fact re­mains that the sci­en­tific es­tab­lish­ment in In­dia is yet to de­ci­pher the cause of th­ese deaths.

A re­view of re­search to iden­tify the cause of the disease says that most stud­ies be­tween 1975 and 1999 iden­ti­fied Ja­panese En­cephali­tis Virus (jev) as the main cause of en­cephali­tis across the coun­try. How­ever, stud­ies pub­lished af­ter 2000 point to a shift to Chandipura virus and en­teroviruses, says the study pub­lished in the Na­tional Med­i­cal Jour­nal of In­dia in 2012. So the mys­tery of en­cephali­tis re­mains un­re­solved. In fact, re­searchers say the cause of the disease in as many as 59 per cent of pa­tients be­tween 2013 and 2014 in Go­rakh­pur re­mains un­known.

Apart from jev, Chandipura virus and en­teroviruses, aes pa­tients have also been tested for her­pes sim­plex, measles, mumps, dengue, vari­cella, Par­vovirus, West Nile virus, malaria, ty­phoid, Bagaza virus, Cox­sackie virus, lep­tospiro­sis, heat stroke, Reye’s syn­drome and plant tox­ins like those in litchi fruits and pods of Cas­sia oc­ci­den­talis.

This year, the mys­tery deep­ened when re­searchers came up with an­other causal agent. It was linked to Ori­en­tia tsut­sug­a­mushi, a bac­terium which causes a disease known as scrub ty­phus. The disease was on the de­cline in Asia for many decades, but now it seems to have re-emerged. “Go­rakh­pur and As­sam have re­ported the max­i­mum num­ber of scrub ty­phus cases lead­ing to aes in the coun­try,” says Si­raj A Khan of the Re­gional Med­i­cal Re­search Cen­tre, North­east Re­gion, In­dian Coun­cil of Med­i­cal Re­search (icmr), Di­bru­garh, As­sam. The most com­mon symp­toms of scrub ty­phus in­clude fever, headache, body ache, and some­times rashes. Re­cent stud­ies sug­gest that it can cause aes too.

When 46 chil­dren ad­mit­ted to brd be­tween Au­gust 17 and Oc­to­ber 16, 2016 were tested for scrub ty­phus, im­munoglob­u­lin M—the first an­ti­body to ap­pear in re­sponse to an anti­gen—was de­tected in 63 per cent of cases. Sim­i­larly, im­munoglob­u­lin G—which is the most com­mon type of an­ti­body in blood—was found in 82.6 per cent of cases. This in­di­cates that th­ese chil­dren were suf­fer­ing from this disease. This study was pub­lished in Emerg­ing In­fec­tious Dis­eases in Au­gust this year. Apart from In­dia, scrub ty­phus cases have been also re-emerged in South Korea, China, Mi­crone­sia and Mal­dives. The disease has now spread to new coun­tries such as Cameroon, United Arab Emi­rates and Chile.

Scrub ty­phus is present in ar­eas with scrub veg­e­ta­tion which grows where ma­ture forests have been cut down. Ro­dents and hu­mans are in­ci­den­tal hosts to the mite, which is both a reser­voir and the vec­tor for the bac­te­ria. Its reemer­gence and spread to newer ar­eas sug­gest that ro­dents bear­ing in­fected mites may be ex­pand­ing their range due to cli­mate change, ar­gues David M Walker in

The mys­tery deep­ened this year when re­searchers came up with a new causal agent. Most of the deaths in Go­rakh­pur were due to Scrub ty­phus, a disease which led to en­cephali­tis

an ar­ti­cle pub­lished in the New Eng­land Jour­nal of Medicine in Sep­tem­ber 2016. Walker is the di­rec­tor of the Cen­ter for Biode­fense and Emerg­ing In­fec­tious Dis­eases, the Univer­sity of Texas Med­i­cal Branch.

A Sep­tem­ber 2012 study pub­lished in Eco­log­i­cal Ap­pli­ca­tions shows that the pres­sures of global trade too in­creases the risk of disease in­ci­dence due to chang­ing land use. For ex­am­ple, af­ter Tai­wan joined the World Trade Or­ga­ni­za­tion in 2001, rice cul­ti­va­tion fell from 80 to 55 per cent. This led to an ex­po­nen­tial in­crease in the num­ber of ticks and chig­gers in aban­doned rice fields. Flooded pad­dies are poor habi­tats for the mites. The au­thors say that this study shows that apart from cli­mate change, global travel and habi­tat de­struc­tion; eco­nomic poli­cies can also af­fect hu­man health by in­flu­enc­ing and chang­ing the land­scape.

