Encephalitis deaths in India - The same story of poverty, neglect, disaster and disease, but for how long?

Guest post by : Aarti Kelkar-Khambete

Image Courtesy: Yahoo News

The encephalitis episode aptly indicates that temporary solutions that do not seek to address the root of the problem cannot help and that there is a risk that one problem gets replaced by another, like Japanese encephalitis being followed by viral encephalitis. The time has certainly come to end the long wait and the plight of the poor who continue to be deprived of basic health and sanitation needs in the area

Following the news on extensive rainfall in the north and south of the country and reports of heavy flooding in the north and the east, the story that has been making headlines has been that of the rapid spread of viral encephalitis in the northern parts of the country, with the most severely affected being Gorakhpur district in Uttar Pradesh, which has witnessed one of the worst outbreaks.

Image Source: Yahoo News

Current figures indicate that the cumulative death toll of encephalitis in Purvhanchal and adjoining regions of Gorakhpur, Uttar Pradesh has reached 488 with a majority of them being children [9] according to the October 25th 2011 figures while, 3088 patients have been admitted to the hospital since January this year [9] with between 30 to 40 patients being brought in for treatment everyday [11].
At present, over 280 encephalitis patients are undergoing treatment at Baba Raghav Das (BRD) Medical College and in the nearby district hospitals [9]. 10 deaths have been reported in the last four days [9] according to the 25th October 2011 figures.
What is encephalitis?
Encephalitis is an acute inflammation or swelling up of the brain caused mostly due to a viral infection. Acute encephalitis syndrome generally includes two types of infections, Japanese encephalitis, which occurs due to mosquitoes, and enteroviral encephalitis [1]. Enteroviruses include various viruses that enter the body through the gastrointestinal tract. They account for between 10 - 20% of viral encephalitis cases. Enteroviruses can spread through food or water contaminated by trace amounts of faecal material and through sneezing and coughing [4] The viral encephalitis infections that have been reported in Gorakhpur in Uttar Pradesh have been suspected to be due to contaminated water.

 Encephalitis can begin with flu-like symptoms such as:

• High temperature
• Headache
• Nausea and vomiting
• Joint pain

More serious symptoms can include:

• Changes in mental state, such as confusion, drowsiness or disorientation
• Seizures (fits)
• Changes in personality and behaviour

Other symptoms of encephalitis can include:

• Sensitivity to bright lights
• Inability to speak
• Inability to control physical movements
• Stiff neck
• Hallucinations – seeing and hearing things that are not actually there
• Loss of sensation in certain parts of the body
• Partial or total vision loss
• Involuntary eye movements, such as moving the eyes from side to side
• Involuntary movements of the face, arms and legs [5]

Infants and the elderly are particularly at risk of severe illness [6]. The severity of viral encephalitis depends on the particular virus and how quickly treatment is given. The acute phase of the illness lasts around one or two weeks, and the symptoms either disappear quickly or subside slowly over a period of time. However, if the person does not get prompt treatment, then he or she can be left with varying degrees of brain damage, which may require long-term supportive care and therapy [7].

Encephalitis in Gorakhpur: The context

There are three peculiarities in the context of encephalitis in Gorakhpur. Firstly, this is not the first time that cases of encephalitis have been detected in Gorakhpur. The first case was detected as far behind as 1978 and nearly 6,000 children have died of encephalitis in the hospital since then.
However, until 2005, the majority of deaths were caused by Japanese encephalitis, caused by a mosquito-borne virus. But in the past six years, these cases have dropped and children have been dying of another form of viral encephalitis, which has been feared to be transmitted through contaminated water. Thus, the type of virus and the mode of transmission have changed.

Secondly, children in the age group of six months to 15 years are the worst affected and most of the victims have been found to be from poor economic backgrounds and from rural areas [2]. Also, most of the deaths this year have happened since July. The disease occurs regularly during the monsoon in the Gorakhpur region bordering Nepal in the foothills of the Himalayas. The low-lying areas are prone to floods and water-logging.
Lack of adequate sanitation facilities coupled with the regular habits of defecating out in the open often leads to the possibility of water getting contaminated with faecal matter. This increases the possibility of drinking water getting contaminated where water is consumed by people in the village using shallow hand pumps [8]

It has proved to be a tough challenge to deal with viral encephalitis as compared to Japanese encephalitis, since controlling it will require a vast improvement in sanitation and drinking water supply in rural areas [2]. The collapse of the health system and water and sanitation mechanism in the area has further complicated matters making it necessary to deal with the situation on an urgent basis [1].
Experts inform that around 30,000 people may have been left disabled by the diseases since they were first detected in 1978 and government records show that 15,000 have died, and another 15,000 are permanently disabled [10].

Concerns raised by the epidemic

The intensity of the epidemic this year has raised a number of uncomfortable questions that shed light on the government apathy towards dealing with the problem in a systematic manner. For example, the very fact that the problem is not a new one and that it has been repeating every year during the monsoons indicates the lack of efforts made at understanding the problem and planning coping mechanisms to deal with the problems due to flooding and water logging in the area.

