Bihar child death toll 111, anger mounts

Aditi Tandon

Tribune News Service

New Delhi, June 18

As the tragedy of child deaths attributed to acute encephalitis syndrome unfolds in Bihar, virologists and public health experts across the country are struggling to determine the exact cause of 111 fatalities and counting.

The National Centre for Disease Control data as of today showed 470 AES cases in Bihar’s Muzaffarpur and 111 deaths.

The exact cause of AES deaths is still under investigation with Union Health Minister Harsh Vardhan hoping for a central team of experts, dispatched to Muzaffarpur, to pinpoint some agent that’s carrying the disease.

“The team has only gone and investigations will take a while,” Vardhan said today, adding that the Centre and the state were doing their “best”. But the fact is this “best” is not enough. India has seen AES cases since 1955 and fatal outbreaks starting the one in Bengal in 1973, spreading to UP, Bihar and beyond to 19 states. But lessons have not been learnt.

“Surveillance and epidemiology studies to determine AES causes should have been mounted long ago. AES is not new to India. It has been causing child deaths for years and continues to do so. AES for long was primarily attributed to the Japanese encephalitis virus but of late the viral link to AES has come down to 10 pc with other causes taking over. Not much is known of what’s exactly causing the AES deaths in Bihar. But there’s a recent study that links Muzaffarpur child deaths to toxins in locally produced litchi. “There’s enough literature to show that malnourished children who consume litchis empty stomach in the evening face a bout of low blood sugar by the next morning, leading to sudden fever, convulsions and death in a matter of a few hours. This link needs to be explored in detail,” says Jai Prakash Narain, former regional adviser and director, WHO.

The AES and litchi link was established in a 2014 study by the Indian NCDC and the Centre for Disease Control US and published in The Lancet. This study concluded, “Investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. The toxins are present in litchi fruit. To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal by children and implementing rapid glucose correction for suspected illness.”

Other experts, however, add that the toxin in litchi per se is not the cause of AES, which mainly affects children from poor socio-economic conditions and those under 15 years of age.

Studies also show the litchi toxin affects only those children who are malnourished and have litchi on empty stomach in the evenings. The toxin unleashes a decline in blood sugar levels in kids and although simple administration of glucose can help revive the child, remote Bihar village health facilities have no way to even administer glucose in time.

Harsh Vardhan has now said the state will have five virology labs to study the cause of AES. But public health experts who followed AES outbreak in Muzaffarpur in 2014 say primary health facilities must be strengthened to ensure timely treatment and referral to district or tertiary facilities to save children from dying. “The affected children are mainly from poor families. The government must address social determinants of health and the economic condition of these families along with the medical aspect,” says Rakesh Kumar, who was Joint Secretary (Health) when Mission Indradhanush was rolled out to vaccinate kids.

Cong slams Vardhan over death of kids

The Congress hit out at Union Health Minister Harsh Vardhan over the AES outbreak in Bihar. “In 2014, 139 children were killed in Muzaffarpur. In 2019, toll 111 already. Same minister, Shri Harsh Vardhan, same reasons, same promises, no work, all talk (sic),” Congress’ chief spokesperson Randeep Surjewala tweeted. PTI

What is Acute encephalitis syndrome

Acute encephalitis syndrome is defined as the acute onset of fever and a change in mental status

Symptoms

• Confusion
• Disorientation
• Inability to talk
• Coma, seizures

Clearly a pressing public health emergency in India, it is characterised by high case-fatality rate. The disease occurs in seasonal outbreaks every year, taking a heavy toll of life, especially on kids below 15 years.

Toxic litchi link 

• Strong association is suspected between AES deaths in Muzaffarpur and the presence of a toxin in locally produced litchi
• At risk are poor malnourished children who consume litchi empty stomachs in the evening 
• They fall victim to low blood sugar by wee hours, leading to death in absence of timely care

44,000 cases between 2008 and 2014

6,000 deaths particularly in UP and Bihar

18 states/UTs where outbreak reported since 1978

1st outbreak in 1978

• In Uttar Pradesh, first report of an epidemic was in 1978, with over 3,500 cases and 1,100 deaths 
• Epidemics continue to date and JE vaccine was introduced in National Immunisation Programme in 2014
• But not all AES deaths (Muzaffarpur deaths for instance) are caused by the JE virus