Tuesday, November 29, 2011

Encephalitis taking a huge toll

85 children between 3-13 years died at Gaya's Anugrah Narain Medical College and Hospital. Governments are at sea.

Kumari Chitra/ Gaya (Muzaffarpur)

It is a great irony when Bihar Chief Minister Nitish Kumar, now on much-hyped Sewa Yatra in his obvious pan-Indian scheme of things, has started working on health cards of over three crore children between six and 14 years under Nayi Pidhi Swasthya Guarantee Scheme, state health department has little clue on suspected encephalitis/ brain fever/ cerebral malaria in Gaya and Muzaffarpur reporting 137 deaths in last four months. Precisely, over 500 children were admitted in two Muzaffarpur hospitals and one Gaya hospital.
Eighty five children between three and 13 years died at Gaya's Anugrah Narain Medical College and Hospital (ANMCH) and 20 have been still undergoing treatment. Of 390 admissions in Gaya - from Gaya,
Aurangabad, Arwal and Chatra and Palamu Jharkhand), those who returned home are also not without neuro-psychiatric side-effects.
While Muzaffar[ur hospitals have no cases now, Gaya is in thick of news with National Centre of Disease Control (NDCD), Delhi and National Institute of Virology (NIV) teams visiting Gaya's premier government hospital and "fine tuning" diagnosis being offered and most importantly, collecting blood samples.
But it has been part of routine process every year: Central teams come, seldom give their reports. Doctors here are left with little option but to offer symptomatic treatment, which is so predictable.
These patients often come with complaints of acute convulsions (chamki
in local parlance), high grade fever, unconsciousness leading patients to go into coma at times and vomiting in some cases. ANMCH doctors have pasted the line of treatment at entrance of children's wards. Nurses find it comprehensive but not conclusive.
A visit to Gaya hospital shows there are constraints. Only generator for back-up power supply has not been working for days. X-ray machine has also gone out of order. There is no bed-to-bed oxygen point to meet emergency situations. Oxygen cylinders have to be moved from ward to ward manually.
But Gaya hospital administration calls it trifle complaints. They pat their back with death figures and its comparison with global mortality percentage. Dr AK Ravi, head of department of pediatrics at the hospital, good at explaining medical jargons to journos, said: "We reported only 21 per cent death as against global mortality rate of 40 per cent".
He, however, is surely worried that all types - four in all - of encephalitis are not detected and diagnosed. Though Gaya cases were mostly Japanese Encephalitis, Bihar hospitals had no wherewithal to test non-JE cases. Doctors also did not rule out possibility of some Gaya encephalitis cases being similar to Gorakhpur cases, mostly acute encephalitis syndrome (AES), which can be cerebral or bacterial meningitis and other unknown types.
The hospital also blamed NCDC, Delhi, which had already taken 30 blood samples from the hospital, had not yet given its reports. Bihar medical hospitals can only diagnose JE cases with Elisa test of cerebral spinal fluid. The 100 per cent confirmatory test - Advanced Reverse Transcriptase Polymerase Chain Reaction (RT-PCR - is available only at NIV, Pune. Elisa can test category I and II of encephalitis cases marked by high fever, convulsions and occasional vomiting. Elisa test, however, cannot diagnose Category III case which has same
symptoms with non-JE virus. Muzaffarpur, where 52 patients died of suspected encephalitis this year, might fall in category four, indeterminate type. Of 40 samples collected from Muzaffarpur, no JE case was confirmed. The state government, whose JE vaccination programme is not going great, has readymade excuse to offer - even JE vaccination will not prevent spurt of encephalitis every year. They blame it on low-lying temporal region suitable to encephalitis virus, some of them still not known.
Bihar principal health secretary Amarjit Sinha said there was little the state government could do besides offering symptomatic treatment.
He also did not rule out some AES cases in Gaya and Muzaffarpur but then, there was no evidence in absence of sophisticated test. Bihar hospitals can test only category I and II - which is JE and probable JE - with same symptoms but coming from different tempral regions. The third category has AES that can be cerebral malaria, bacterial meningitis and cerebral meningitis. The fourth category disease can have same symptoms but high degree of acuteness because of presence of non-JE virus.
But one thing was similar in both regions reporting these cases. Almost 90 per cent patients came from poor socio-economic background. In Nitish Kmar's definition, they are Mahadalits (read schedule castes), rearing pigs, living bare-chested amidst flies and mosquitoes. Ask any one about fumigation and DDT spray, they will put the question back to you - What is all this?
Take case of Phulwanti (10), daughter of Surendra Kumar, a small farmer from Atri, at Gaya hospital. "She has yet been able to keep her right hand and leg straight. She also cannot take food properly," said Kumar wishing everything will be alright soon. He said with media intervention and expert teams frequenting the hospital, the level of alertness has surely increased. But they want permanent cure. Another summer, they may complain same problems.
Jhunnu (7) from Arwal has been admitted with similar complaints of convulsion and high fever. Jhunnu has also shown some improvements but his brother Nawlesh is deeply concerned. Nawlesh says doctors have been coming four times these days after frequent media and expert teams visit.
Dr A K Ravi said: "We have been offering best services under limited staff constraints. No patient has gone to any private hospital. There is no sure-shot cure for encephalitis in absence of 100 per cent diagnosis". Dr Ravi conceded that the hospital should be provided wherewithal to diagnose category III cases so that AES can be treated with definite line of treatment. He, however, said Gaya cases had no parallel with Muzaffarpur cases falling under "category IV of
indeterminate" cases. He said most cases came from areas rearing pigs, vectors of JE virus.
Bihar government has approached Union health ministry for a comprehensive study to decode the disease striking Muzaffarpur and adjoining districts since 1995 during or before monsoon. "Litchi plants and mosquitoes present in the region can be studied", suggested Dr Arun Shah, a leading Muzaffarpur pediatrician, also president of Indian Academy of Pediatrics.
Dr Shah said NIV that already ruled out Japanese Encephalitis needed brain tissues to decode any virus or any other type of disease. The NIV team visiting Muzaffarpur hospitals suggested that brain tissues would tell if it is any other viral encephalitis, some kind of meningitis, Ray's Syndrome, cerebral malaria or heat stroke. He added all these diseases had symptoms of fever and convulsions, as being reported in Muzaffarpur.
Dr Shah said they learnt from experience that the disease subsided with mercury shooting down. The mystery disease outbreak hit Muzaffarpur first in 1995 and continued to cause deaths in subsequent years. ICMR or any other medical body has not conducted any research on Muzaffarpur or Gaya.
The safest option for state health minister Ashwini Kumar Choubey is to play blame game with Centre and seek reports from central teams.
Meanwhile, Nitish Kumar's vision of healthy new generation may well have to wait.

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