H5N1

Forget Ebola, SARS and Zika: Ticks are the next global health threat

Via The Guardian: Forget Ebola, Sars and Zika: ticks are the next global health threat. Excerpt:

Since the beginning of our species we have been at war. It’s a continuous, neverending fight against the smallest of adversaries: armies of pathogens and parasites. As we have developed new ways to survive and stop them, they have evolved ever more complex and ingenious methods to thwart our efforts.

Humans have faced numerous attempts to challenge our dominance on planet Earth , and from the Black Death to the Spanish flu, we have weathered them all. However, since the start of the 21st century, with its trend towards global interconnectedness, these onslaughts are ever-increasing. In the past 17 years we have battled Sars, the Ebola virus, Mers, and more recently the mysterious mosquito-borne Zika virus. These diseases seem to appear from nowhere and rapidly ravage our populations. One commonality is that they almost always originate in animals before jumping across to people, and few parasites are as good at jumping between animals and people as the tick.  

Ticks could be best described as the used syringes of the natural world due to their promiscuous feeding habits. Most ticks go through three stages in their lives and feed on a different host at each stage, whilst simultaneously collecting hitchhiking microbes in their blood meals. Ticks also have one of the widest distributions of any vector on Earth – they can be found on every continent, including frigid Antarctica. This combination of ubiquity and a bad habit for accumulating pathogenic microbes make ticks some of the most dangerous vectors on the planet.  

So why ticks? And why now? 

Partly, it’s because ticks have been understudied for so long that only recently have we begun to realise just how much they affect our health. It took until 1975 for the infamous Lyme disease even to be formally described, and today the list of microbes found within ticks grows ever larger every year as numerous new species are discovered. 

Changing ecosystems are also forcing ticks into closer contact with humans. Perhaps the most immediate changes are being driven by land clearing, which is forcing wildlife into closer contact with humans; with wildlife come ticks and the diseases they carry. 

Climate change has also been implicated: as the climate gets warmer, some ticks are expanding their ranges into places where cool winter temperatures previously limited their distribution. Geographical boundaries are also being eroded as rapid transport links environments which were previously isolated from one another. This presents easy opportunity for ticks to cross borders and spread to new habitats they may not have previously occupied. 

In short, our manipulation of the environment has set the stage for a tick-driven health crisis.

See also this recent report in Eurosurveillance on tick-borne encephalitis in Sweden.

India: Gorakhpur doctors want encephalitis in school curriculum

Via The Indian Express: Gorakhpur docs want encephalitis in school curriculum.

A group of doctors in the chief minister’s hometown of Gorakhpur has demanded the inclusion of encephalitis and its preventive measures in primary and secondary school curriculum. 

In August, Gorakhpur’s B R D Medical College hospital was in the news after many children died due to different medical reasons, including acute encephalitis syndrome (AES). 

“We began this campaign because AES has 30 per cent death rate, which is higher than any other disease in the region, especially eastern Uttar Pradesh. While dengue and other diseases have found place in the curriculum, it is high time that encephalitis and its preventive measures were also included,” said Dr R N Singh, the Gorakhpur-based social activist and a doctor who has been raising the issue of preventive measures for encephalitis in the past as well. 

“AES can be prevented through basic measures like personal hygiene, keeping hair and hands clean, drinking clean water, keeping piggeries out of residential areas, among others,” he said. “These are more of a social issues rather than the medical ones and require participation from public.” 

Dr Singh said he had written to the chief minister’s office on the matter and also submitted a request on the “Jan Sunvayi” portal.

My daughter was not a number, cries a father of the forgotten Gorakhpur tragedy

Thanks to Ronan Kelly for sending the link to this Huffington Post report: My Daughter Was Not A Number, Cries A Father Of The Forgotten Gorakhpur Tragedy. Excerpt:

GORAKHPUR, Uttar Pradesh — Rihana Khatoon turned to her husband and said she loved the name Jasmine for their daughter. Mohammad Zahid preferred Khushi, the name he gave her when she was born.  

"He's just being stubborn," his wife said, "I thought Jasmine would be a lovely name for school." 

