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India: Encephalitis still kills one in three children in Gorakhpur hospital

Via Hindustan Times: Encephalitis still kills one in three children in Gorakhpur hospital. Excerpt:

Uttar Pradesh chief minister Yogi Adityanath has ordered criminal action against hospital staff and the gas firm for 30 child deaths between August 9 and August 11. However, 15-18 children continue to die every day at the 950-bed Gorakhpur’s Baba Raghav Das (BRD) Medical College and Hospital. 

One third of these deaths are due to encephalitis.  

Japanese Encephalitis (JE) and the deadlier Acute Encephalitis Syndrome (AES) became the national buzzwords after 30 children died between August 9 and 11 in BRD Medical College, Gorakhpur’s largest government hospital, amid allegations that a private company contracted to supply oxygen cylinders cut supply over a payment dispute. 

A total of 97 of the 1,527 child deaths between July 1 and August 14 were from the mosquito-borne Japanese Encephalitis and AES, which is caused by other toxins, viruses and bacteria, among others. 

JE and AES deaths continue to account for roughly two-thirds of child deaths from all causes. 

Encephalitis is the swelling in the brain that leads to sudden high fever, headache, neck stiffness, disorientation, coma, seizures, spastic paralysis and, finally, death. 

From January 1 till August 22, the hospital recorded 625 AES admissions, of which 158 children died. More than 30% of the cases and deaths were reported during July and till mid August.  

Of the 2,729 child deaths from all causes in 2016, close to 45% (1,218) occurred when monsoon peaks between July and October. 

On August 14, 24 deaths occurred within a single day, when there were no disruptions of any kind. 

“On an average, there are between 10 and 20 deaths each day at this time of the year. AES has got very high mortality rate of around 30% and since this is a referral hospital, all the infants admitted in the neonatal wards are brought in when they are critical,” said a senior administrative official, requesting anonymity.

Uttar Pradesh: Ritual of announcements fails to check encephalitis deaths

Via the Hindustan Times: Uttar Pradesh: Ritual of announcements fails to check deaths. Excerpt:

Announcement of projects and schemes has become a ritual for successive governments even as children have kept falling prey to Japanese Encephalitis (JE) and Acute Encephalitis Syndrome (AES) in Gorakhpur and the adjoining districts for four decades. 

The death of over 30 children in 48 hours last week shows that the BRD Medical College hospital still lacks basic infrastructure despite announcements that the central and state governments have made from time to time about providing better facilities. 

Adding to the list, union health minister JP Nadda on Sunday declared that central government had sanctioned Rs 85 crore [US$13.256 million] for establishment of the National Virology Research Centre in Gorakhpur.  

In 2004, the then Union health minister Anbumani Ramadoss visited Gorakhpur and announced establishment of a research centre and a separate block for treatment of encephalitis patients. The research centre is yet to see the light of the day. 

When the Bahujan Samaj Party (BSP) was voted to power in 2007, the then chief minister Mayawati announced the BRD Medical College would be upgraded to a centre of excellence for treatment of encephalitis patients. But the project failed to take off. 

The then union health minister Ghulam Nabi Azad visited Gorakhpur in 2011 and announced establishment of a super-specialty hospital, rehabilitation centre and para medical staff training centre in the district. The project remained limited to paper.  

After the SP formed the government in 2012, the then chief minister Akhilesh Yadav visited Gorakhpur in October and announced establishment of a 500-bed hospital for the encephalitis patients. Though five years have gone by, construction of the hospital is yet to be completed. 

Dr KP Kushwaha, former principal of BRD Medical College, told HT,“In 1978, a report by the Indian Council for Medical Research said the mysterious virus that was killing children in Gorakhpur and its adjoining districts was Japanese Encephalitis (JE). But it took the central and state governments over two decades to realise that hundreds of children were dying due to lack of proper health facilities.”  

In 2004, the then chief minister Mulayam Singh Yadav released Rs 93 lakh [US$145,000] for establishment of oxygen pipeline in wards and purchase of ventilators at BRD Medical College. In 2005, the central government decided to launch a vaccination drive in districts infested with JE virus. But no concrete measures were taken to improve facilities for patients, he said.  