How­ever, some ex­perts are not con­vinced that all the cases in Go­rakh­pur were due to the scrub ty­phus. “It seems to be a mix of ill­nesses and the ma­jor cause of the out­break still re­mains elu­sive,” says Ge­orge M Vargh­ese, pro­fes­sor, De­part­ment of In­fec­tious Dis­eases, Chris­tian Med­i­cal Col­lege, Vel­lore, Tamil Nadu. The symp­toms re­ported from Go­rakh­pur are atyp­i­cal to scrub ty­phus. Most of the pa­tients were in­fants, but they are un­likely to have any ex­po­sure to veg­e­ta­tion, which is the mode of ac­qui­si­tion of scrub ty­phus, he adds.

Con­fu­sion kills

The un­cer­tainty in the causal or­gan­ism is one of the rea­sons for the high num­ber of deaths. In As­sam, which is recog­nised as an en­demic zone for aes caused by the JE virus, scrub ty­phus is usu­ally not sus­pected. Though scrub ty­phus is treat­able, death rates are as high as 49 per cent, says a study pub­lished in Emerg­ing In­fec­tious Dis­eases in Jan­uary 2017.

The re-emer­gence may also be due to changes in the an­tibi­otics used to treat fevers. Ear­lier, fever pa­tients would be rou­tinely pre­scribed an­tibi­otics such as tetra­cy­cline and chlo­ram­pheni­col, which ef­fec­tively treat scrub ty­phus. But now the com­monly-used an­tibi­otics are cephalosporins, which are in­ef­fec­tive against this disease, says Vargh­ese. Nev­er­the­less, it is clear that scrub ty­phus is back. Ear­lier, com­mu­nity sam­ples in In­dia showed around 5 per cent sero­log­i­cal preva­lence of past in­fec­tions, but now the preva­lence rates are as high as 30 per cent, says Vargh­ese.

Way ahead

The world is fac­ing a re-emer­gence of scrub ty­phus and it is cru­cial that doc­tors are made aware to en­sure early di­ag­no­sis and proper treat­ment, says Vargh­ese. In 2015, icmr de­vel­oped guide­lines for di­ag­no­sis and man­age­ment of such dis­eases. Early di­ag­no­sis and pre­scrib­ing the drug, doxy­cy­cline, which costs less than 200, can eas­ily save a pa­tient. In­dia is also part of an on­go­ing trial in high bur­den coun­tries to eval­u­ate the best treat­ment for se­vere scrub ty­phus,” re­veals Vargh­ese.

While re­searchers like Vargh­ese are work­ing to im­prove and de­velop treat­ment and di­ag­nos­tics, the need of the hour is to quickly solve the mys­tery around the disease to help pa­tients.

Walker points out that re­searchers sel­dom work on rick­ettsial dis­eases, which in­cludes scrub ty­phus due to dif­fi­cul­ties in car­ry­ing out re­search, even though it is of­ten as preva­lent as malaria and dengue. “This ne­glect has led to spotty and in­com­plete data that pre­clude the cal­cu­la­tion of dis­abil­ity-ad­justed life-years lost to the disease—in­for­ma­tion that is es­sen­tial for so­lic­it­ing phil­an­thropic sup­port for re­search,” he writes.

What we need is “fo­cused re­search to iden­tify the cause of th­ese dis­eases,” says Kush­waha. When asked about what could be caus­ing aes, D T Mourya, di­rec­tor, Na­tional In­sti­tute of Virol­ogy, Pune, says that the in­sti­tute is work­ing on sev­eral as­pects of this prob­lem rang­ing from epi­demi­ol­ogy to lab­o­ra­tory in­ves­ti­ga­tions and that “it is pre­ma­ture to make any com­ments at this stage”. Till the time a so­lu­tion is found, doc­tors must also keep scrub ty­phus in mind while treat­ing pa­tients. Preven­tion too can re­duce cases. “There is no vac­cine to pre­vent this disease. Hence, the pre­ventable mea­sures are per­son­nel pro­tec­tion and vec­tor con­trol,” sug­gests Khan.”

Scrub ty­phus is present in ar­eas with scrub veg­e­ta­tion which grows in ar­eas where ma­ture forests have been cut down. Ro­dents and hu­mans are in­ci­den­tal hosts to the mite, which is both a reser­voir and the vec­tor for the bac­te­ria

The Baba Raghav Das Med­i­cal Col­lege Hospi­tal caters to pa­tients from 15 dis­tricts of eastern Ut­tar Pradesh and also from a few dis­tricts in Bi­har

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