"I'm not being stubborn," Mohammad replied. "Khushi is the name that describes her best. It means joy."  

In the few minutes they had bickered on a warm and humid morning last week, the young couple spoke of their five-year-old daughter as if she were still alive. But it wasn't long before their eyes were heavy once again with the horror and grief they have carried since losing her on 11 August. 

It was the second day of the oxygen crisis that had erupted at the Baba Raghav Das Medical College in Gorakhpur in Uttar Pradesh. 

There are two images stuck in Rihana's head from that day. The first is of her husband using an Ambu bag to manually pump oxygen into their daughter's lungs. 

The second is of the unused diapers she had left on the hospital bed. 

Staring at the floor, she said, "When I asked a nurse to change her diaper, she said, 'What's the point? Your daughter is going to die anyway.' I told her, 'Please don't say that.' My daughter died soaked in her own urine."

As her voice trailed off, Mohammad waited a few minutes before saying, "I expect her to come around the corner, look into my pocket and say, 'Papa, where is my Five Star chocolate.' I always had one for her. She was my doll. When I went to work, she would wave at me until I turned the corner." 

The government hospital in Chief Minister Yogi Adityanath's constituency allegedly ran out of liquid oxygen on 10 and 11 August because hospital officials had delayed paying the supplier dues amounting to ₹70 lakh for over five months. At least 30 children died in 48 hours.  

Devastated parents narrated how they were given Ambu bags to manually pump oxygen into their ailing children for several hours. But even before any manner of investigation was under way, the CM had ruled out lack of oxygen as a possible cause of death in any single case, sealing the chances of an impartial future probe, at least by a state agency.  

Mohammad and Rihana were told that their daughter had encephalitis, an inflammation of the brain caused by several viruses, bacteria and parasites, which is a deadly killer in the marginalised communities of eastern UP. But they believe that it was the oxygen shortage that killed her. 

The first response of the state government was to cite death toll numbers from the previous years to prove that 30 deaths at the medical college were hardly unusual. While Health Minister Siddharth Nath Singh said it was normal for August to see a high number of fatalities in the encephalitis-prone region, Adityanath had blamed the deaths on the lack of cleanliness. 

The insensitivity cuts deep.  

"My daughter was not a number. If all they have to say is that it is normal for children to die in August, then what chance do the children of the poor have?" asked Mohammad. "Would they have dared say such a thing if the child of a minister or rich man had died? Would they want to hear something like that if it was their own children?"

Over 60 children die in a hospital in north India

Via The Lancet: Over 60 children die in a hospital in north India. Excerpt:

Although investigations are still ongoing to assess the chain of responsibility, the Gorakhpur tragedy exposes the malaise of India's health system. Dinesh C Sharma reports. 

About 60 critically ill children have died in the neonatal and encephalitis wards of the Baba Raghav Das (BRD) Medical College Hospital in Gorakhpur, Uttar Pradesh (UP), India, between Aug 10–11. The deaths were allegedly due to disruption in oxygen supply stopped by the supplier over unpaid bills. 

The medical education department of the UP Government has suspended Rajiv Mishra, the BRD Medical College Hospital's Principal, but denies that deaths occurred due to disruption in oxygen supply. Mishra and other officials of the hospital have been charged for negligence and corruption. Enquiries instituted by the central Ministry of Health and the UP Government, the contents of which are yet to be made public, have found that the deaths occurred due to illness, including sepsis and Japanese encephalitis. 

Amnesty International India has raised “serious discrepancies” in the findings of the investigations. A criminal complaint was also filed against the oxygen supplier. A fact-finding team deputed by the Indian Medical Association (IMA) found that “oxygen supply was interrupted for a short time on the night of August 10, as the liquid oxygen supplier had not been paid dues for the past six months”. 

In light of this, the IMA has concluded that it was a case of administrative negligence and not medical negligence. Clinical autopsies, which could reveal whether the deaths were linked to lack of oxygen, have not been conducted. 