Kushwaha said the Allahabad high court in 2006 directed the state government to increase the number of beds for encephalitis patients in wards, set up intensive care units, a rehabilitation centre and research centre.  

In 2007, the state government set up two wards. In 2009 a unit of National Institute of Virology (NIV), Pune was set up in BRD Medical College to conduct research on patients. 

In 2011, the high court again directed the state government to set up an expert committee and improve facilities for encephalitis patients. The state government released Rs 11 crore [US$1.75 million] for upgradation of 100 bed encephalitis wards, he said.  

Kushwaha called for establishment of a separate authority for the treatment of the encephalitis as was the case in Thailand, Taiwan and Singapore that have successfully controlled the outbreak of the disease. 

Rather than working in an ad-hoc manner, the state government should set up sustainable infrastructure for the working of the authority, he said.

India: Assam tops list of most encephalitis deaths

Via the Hindustan Times: Assam tops list of most encephalitis deaths. Excerpt:

Thirty-seven more people have succumbed to Acute Encephalitis Syndrome (AES), a disease that affects the brain, in a week in the country, taking the total number of deaths to 406, shows government data.  

The number of people infected with the disease has also gone up to 5,926 while that for Japanese Encephalitis (JE) is 903, with 93 deaths. 

Till August 6 this year, the country had recorded 5,413 AES cases and 369 deaths while JE cases were at 838, with 86 deaths. 

Even though the spotlight is on Uttar Pradesh, Assam is the worst affected state. Till August 13, the last day until when data is available with the Union health ministry, Assam recorded 2,016 JE and AES cases and 195 deaths. UP reported 1,320 cases and 155 deaths in the same period. 

Assam topped the list with 1,534 cases of AES and 128 deaths, followed by UP with 1,208 cases and 152 deaths, West Bengal at 826 cases and 81 deaths, and Manipur with 690 cases and six deaths. The most number of JE cases, 482, have also been reported from Assam with 67 deaths, followed by Manipur with 141 cases and six deaths, and UP with 112 cases and three deaths. 

Encephalitis is the swelling in the brain that leads to sudden high fever, headache, neck stiffness, disorientation, coma, seizures, spastic paralysis and, finally, death. If the symptoms are not treated within hours of the first few appearing, 30% of those affected die. 

Encephalitis symptoms can be caused by both JE and AES, with cases for both peaking during monsoon. Children under the age of 15 are the worst hit, with AES usually affecting children under five who are severely malnourished. 

Of those affected, the ones who pull through rarely do so without some degree of disability. About one in three suffer permanent intellectual, behavioural or neurological problems, including partial paralysis, recurrent seizures and the inability to speak.

Gorakhpur tragedy: Most children’s deaths not due to encephalitis, hospital records show

Via Livemint.com: Gorakhpur tragedy: Most children’s deaths not due to encephalitis, hospital records show. Excerpt:

New Delhi: Most of the deaths of children at Gorakhpur’s BRD Medical College Hospital over the past five days are not due to encephalitis, the hospital’s own medical records reveal.  

Over 70 children have died in just five days in the hospital in the Uttar Pradesh city and questions are being asked (and fingers pointed) about the cause of death. 

The state government believes encephalitis—a long-time scourge in this part of the state—is the reason for the mounting death toll of children.  

It has dismissed reports attributing some of the deaths to the temporary, but fatal, termination of liquid oxygen supplies at the hospital.

If the data available with the hospital is to be believed—Mint has a copy of the details —of the first 30 deaths that occurred on 10 and 11 August, only five were due to acute encephalitis syndrome or AES; one was due to hepatic encephalopathy, which is related to AES. The other deaths were of terminally ill newborns. 

Some of them suffered from diseases such as pneumonia, sepsis, and swine flu while others were preterm babies in a critical condition. Among the 13 children who died on 12 August only one was due to AES. 

“Newborn babies don’t suffer from AES. The list of deceased clearly shows that only five children died of AES and one due to hepatic encephalopathy. As per the list, all other babies were newborns who were apparently in need of expert emergency care services. Such cases are very critical and need continuous supply of ventilation,” said Dinesh Kapil, senior consultant, pediatrics, at Red Cross Hospital, New Delhi. Kapil was formerly at All India Institute of Medical Sciences (AIIMS). 

