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Encephalitis continues to claim lives in Bihar

In the period of a week, several contrasting statements have been released by various media outlets regarding the situation in Bihar where 128 child deaths have been reported at the time of writing. As first suspected, encephalitis seems to be the cause – although mismanagement could be playing a significant role in the tragedy.  

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Toxins within unripened lychees are thought to have played a role in the development of encephalitis

Encephalitis – which involves inflammation of the brain –  – was implicated as the cause of the numerous child deaths in the state. This was followed by claims disputing encephalitis as the cause, instead blaming the fatalities on hypoglycemia.

Encephalitis is now being acknowledged as the cause once more against a backdrop of rising mortality. In the short space of time between those reports, the death toll rose from 31 to 83. Now the death toll stands significantly in excess of 100 – attributed to acute encephalitis syndrome (AES).

State officials have confirmed that the majority of the child deaths have been caused by AES. Bihar health minister Mangal Pandey commented on the matter following an inspection of the Sri Krishna Medical College and Hospital (SKMCH) in the Muzaffarpur district. “The situation has worsened after June 2, following high temperature and excessive humidity, resulting in admissions of encephalitis-afflicted children in bulk, and leading to [more] deaths,” one official said.

Whether through AES or hypoglycemia, the conditions can largely be traced back to the same root: lychee consumption. Illness related to lychee consumption was first mentioned in the media in July 2013, yet has been documented as far back as 1995. Doctors in Muzaffarpur have on a yearly basis struggled to accommodate numerous instances of the disease, affecting only children. In a third of cases, the condition proves lethal only a few hours after onset.

The rapidly rising death toll is of great concern. Deaths related to lychee consumption occur every year within the state, though no single year has yet rivalled that of 2014, which saw the disease claim as many as 379 lives throughout the state. Given the high death toll thus far, it is possible that this year’s outbreak could exceed that of the 2014 crisis.

Besides the lychees, there are two common factors linking the deaths. They have all occurred in children, and these children have been malnourished before succumbing to encephalitis. The outbreak thus far has covered 222 blocks of the Muzaffarpur district and its adjacent areas, with 93 deaths reported in SKMCH alone – dubbed by India Today as a ‘hospital of horror’. Union Minister of Health and Family Welfare Dr Harsh Vardhan visited the hospital on Sunday, June 16th, where he announced the establishment of a multi-disciplinary institute to investigate the causes of the disease outbreak.

Deaths due to encephalitis spike in the area every year during the lychee season. It is likely that since the illness occurs during the season in which lychees are ripening, children may be eating large quantities of unripened lychees to compensate for the lack of available food.

Due to toxins within these lychees which are only dangerous in large doses, a diet consisting of a high quantity of unripened lychees becomes lethal to these children. Little can be done regarding these naturally occurring chemicals within the lychees. However, addressing the issue of child malnourishment may be a means to reduce the risk of both encephalitis and a host of other associated health conditions.

As well as the lychees themselves, mismanagement and improper handling of the condition could be playing a role. On June 14th, a seven-member team from the Centre examined patients at the Sri Krishna Medical College and Hospital (SKMCH) and prepared a report on the hospital’s management of the disease. The report found that resources were not being allocated properly in efforts to deal with the influx of AES patients. It also mentioned that doctors were not performing the standard procedures in diagnosing AES, which involves CT (computed tomography) scans and were not familiar with the diagnosis and management protocols for AES.

“Though ventilators — at least six of them — were available in paediatric intensive care units, they were not being put to use as the doctors were not trained.” the report said. “No trained intensivist was available at the hospital to run the ventilator. Even arterial blood gas (ABG) analysers were not being put to use as doctors did not know precisely when to use them in such cases.”

Considering encephalitis cases spike in the region every year during the lychee season, it is nothing short of neglect to have no staff available that are trained to deal with the issue. If diagnosis is not rapid for the children who succumb to encephalitis, a high death toll will be almost inevitable.

The report suggests intervention from the centre to send over medical personnel to assist in training local doctors. As it was noted that equipment was already in place, the hospital needs no adjustments to its facilities, simply an improved capacity to utilise the facilities that are already in place, as well as a model on which they may act in the case of encephalitis outbreaks.

Dr Vardhan, on visiting SMCKH, said that “the doctors here at the hospital are doing their best under such a difficult situation in treating the children.” Yet this does not seem to reflect the reality on the ground, with many reports implicating lapses in management of the condition as a reason behind its lethality. Following the 2014 outbreak, according to a report in India Today, the Centre outlined measures to prevent similar occurrences in future. This included a super-specialty facility with a capacity of 100 beds, where patients could be treated immediately on presenting with encephalitis, and an awareness campaign.

Dr Vardhan was the Union Health Minister at the time of the 2014 outbreak. This year, he is making similar pledges as to the super-specialty facility, which he says will be operational within a six-month timeframe. However, it is important that the measures are implemented to prevent recurrences of this year’s tragedy and the tragedies of years past – as well as to ensure that doctors are properly trained. Raising awareness in communities is one thing: raising awareness among medical professionals about a disease they are likely to have to treat ought to be standard practice.

Meanwhile, senior officials are facing flak over the situation. Bihar Chief Minister Nitish Kumar, who convened an internal meeting to assess the situation, was the subject of protests alleging that the state government had been inadequate in its handling of the crisis. He has announced an ex gratia payment of Rs 400,000 to affected families. Social activists have filed complaints against the Union Health Minister and state officials over their handling of the tragedy.

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