Lack of existing water and sanitation systems have been found to exacerbate the problem in an area that is already a rural, poor and neglected one, where people still continue to practice open defecation. Flooding has been found to worsen the situation where water contaminated with faecal matter contaminates water sources used for drinking purposes by people in the area. This calls for a need to improve the existing water and sanitation systems in the area with plans in place to deal with the situation in cases of disasters such as floods.

Efforts made by the government to tackle the situation have been found to be equally ineffective and directionless. For example, the state government had disbursed millions of rupees from a federal (central government) health programme for treatment of patients at the state-run BRD Medical College in 2009. Part of this money was spent in hiring 135 researchers, doctors and paramedical staff to beef up treatment. However, most of the money ran out by August, leaving only 36 of them receiving regular salaries, say authorities [2].
Recent news indicates that following criticism from the National Disaster Management Authority (NDMA), a high-level committee of experts has now been constituted in the Ministry to deal with the encephalitis problem. Following discussions between the Union Health and Family Welfare Minister who visited the site and the State and Central government officials, it has been realised that the acute encephalitis syndrome (AES) needs to be dealt through a multi-pronged strategy that would require involvement of mainly the Ministries like Drinking Water and Sanitation as well as Social Justice and Empowerment and Women and Child Development [12].
The encephalitis episode thus calls upon an urgent need to set right a number of lacunae in the public health system in the area that include:

• Setting right the already broken down systems such as sanitation and provision of pure drinking water in the area
• Dealing with the regular problem of water logging and flooding in the area by establishing and planning of disaster management systems to cope with problems arising in case of such events
• Establishing regular monitoring systems to take care of and deal with the epidemics arising during the floods
• Strengthening the already existing public health system to deal with such emergency situations, better preparation against water-borne and vector-borne diseases

Time and again, evidence has indicated that providing temporary fixes to deal with situations such as this epidemic in Gorakhpur cannot help in finding long term solutions because they often do not address the root cause of the problem. For example, vaccines cannot be found to be the only solution to the problem in the area where long term efforts should also focus on mechanisms to take care of the poor water and sanitation situation in the area, which gets exacerbated during natural events such as floods.

This case amply indicates that temporary solutions that do not seek to address the root of the problem cannot help and one problem gets replaced by another, like Japaneses encephalitis being followed by viral encephalitis. The time has certainly come to end the long wait and the plight of the poor who continue to be deprived of basic health and sanitation needs in the area, but for how long?
(The author is a public health researcher based in Trivandrum, and also works with the India Water Portal)
The author is grateful to Dr Shiraj Wajih, President, Gorakhpur Environmental Action Group (GEAG), for his valuable insights, while writing this article.
References
1. Asia Calling (2011) India Encephalitis Outbreak Kills Hundreds of Children . Downloaded from the site http://www.asiacalling.org/en/news/india/2276-india-encephalitis-outbrea... on 19th October 2011
2. Biswas Soutik (2011) India encephalitis outbreak kills 400, mainly children, BBC News, South Asia. Downloaded from the site: http://www.bbc.co.uk/news/world-south-asia-15269441 on 19th October 2011
3. Yahoo News (2011) Encephalitis kills at least 430 in India.
 Downloaded from the site: http://news.yahoo.com/encephalitis-kills-least-430-india-004959246.html on 19th October 2011.

4.University of Maryland Medical Centre (2011) Viral Encephalitis: Causes. Downloaded from the site: http://www.umm.edu/patiented/articles/what_causes_encephalitis_000096_2.htm on 19th October 2011.

5. NHS Choices Information (2011) Encephalitis Information: Downloaded from the site : http://www.nhs.uk/Conditions/Encephalitis/Pages/Symptoms.aspx on 19th October 2011.

6. World  Health Organisation (2011) Encepahlitis, Viral. Downloaded from the site: http://www.who.int/topics/encephalitis_viral/en/ on 19th October 2011.

7. Better Health Channel (2011) Viral Encephalitis. Downloaded from the site: http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/viral_enc... on 19th October 2011.
8. Midnight Watchers Bligspot (2011) India: Encephalitis Outbreak Kills 400, Mainly Children. Downloaded from the site:
http://midnightwatcher.wordpress.com/2011/10/12/india-encephalitis-outbr... on 19th October 2011.
9. Deccan Herald (2011) Encephalitis toll climbs to 488. Downloaded from the site: http://www.deccanherald.com/content/200325/encephalitis-toll-climbs-488.... on 1st November 2011
10. Dhar Aarti (2011) In eastern Uttar Pradesh, a season of death. The Hindu, 29th October 2011, p 12. Downloaded from the site: http://www.thehindu.com/news/national/article2577631.ece on 29th October 2011
11.Medical Express (2011) Encephalitis kills at least 430 in India. Downloaded from the site: http://medicalxpress.com/news/2011-10-encephalitis-india.html on 1st November 2011.
12. The Hindu (2011) Azad for GoM to deal with Japanese encephalitis. Downloaded from the site: http://www.thehindu.com/news/national/article2568496.ece on 1st November 2011.

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