Data shows that the hospital’s record in curing patients admitted to its paediatric and intensive care units isn’t good.  

In 2017 (till July), the total number of admissions to the pediatrics department was 3,878, of which 596 patients died. The figures for the neonatal intensive care unit (newborns) arouse even more concern—of the total 2,386 admissions, 931 died.  

Uttar Pradesh has the worst infant mortality rate in the country of 78 (per 1,000 live births) according to the National Family Health Survey- IV (2015-16). The national average is 41.

Gorakhpur: Weekend child deaths push India hospital toll to 85

To paraphrase Oscar Wilde's Lady Bracknell, losing one child is a misfortune; losing 85 begins to look like carelessness. 

Via Yahoo!News, an AFP report: Weekend child deaths push India hospital toll to 85. The full report and then a comment:

Twenty-five children died over the weekend at a northern India government hospital that suffered oxygen shortages, taking the overall death toll to 85, authorities told AFP. 

Indian media have linked 30 of these deaths last Thursday and Friday to a lack of oxygen as suppliers' bills were not paid. 

Authorities have since launched an inquiry into the causes of the oxygen disruption but have denied reports that it was responsible for any deaths at the Baba Raghav Das Medical College in Gorakhpur in Uttar Pradesh state. 

"I can confirm 12 child deaths on Saturday and 13 on Sunday," P.K Singh, the hospital's new principal, told AFP late Monday. 

Singh was appointed after the unceremonious removal of his predecessor last week.  

An earlier official statement confirmed 60 child deaths in five days starting last Monday.  

State chief minister Yogi Adityanath, a hardline Hindu priest from Prime Minister Narendra Modi's party, has vowed to punish anyone found to have been negligent.  

The region is one of India's poorest and registers hundreds of child deaths each year from Japanese Encephalitis and Acute Encephalitis Syndrome (AES), which is rife in parts of eastern and northern India. 

"Most of the 25 who died on the weekend were suffering from AES," Singh said, vowing to "improve the patient experience" at the hospital.

An Indian doctor was recently quoted as saying that AES is a "dustbin diagnosis," encephalitis that India's healthcare system can't identify with any precision. 

India restores hospital oxygen supply as anger mounts over child deaths

Via Thomson Reuters, the horror story in Gorakhpur continues: India restores hospital oxygen supply as anger mounts over child deaths. Excerpt:

Indian health authorities on Monday delivered oxygen to a public hospital where 63 people have died of encephalitis in recent days, nearly half of them children, as it ran out of medical supplies because of unpaid bills, triggering public outrage. 

The deaths of the children have again exposed India's underfunded and poorly managed public healthcare despite Prime Minister Narendra Modi government's vows to revamp the system.  

Hundreds of people die each year in India of encephalitis, a mosquito-borne disease common during the monsoon season, and no medical official directly linked the recent deaths to a lack of oxygen. 

But complaints that the hospital in the eastern city of Gorakhpur did not have enough supplies has stoked anger against the ruling Bharatiya Janata Party which governs Uttar Pradesh state. 

"We now have adequate supplies of oxygen cylinders, there was a shortage last week... but I am not in a position to say whether they were the cause behind the deaths," R.K. Sahai, a senior medical officer in the hospital, said. 

Television images of parents emerging from the hospital carrying the bodies of infants and alleging they died because there they didn't get oxygen have led to a firestorm of criticism of chief minister Yogi Adityanath, a saffron-robed Hindu hardliner who took office earlier this year.  

Bipin Singh said his six-year-old daughter died on Thursday because of lack of oxygen and he had seen six other children die for the same reason.  

"My daughter and other children were unable to breathe. We kept telling the nurses that they should call the doctors. The doctors said they have ordered for oxygen cylinders but we never saw them being used." 

Bahadur Nishad, who lost a four-year-old son suffering from encephalitis, said he was ready to pay for the oxygen cylinders himself. 

"They told me there was a shortage of cylinders," he said and turned his wrath on chief minister Yogi Adityanath whose electoral constituency is Gorakhpur.  

Other parents spoke of desperately trying to arrange basic materials such as cotton gauze, glucose injections and blood supplies as their children struggled for life in the wards.  

Patients continued to stream into the hospital over the weekend. Some 450 patients suffering from encephalitis were admitted on Saturday alone, of whom 200 were children under 12, hospital records showed.  

