Acute Encephalitis Syndrome (AES) has till now claimed 100 lives in Muzaffarpur and the adjoining districts in Bihar. Most of the casualties affected by the Syndrome are between the age group of 1-10.
With the death toll reaching 100, the situation in Bihar is only deteriorating.
These are only official reported deaths. Actual toll could be much higher as many from villages fail to make it to hospitals.
On Sunday, Union Health Minister Harsh Vardhan visited the Sri Krishna Medical College and Hospital (SKMCH) in Muzaffarpur. Maximum casualties due to the Syndrome are reported from SKMCH. The Syndrome is locally called the ‘Chamki’ fever.
The health minister reviewed the situation arising out of sudden spurt in the number of deaths for four hours at the hospital. However, he did not find any fault with the lack of facilities at the hospital and supported the doctors for their efficiency in dealing with the crisis.
Harsh Vardhan said, “The doctors here at the hospital are doing their best under such a difficult situation in treating the children. A multi-disciplinary institute will be set up here in the next one year to identify the reason behind this disease.”
In 2014, a similar AES outbreak claimed 379 lives. Harsh Vardhan, who was the Union health minister in the Centre then had visited the hospital and declared slew of measures to contain the crisis but even after five years, the situation on the ground has not changed much.
June 15 update:
The death toll due to Acute Encephalitis Syndrome (AES) has risen to 75 in Muzaffarpur district. Union Health Minister Dr Harsh Vardhan will visit Muzaffarpur on Sunday to review the situation prevailing in the region.
All the deaths have been reported from Shri Krishna Medical College and Hospital (SKMCH) and Kejriwal Matrisadan. Since January, 134 children have been admitted to the two hospitals, 119 at SKMCH alone. Two days ago, the death toll was 48.
On Thursday, a seven-member central team had visited both the hospitals in the state and had recommended for a separate ward for children, along with a laboratory at SKMCH. “The team asked us to stick to the standard operating procedure of giving symptomatic treatment but asked for setting up a separate children ward with a laboratory at SKMCH. The team felt a laboratory at the hospital would provide reports quickly and help in the treatment of AES,” Muzaffarpur civil surgeon Dr Shailesh Kumar Singh had said.
MUZAFFARPUR – A seven-member central team of experts visited Muzaffarpur on Wednesday to take stock of the situation as three more children died at Sri Krishna Medical College and Hospital in the town due to suspected acute encephalitis syndrome (AES), taking the death toll in the district and adjoining areas to 48 within a fortnight.
Muzaffarpur DM Alok Ranjan Ghosh confirmed 48 deaths due to the symptoms similar to AES.
So far 143 cases of AES have been reported from 11 districts of Vaishali, Sitamarhi, Sheohar, East Champaran, Patna, Nalanda, Muzaffarpur, Jehanabad, Gaya, Bhojpur and Aurangabad.
Union minister of state for health Ashwini Kumar Choubey was scheduled to reach on Thursday to take stock.
June 10 update:
At least 23 children have lost their lives in Bihar due to a fresh outbreak of AES caused by Japanese Encephalitis (JE) over the past week.
Muzzafarpur is the worst-affected district as 14 children have been reported dead due to the fatal fever here.
June 9 update:
At least 14 children have died in the past one week of suspected AES by the Japanese Encephalitis (JE) in Muzaffarpur, while 15 are being treated at the city’s two hospitals.
Five children died of suspected AES and JE over the past 24 hours, while 12 new patients were admitted, said a District Health official on Saturday.
Some 21 children were admitted at the Shri Krishna Memorial College Hospital (SKMCH) and 14 were admitted at Kejriwal Hospital on Friday.
“The death of two children by AES has been confirmed,” said District Civil Surgeon S P Singh. “We are investigating the reasons for the other deaths,” he added.
According to Singh, most patients were brought in with high fever and hypoglycemia (a condition caused by a very low level of blood sugar (glucose)).
“All primary health centres in the district have been put on high alert. But people need to be cautious about their children as well. Give them as much liquid as you can and keep them hydrated,” he said.
SKMCH pediatrician Dr G S Sahni said: “In children, the symptoms of AES are high fever, body stiffness and loss of consciousness. We’re informing the public to be aware of these symptoms.”
The rising number of death of children has set the alarm bells ringing in the state health department, which sent a high level team to Muzaffarpur to take stock of the situation.
AES outbreaks are a routine in areas in and around Muzaffarpur in the summer months. The epidemic mostly affects children from poor families below 15 years of age.
The disease is no longer confined to Muzaffarpur but has also spread to five neighbouring districts such as Vaishali, Sitamarhi, Sheohar, East Chamaran and West Champaran.
Acute encephalitis syndrome (AES)
Acute encephalitis syndrome (AES) is a serious public health problem in India. It is characterized as acute-onset of fever and a change in mental status (mental confusion, disorientation, delirium, or coma) and/or new-onset of seizures in a person of any age at any time of the year. The disease most commonly affects children and young adults and can lead to considerable morbidity and mortality.
Viruses are the main causative agents in AES cases, although other sources such as bacteria, fungus, parasites, spirochetes, chemicals, toxins and noninfectious agents have also been reported over the past few decades.
Japanese encephalitis virus (JEV) is the major cause of AES in India (ranging from 5%-35%).Herpes simplex virus, Influenza A virus, West Nile virus, Chandipura virus, mumps, measles, dengue, Parvovirus B4, enteroviruses, Epstein-Barr virus and scrub typhus, S.pneumoniae are the other causes of AES in sporadic and outbreak form in India. Nipah virus, Zika virus are also found as causative agents for AES. The etiology in a large number of AES cases still remains unidentified.
