Fifteenth of August is a big day for Indians. When the rest of the country was gearing up for the early morning Independence Day flag hoisting ceremonies, people in Gorakhpur, a district town in eastern Uttar Pradesh, woke up to the news of the rising death toll from encephalitis. Encephalitis is not new to Gorakhpur, the first outbreak took place in 1978, and since then every year with the advent of monsoons the deadly Japanese Encephalitis (JE) rears its ugly head, to disappear once the rains are gone.
During 2004, 1695 cases and 367 deaths due to suspected JE were reported in the country from 12 States. Of these, 1030 cases (60%) and 228 deaths (62%) were reported from U.P. alone.
-- Dr Anbumani Ramadoss, Union Minister for Health, Lok Sabha, 12 August 2005.
Healthcare systems are in a strange dilemma in India. One section of health care providers are successfully dealing with the challenges of life-style and non-communicable diseases, while in large tracts across the country communities continue to perish without appropriate care for age old infections like malaria, tuberculosis or even dengue. Encephalitis, more particularly Japanese Encephalitis belongs to this second category of diseases. Unfortunately there is no cure for this disease and experience shows that between fifteen to thirty percent of children (who are predominantly affected) with symptoms perish.
However there are ways to deal with the disease which includes treating the symptoms. Since the disease has been occurring annually in this region (Gorakhpur is an endemic region for JE which means that the disease occurs regularly and there are a substantial number of cases) one would have expected that all doctors and hospitals would be familiar with the drill. Unfortunately the common complaint during this round of the epidemic was that most patients were not attended to in peripheral hospitals (community health centres), and the case load at the Baba Raghav Das Medical College, Gorakhpur made it difficult for the doctors to provide proper attention to all. When complaints were made to political leaders in the capital, a group of junior doctors was hurriedly trained and dispatched to Gorakhpur from Lucknow. (Gorakhpur is served by the BRD Medical College, one district hospital each for men and women, and one infectious diseases hospital with 10 beds and five peripheral hospitals with 30 beds each.)
What is Japanese Encephalitis
JE is a disease caused by an arbo (arthropod borne) virus. The JE virus is related to the West Nile virus and St.Louis virus which are also known to cause encephalitis. However JE can be particularly severe and is responsible for 10,000 to 15,000 deaths each year. As the name suggests JE was first found in Japan but its presence today covers large tracts of South, South-Eastern and East Asia, a region which is home to roughly three billion people. Like malaria and dengue, it is a mosquito borne disease, but unlike the mosquito responsible for those two conditions, the Culex tritaeniorhynchus which carries the JE virus lives in rural areas, breeding in the flooded paddy fields.
Luckily, humans are incidental prey for this mosquito, as it prefers animals. The virus itself lives in the bloodstream of birds like egrets and herons and in pigs. The flooding irrigation of paddy fields helps the mosquitoes breed, and pigs help the virus multiply. Once there are enough mosquitoes carrying a blood-meal loaded with the virus, the chances of an accidental human infection increases. However infected humans do not continue the life cycle of the virus and the chain of infection is broken.
Preventive vaccination apart, there is no cure for JE. In a vast majority of cases the persons bitten do not show any symptoms and in only 1 in 300 infections is there any symptomatic illness. Children are a greater risk since most adults are immune due to earlier sub-clinical infections -- mild infections where the infected does not show signs and symptoms, but are useful in making the person immune. Most infected persons develop mild symptoms or no symptoms at all. Symptoms appear soon after exposure about 6-8 days after the bite of an infected mosquito with the incubation period being between 5-15 days. However once symptoms appear between 20-30% of cases are fatal, some within a few days while others suffer from protracted coma.
Roughly a third of those who survive may have some residual neurological disability. In people who develop the more severe form of the disease, it usually starts with fever, chills, tiredness, headache, nausea and vomiting. Confusion and agitation can also occur in the early stage. There is change in mental status leading to gradual disturbances in speech or gait. In children the disease usually begins with nausea, or abdominal pain. Irritability, vomiting and diarrhea or a fit may be the earliest signs of illness in an infant or child. Seizures or fits occur commonly in children but occur less frequently in adults.
Japanese Encephalitis in India -- southern states tackle it better
JE is not a new disease in India. It was first reported in 1954 in Tamilnadu with the first major outbreak taking place in Burdwan and Bankura in West Bengal in 1973. Since then outbreaks have been reported from nearly all states. The major outbreaks have usually coincided with heavy rainfall and or floods. Tamilnadu, Karnataka and Andhra Pradesh have in the past been known as the states where the disease has been most endemic, but this dubious distinction has passed on to eastern U.P., particularly Gorakhpur as the southern states have been more successful in dealing with the problem.
The last major outbreak of acute encephalitis took place in Andhra Pradesh in 2003, and nearly 200 persons died. While scientific tests reveal that the virus was most probably not the JE virus but a related virus known as Chandipura virus, the steps taken by the state included negotiating a grant from the Gates Foundation for large scale immunization of children with the JE vaccine. In Tamilnadu steps were taken to spray insecticides on the fields where paddy cultivation takes place in order to prevent the mosquitoes from breeding and these have resulted in controlling outbreaks.
Since JE affects rural areas where there is paddy cultivation and pig rearing, poor rural agricultural classes are certainly more exposed than others.
But the way the epidemic has slowly unraveled itself in U.P. this time, and the responses from the state government reveal a picture of complete chaos and mismanagement of a public health emergency.