Many were being treated on the floor and near toilets due to the shortage of beds.

India: Encephalitis a perennial issue in Uttar Pradesh; over 26,000 cases reported since 2010

Via First Post: Gorakhpur hospital tragedy: Encephalitis a perennial issue in Uttar Pradesh; over 26,000 cases reported since 2010. Excerpt:

BRD Medical College and Hospital is at the centre of most encephalitis outbreaks in Uttar Pradesh. Located in Gorakhpur in eastern Uttar Pradesh, it is one of the major government public health centres in the region which has the doctors and facilities to treat this affliction. Some of the children who died at the hospital, reportedly due to lack of oxygen supply, were suffering from encephalitis.  

Encephalitis is a deadly vector-borne disease which claims hundreds of lives in the state every year. According to a report by the Directorate of National Vector Borne Diseases Control Programme (NVBDCP), 26,686 cases of encephalitis were reported in Uttar Pradesh between 2010 and August 2017. Of this, 24,668 cases were of Acute Encephalitis Syndrome (AES) and 2,018 of Japanese Encephalitis (JE). Out of those reportedly suffering from AES, 4,093 died in the same period. On the other hand, there were 308 JE deaths registered in the state — 15 percent of the total people who suffered from JE between 2010-2017.  

AES and JE – What’s the difference? 

Acute Encephalitis Syndrome (AES) is an umbrella term for all symptoms which cause inflammatory brain diseases. They could be caused by bacteria, fungi or virus of different strains which are difficult to identify individually. As a result, the World Health Organisation (WHO) in 2006, coined the term AES to signify a group of diseases which seem similar to one another but are difficult to differentiate in the chaotic environment of an outbreak, a Fountain Ink report noted. 

In India, the most common pathogen for encephalitis is the JE virus, which accounts for a quarter of the cases. As a result, doctors cannot pinpoint whether the AES is caused by the West Nile virus, dengue virus, Chandipura virus, chikungunya virus, or bacteria such as Streptococcus pnuemoniae, Orientia tsutsugamushi, Haemophilus influenza or fungi like Candida albicans. Illness caused by any of these pathogens triggers fever, an altered mental status causing the patient to behave abnormally and seizures.

Since there exist tests only to confirm JE, all other diseases whose cause cannot be precisely ascertained are relegated to being diagnosed as AES, which is as vague as it can get. 

“For around 80 percent of the patients who come here, we can’t give a proper diagnosis,” Mahima Mittal, head of the department of paediatrics at the BRD Hospital, told Fountain Ink. This explains how the number of AES cases is significantly higher than JE in the statistics mentioned above.  

In the same report, Ravi Vasanthapuram, a neurovirologist from NIMHANS, Bengaluru called AES a “dustbin diagnosis” for all encephalitis cases whose cause one cannot find. If you Google encephalitis in India, a majority of published research is about JE and hardly any about AES.  

Major encephalitis outbreak is Uttar Pradesh 

Uttar Pradesh carries the largest AES burden in India and has succumbed to repeated outbreaks. Nearly 6,000 children have died in Gorakhpur region since the virus was first detected in 1978. One of the major outbreaks of AES/JE major outbreaks was recorded in Gorakhpur between July and November 2005. The outbreak turned out to be one of the biggest epidemic in three decades. Out of the 5,700 cases, nearly 1,000 children died, BBC reported. 

A team of researchers collected samples from 326 people who were admitted at the BRD hospital with encephalitis symptoms during that period. They found that rural populations between the age of three months to 15 years were most affected, while adults in the area were immune to it. It further noted that the patients’ clinical history showed that they experienced fever, headache, convulsions and vomiting leading to paralysis, coma and death eventually.

India: Hospitals brace for encephalitis season in CM Yogi Adityanath’s constituency Gorakhpur

Via The Indian Express: Hospitals brace for encephalitis season in CM Yogi Adityanath’s constituency Gorakhpur. 

Chief Minister Yogi Adityanath’s Lok Sabha constituency of Gorakhpur has witnessed at least 114 deaths due to Acute Encephalitis Syndrome (AES) this year. AES is an umbrella classification under which come the diseases Japanese Encephalitis (JE), water-borne encephalitis and scrub typhus, among others. As a Member of Parliament, Adityanath had actively raised the issue. 