A failing system  

“These tragic deaths…reflect on the state of India's public health system, and are an urgent wake up call to evaluate the functioning of public health facilities everywhere in the country”, said Asmita Basu, Programmes Director of Amnesty International India. 

Critically-ill children are often refered to the BRD Medical College Hospital which is in a region endemic for acute encephalitis syndrome and Japanese encephalitis. The government-run facility often experiences a high burden of patients. Poonam Muttreja, Executive Director of the Population Foundation of India, New Delhi, told The Lancet that this can be traced back to the tendency of “private hospitals, in spite of having comparatively better facilities, not [taking] responsibility of children at acute stage, since they fear loss of reputation in case deaths occur, and refer these children to government tertiary care centres”.  

“When sick children from poor families are admitted to an overcrowded hospital, requisite critical care is not assured in constancy or quality”, K Srinath Reddy, President of the Public Health Foundation of India, New Delhi, told The Lancet. “On top of this chronic problem of suboptimal care, an interruption of oxygen supply may have reversed recovery and hastened death in some children.” 

“Since these children were very sick to begin with, it is difficult to assign oxygen shortage as the precipitating cause of death but a contributory role cannot be ruled out”, he added.

Can India stop its children from dying?

The New York Times takes note of encephalitis in Gorakhpur and much else: Can India Stop Its Children From Dying? Excerpt:

Bengaluru, India — Two children younger than 5 die every minute in India. Even by India’s easy acceptance of child mortality, the death of 70 children within five days at a hospital in the northern city of Gorakhpur was hard to accept. 

A majority of the children who died had been struck by Japanese encephalitis, a mosquito-borne, potentially fatal viral brain infection that periodically ravages the Indian state of Uttar Pradesh. But the immediate reason for at least half the deaths appeared to be the cessation of piped oxygen into the intensive care ward. Japanese encephalitis has no known cure, and as it progresses, patients require oxygen to survive. 

Despite 11 reminders over six months, the Uttar Pradesh government did not pay the company that supplied oxygen to the Baba Raghav Das Medical College hospital. The company acknowledged it had threatened to stop supplies but denied it had actually done so. The state administration, with its own role in question, vaguely promised “stringent action against the guilty.” 

In a country chronically short of medical facilities, the Baba Raghav Das hospital is the largest and most important referral hospital in a poor, populous region, serving a population of more than 50 million in hundreds of nearby towns and villages. Stunned parents — carpenters, construction workers, security guards, homemakers and others from poor families — streamed out of the hospital with the bodies of their dead children.  

Many said the police had removed them from the hospital after their children died. Some who sought autopsies were told to bring masks and gloves for coroners, suggesting the breadth and depth of the state’s health care crisis.

Gorakhpur, a city of nearly 700,000, is home to Yogi Adityanath, a controversial monk and Hindu nationalist politician who was chosen by Prime Minister Narendra Modi to be chief minister of this, India’s most populous state, in March. Mr. Adityanath, who has a penchant for hate speech against Muslims and faces accusations of rioting and attempted murder, has politically dominated Gorakhpur and the adjacent region and represented it in the Indian parliament from 1998 to 2014.  

Although disregard for human life is common in India, the images of dead children from the Gorakhpur hospital were followed by intense criticism. “This is not just a tragedy, it is a massacre,” Kailash Satyarthi, an Indian Nobel laureate, tweeted.

Indian politicians are expected to look after their home constituencies, but Mr. Adityanath defended his record and dismissed allegations that his government was criminally negligent at worst and incompetent at best. One reason for the deaths, he said, is that “we do not lead a clean and hygienic life.”

Several leaders from India’s ruling Bharatiya Janata Party played down the tragedy. Amit Shah, the powerful B.J.P. president and Mr. Modi’s confidante, said, “In such a big country, many incidents happen; this isn’t the first time an incident like this has happened.” 

Irrespective of the local government’s political ideologies, Gorakhpur and Uttar Pradesh have repeatedly witnessed mass death from disease, grim reminders of the state of its public-health system. The Baba Raghav Das hospital’s records reveal that 3,000 children have died within its walls since 2012.

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.