Mismanaging an epidemic
The region around Gorakhpur is well known for being affected by JE. As mentioned earlier the first outbreak took place in 1978. A detailed scientific study of JE in the Gorakhpur region in the decade of the eighties showed that there were major outbreaks in all years except 1984 and 1987 and the number of deaths rose from 118 to 772. Media reports estimate that in the last twenty five years, nearly 10,000 persons have succumbed to this disease from this region. Even last year (2004), there were over 50 deaths from JE reported in Gorakhpur alone.
JE is a self limiting epidemic as it coincides with the period of water-logging in the paddy fields. Studies have shown that there has been a rapid rise in mosquito population in the Gorakhpur area because of changes in irrigation pattern. Changes in rice growing techniques and shifting from non-irrigated to irrigated agriculture is considered one reason for this rapid growth in mosquito numbers. Spraying insecticides in the paddy fields is known to control the mosquitoes. However, this is not done in this region.
Wake up call for U.P.
Cancer: The long fight
Like many other infectious diseases, vaccination can bestow immunity against the virus. A mouse brain derived vaccine is produced in limited quantities at the Central Research Institute, Kasauli, in Himachal Pradesh, and a tissue culture vaccine is produced in China and South Korea. These countries as well as Japan, Thailand, Malaysia, Indonesia have successfully controlled the disease, using these vaccines. CRI has a limited vaccine production capacity and there have been no plans to augment its capacities even though JE is endemic in large parts of the country. Andhra Pradesh had taken the step to import the Korean vaccine and immunize children, no such plans were made in U.P.
This year the lack of timely payments to CRI had interrupted the supply of the already grossly inadequate quantities that U.P. purchases hampering the administration of the booster doses. However the public health system in the state continues to be in the throes of completing unending rounds of the pulse polio campaign even though the number of lives lost to JE is many times more, and the occurrence of the disease is far more certain in pockets.
This years epidemic also reveals the quixotic manner in which epidemics are managed in U.P., a state which is in the last year of a five year Health System Development Project assisted by the World Bank. There was no epidemic preparedness even in the BRD Medical College, Gorakhpur. While the Health Department had made claims that a special encephalitis ward had been built in the hospital, because of substandard equipment this ward had not been made operational. There were no cardiac monitors, suction machines or centralized oxygen supply in the wards where patients with JE were treated. The Subhas Chandra Bose District Hospital in Gorakhpur has a special laboratory for dealing with this disease, but in the absence of trained personnel (who had been transferred to other districts) this laboratory was non-functional. Even though the World Bank HSDP project was specifically meant to upgrade rural hospitals and secondary care centres, reports show that many Community Health Centres were not prepared to handle this disease.
The Chief Minister, Mulayam Singh Yadav, who also holds the health portfolio in the ministry was very busy with the preparation and conduct of the Panchayat Polls during this period and held his first meeting on the epidemic only after Governor T V Rajeswar visited Gorakhpur. Chief Secretary Neera Yadav, who went to Gorakhpur at the Chief Ministers behest, promised free treatment to all patients with encephalitis but doctors at the King George Medical University, Lucknow continued to ask the patients relatives to buy the expensive medicines, jeopardizing the treatment of many.
In a gesture of magnanimity the Minister of State for Health Jaivir Singh was found distributing two thousand rupees to poor patients for their medicines in Lucknow. While the state government had sanctioned 7.2 million rupees for the GRD medical college for medicines in mid August when the epidemic started accelerating, not more that 1 million rupees had been received by the Medical College after two weeks. Meanwhile the death toll from the disease had gone over the two hundred and fifty mark and over fifty persons were being admitted every day at various hospitals.
Will any lessons be learnt?
JE provides a classic case where public health measures play a crucial role in preventing and controlling a predictable, usually circumscribed and self limiting disease. The spread of the disease is closely related to paddy cultivation, presence of wild birds like egrets and herons and pigs and a particular kind of mosquito. It is possible to monitor the density and kinds of birds and mosquitoes and even of the virus present in mosquitoes overtime, and these measures have been used in the past to predict and control epidemics. Such studies have even been conducted in the Gorakhpur region, but these remain confined to the realm of academic journals and do not inform public health decision making.
Measures for mosquito control are well known and have been used successfully in Tamilnadu. Andhra Pradesh has shown its initiative in going ahead negotiating independent funding and in importing vaccines from Vietnam and reaching out to all the vulnerable population. The success of the pulse polio campaign shows that it is possible to implement large scale vaccinations successfully, even in U.P. However if JE vaccination has to become widespread it needs local political interest rather than that of WHO or the Rotary International.
As mentioned earlier, there is no specific cure for JE. Treatment of fever, headache, convulsions and other symptoms form the backbone of management. There needs to be a functional system to provide this treatment. Since the endemic regions are known, and the time of the outbreaks is predictable, preparation is possible -- both in terms of supplies and equipment as well personnel. However, twenty seven years since the first outbreak in the state, the health department was caught totally unawares. And this despite the fact that millions of dollars of World Bank lent money has been spent in upgrading the system.
Uttar Pradesh has grand plans to become Uttam Pradesh (best state) and has recently spent hundreds of thousands of rupees releasing a full page full colour advertisement recounting the achievements of the current government. The U.P. Development Council has none other than Amitabh Bachchan, the most famous face in the country, as the brand ambassador for the state. Unfortunately no amount of fanfare and drums will improve the health status of its citizens until politicians taking a greater interest in the lives of the people and there is a systematic and soul-searching review of the health department's priorities and performance.