AES due to JEV was clinically diagnosed in India for the first time in 1955 in the southern State of Madras, now Tamil Nadu. During 2018, 10485 AES cases and 632 deaths were reported from 17 states to the National Vector Borne Diseases Control Programme (NVBDCP)*in India, with a case fatality rate around 6 per cent. AES cases were reported mainly from Assam, Bihar, Jharkhand, Karnataka, Manipur, Meghalaya, Tripura, Tamil Nadu, Uttar Pradesh.
According to the World Health Organisation (WHO), Japanese Encephalitis Virus (JEV) is a flavivirus related to dengue, yellow fever and West Nile viruses, and is spread by mosquitoes.
JEV is the main cause of viral encephalitis in many countries of Asia with an estimated 68 000 clinical cases every year.
Although symptomatic Japanese encephalitis (JE) is rare, the case-fatality rate among those with encephalitis can be as high as 30%. Permanent neurologic or psychiatric sequelae can occur in 30%–50% of those with encephalitis.
Twenty four countries in the WHO South-East Asia and Western Pacific regions have endemic JEV transmission, exposing more than 3 billion people to risks of infection.
There is no cure for the disease. Treatment is focused on relieving severe clinical signs and supporting the patient to overcome the infection.
Safe and effective vaccines are available to prevent JE. WHO recommends that JE vaccination be integrated into national immunization schedules in all areas where JE disease is recognized as a public health issue.
The first case of Japanese encephalitis viral disease (JE) was documented in 1871 in Japan.
JE primarily affects children. Most adults in endemic countries have natural immunity after childhood infection, but individuals of any age may be affected.
Signs and symptoms
Most JEV infections are mild (fever and headache) or without apparent symptoms, but approximately 1 in 250 infections results in severe clinical illness. The incubation period is between 4-14 days. In children, gastrointestinal pain and vomiting may be the dominant initial symptoms. Severe disease is characterized by rapid onset of high fever, headache, neck stiffness, disorientation, coma, seizures, spastic paralysis and ultimately death. The case-fatality rate can be as high as 30% among those with disease symptoms.
Of those who survive, 20%–30% suffer permanent intellectual, behavioural or neurological sequelae such as paralysis, recurrent seizures or the inability to speak.
24 countries in the WHO South-East Asia and Western Pacific regions have JEV transmission risk, which includes more than 3 billion people.
JEV is transmitted to humans through bites from infected mosquitoes of the Culex species (mainly Culex tritaeniorhynchus). Humans, once infected, do not develop sufficient viraemia to infect feeding mosquitoes. The virus exists in a transmission cycle between mosquitoes, pigs and/or water birds (enzootic cycle). The disease is predominantly found in rural and periurban settings, where humans live in closer proximity to these vertebrate hosts.
In most temperate areas of Asia, JEV is transmitted mainly during the warm season, when large epidemics can occur. In the tropics and subtropics, transmission can occur year-round but often intensifies during the rainy season and pre-harvest period in rice-cultivating regions.
Individuals who live in or have travelled to a JE-endemic area and experience encephalitis are considered a suspected JE case. A laboratory test is required in order to confirm JEV infection and to rule out other causes of encephalitis. WHO recommends testing for JEV-specific IgM antibody in a single sample of cerebrospinal fluid (CSF) or serum, using an IgM-capture ELISA. Testing of CSF sample is preferred to reduce false-positivity rates from previous infection or vaccination
Surveillance of the disease is mostly syndromic for acute encephalitis syndrome. Confirmatory laboratory testing is often conducted in dedicated sentinel sites, and efforts are undertaken to expand laboratory-based surveillance. Case-based surveillance is established in countries that effectively control JE through vaccination.
There is no antiviral treatment for patients with JE. Treatment is supportive to relieve symptoms and stabilize the patient.
Prevention and control
Safe and effective JE vaccines are available to prevent disease. WHO recommends having strong JE prevention and control activities, including JE immunization in all regions where the disease is a recognized public health priority, along with strengthening surveillance and reporting mechanisms. Even if the number of JE-confirmed cases is low, vaccination should be considered where there is a suitable environment for JE virus transmission. There is little evidence to support a reduction in JE disease burden from interventions other than the vaccination of humans. Thus, vaccination of humans should be prioritized over vaccination of pigs and mosquito control measures.
There are 4 main types of JE vaccines currently in use: inactivated mouse brain-derived vaccines, inactivated Vero cell-derived vaccines, live attenuated vaccines, and live recombinant (chimeric) vaccines.
Over the past years, the live attenuated SA14-14-2 vaccine manufactured in China has become the most widely used vaccine in endemic countries, and it was prequalified by WHO in October 2013. Cell-culture based inactivated vaccines and the live recombinant vaccine based on the yellow fever vaccine strain have also been licensed and WHO-prequalified. In November 2013, Gavi opened a funding window to support JE vaccination campaigns in eligible countries.
To reduce the risk for JE, all travellers to Japanese encephalitis-endemic areas should take precautions to avoid mosquito bites. Personal preventive measures include the use of mosquito repellents, long-sleeved clothes, coils and vaporizers. Travellers spending extensive time in JE endemic areas are recommended to get vaccinated before travel.
Major outbreaks of JE occur every 2-15 years. JE transmission intensifies during the rainy season, during which vector populations increase. However, there has not yet been evidence of increased JEV transmission following major floods or tsunamis. The spread of JEV in new areas has been correlated with agricultural development and intensive rice cultivation supported by irrigation programmes.