In the last two days, 16 new cases of AES and three deaths were reported from Baba Raghav Das (BRD) Medical College, the largest in the district. However, the hospital and district health officials are claiming that the situation is much better than the previous years. 

According to Ravindra Kumar, Chief Medical Officer (CMO) Gorakhpur, the Case Fatality Rate (CFR) is reducing with each passing year. “The CFR last year was more than 20 percent and this year we have reduced it to 16 percent. In 2015, the CFR was somewhere near 30 percent,” CMO said, adding that the threat of JE has nearly ended although it has, like last year, claimed three deaths this year.  

“In the months of August to October, people are more prone to acquiring some form of AES. Therefore we are trying to make people aware of the importance of cleanliness, drink clean and boiled water, and should rush to hospital if there is fever,” said the CMO. “We have prepared separate wards and the tests and treatment for AES and JE are free of cost,” CMO added.  

According to Dr. R N Singh, social activist and a campaigner in the Encephalitis Eradication Movement, there hasn’t been a significant decrease in the number of cases and deaths. “It is just the start of August. Though we hope that the figures doesn’t match the earlier ones,” Singh said, adding that the government soon needs to implement the National Encephalitis Eradication Program (NEEP), which is ready and focuses mainly on prevention, which according to him is “surely possible if exercised timely”.

India: Disease sleuths unmask deadly encephalitis culprit

Via Science: Disease sleuths unmask deadly encephalitis culprit. The summary and then a comment:

Soon after the monsoon rains arrive in June, the northern city of Gorakhpur transforms into the "encephalitis capital of India." Hundreds of children from across the surrounding Uttar Pradesh state arrive at Baba Raghav Das Medical College with the brain inflammation that causes delirium, seizures, and—in about 20% of those patients—death. 

For decades, the recurring spates of cases and high mortality rate stumped experts. Now, medical detectives think they have solved the mystery: A major cause of the seasonal encephalitis outbreaks is scrub typhus, a bacterial malady transmitted by a microscopic mite. The culprit was first unmasked 3 years ago—but most researchers didn't believe it then. The new evidence, described this month in Emerging Infectious Diseases, indicates the responsible bacterium is far more dangerous than realized.

I posted an item about scrub typhus and encephalitis in October 2015.

India: Encephalitis toll goes up to 24 in Gaya

Via The Times of India: Encephalitis toll goes up to 24 in Gaya.

With one more death reported from Anugrah Narain Magadh Medical College Hospital, the number of Encephalitis deaths has gone up to 24. Altogether, 123 AES[acute encephalitis syndrome] patients were admitted to the children's ward of the ANMMCH with AES symptoms. Of these, 35 of the patients were found suffering from Japanes Encephalitis, the more deadly form of the disease. 

Confirming 24 deaths due to AES this season, ANMMCH superintendent Dr SK Sinha said that 35 of the 123 AES patients admitted to the hospital this season were tested JE positive. Giving a further break up, the superintendent said that of the 23 deaths reported this season, eight suffered from Japanese Encephalitis while the other 15 died due to AES. 

Now that the temperature has come down and winter has is beginning to set in, there was little likelihood of the disease spreading any further. Altogether 96 Encephalitis patients have been discharged while another four were undergoing treatment in the children's ward of the hospital. Two of the patients were discharged on Friday after satisfactory recovery. 

The Encephalitis survivors have suffered mild to severe mental retardation and physical infirmities, particularly weakening of the upper and lower limbs. The facility for the rehabilitation of the AES survivors is not available in the hospital and as such the discharged patients have to fend for themselves. According to activist Brajnandan Pathak, the affected patients - being very poor(almost all of them belong to the Mahadalit social group) - cannot afford rehabilitation at centres outside the district. 

As per available statistics, the maximum number of AES deaths were reported in 2011 when no less than 70 children died of Encephalitis in ANMMCH alone. In 2009 too, 46 AES deaths took place. The number of affected children in 2011 and 2009 was 321 and 151 respectively. 

Health officials claim to have undertaken massive immunisation drive in the district to prevent the deadly disease. But the claims have fallen flat after the outbreak of the disease which took almost epidemic form.