A child arrives at a hospital with Acute Encephalitis Syndrome as family members react,
in the Muzaffarpur district of BiharWith the death of 53 children due to encephalitis in the Muzzafarpur district in the state of Bihar in India in the last 10 days, the scourge of this viral disease has re-erupted, raising serious concerns about its recurrent nature.
Between 2008 and 2014, there have been more than 44,000 cases and nearly 6,000 deaths from encephalitis in India, particularly in the states of Uttar Pradesh and Bihar, according to ‘Acute encephalitis in India: An unfolding tragedy’ by Jai Prakash Narain, A. C. Dhariwal, and C. Raina MacIntyre published in the Indian Journal of Medical Research (IJMR).AF
In 2016, there was a rise in encephalitis, with over 125 children reported to have died in one hospital in Gorakhpur in Uttar Pradesh alone.
The state of Bihar, particularly the Muzaffarpur district, has been reporting cases of acute encephalitis among children since 1995, the paper says.
Gulf News takes a look at the cause, symptoms and treatment of this viral disease.
What is it?
Encephalitis is an inflammation of the brain and a viral infection is the most common cause. Bacterial infections and non-infectious inflammatory conditions also can cause encephalitis.
Encephalitis can be life-threatening if it is not detected in time and prompt treatment administered. A majority of cases happen in children and the elderly and individuals with compromised immune systems.
The first major epidemic caused by JEV was reported from Burdwan and Bankura districts of West Bengal in 1973 followed by another in 1976. In the 1973 outbreak, 700 cases and 300 deaths were reported.
In 1978 and thereafter, outbreaks were reported from 18 States and Union Territories.
The most devastating outbreak was in Gorakhpur district in 2005; 6,061 cases diagnosed with 1,500 of those infected dying. It was followed by further outbreaks in 2006 and 2007, with 2,320 cases and 528 deaths and 3,024 cases and 645 deaths, respectively.
India launched a JE vaccination programme in 2006, which in 2014 became part of the National immunisation programme.
However, outbreaks across the country have continued.
In 2011, for instance, there were 147 cases and 54 deaths in Bihar. In the following year, 469 cases and 178 deaths were reported from health facilities with CFR of 38.6 per cent.
In 2016, 11,651 cases and 1,301 deaths were reported to the National Vector Borne Diseases Control Programme (NVBDCP).
Most deaths were from Uttar Pradesh, followed by West Bengal, Assam and Bihar.
In 2018, 10,485 AES cases and 632 deaths were reported from 17 states to NVBDCP, with a case fatality rate of around 6 per cent. These cases were reported mainly from Assam, Bihar, Jharkhand, Karnataka, Manipur, Meghalaya, Tripura, Tamil Nadu and Uttar Pradesh.
Most people who contract encephalitis exhibit symptoms of flu such as:
- Muscles or joints aches and pains.
- Fatigue or weakness.
There are more severe symptoms that include high fever, confusion, drowsiness, hallucinations, slower movements, seizures and irritability.
Researchers also said more study was needed to uncover the cause of the illness, which leads to seizures, altered mental state and death in more than a third of cases.
Outbreaks of neurological illness have also been observed in lychee-growing regions of Bangladesh and Vietnam.
What are the signs in children that suggest they may have this viral inflammation?
• Bulging of the soft spots (fontanels) of an infant’s skull
• Nausea and vomiting
• Body stiffness
• Poor feeding or not waking for a feeding
Encephalitis occurs in two types
Primary encephalitis: This involves a virus, fungus or bacterium directly infecting the brain. It could also be that the infection may be a reactivation of the virus after a previous illness.
Secondary encephalitis: This can occur due to the immune system responding to a previous infection and mistakenly attacking the brain. Secondary encephalitis often occurs two to three weeks after the initial infection.
Causes of encephalitis
There are different causes for various types of encephalitis:
Common viruses, including HSV (herpes simplex virus) and EBV (Epstein-Barr virus).
Childhood viruses, including measles and mumps.
Arboviruses (spread by mosquitoes, ticks, and other insects), including Japanese encephalitis, West Nile encephalitis, and tick-borne encephalitis.
People living in regions or areas in countries that are mosquito-or tick prone are susceptible to encephalities. Summer and the onset of monsoons are also the times of the year that are more likely to trigger the onest of encephalitis.
Treatment will depend largely on age and condition, as well as the form and cause of the disease. If encephalitis is due to a bacterial infection, it can be treated with intravenous antibiotics. Treatment for herpes-related encephalitis includes supportive care, as well as intravenous antiviral therapy with drugs. Other treatments may be used to lower fever, provide hydration, treat seizures if they develop, and reduce any pressure in the skull.
Can you prevent it?
The best form of prevention is to take all precautions to avoid exposure to the disease-causing viruses.
Practice good hygiene. Wash hands frequently and thoroughly with soap and water, particularly after a visit to the toilet and before and after meals.
Don’t share personal items such as utensils, tableware or drink from the same glass.
Ensure all vaccinations for your infants and children are administered on time. Enquire with your treating doctor about vaccinations for countries that may have potential conditions for encephalities.
Protect yourself and your childen fully from mosquitoes and ticks by full-body clothing and avoid going near any stray animals and places where the mosquito population thrives such as water bodies, stagnant ponds, pools of water, etc.
Keep your suroundings clean and sanitised. More importantly, keep surroundings dry around your house or garden or plants so mosquitoes and insects do not breed.
Stay indoors after sunset.
Sources: Mayo Clinic/kidshealth.org/medicalnewstoday
Dr. Chelladurai Pandian Hariharan, Specialist Neurosurgery, Aster Hospital, Qusais
What is the cause for the repeated outbreaks of encephalitis in India?
Outbreaks of encephalitis in India have a strong seasonal pattern and a limited geographical range. It is basically an endemic disease that means the disease causing virus are prevalent to that geographical location and its intensity and the virulence gets changed with the climate.
Japanese encephalitis Virus - commonly caled JE virus - is transmitted to humans through bites from infected mosquitoes of the Culex species. Humans, once infected, do not develop sufficient viraemia to infect feeding mosquitoes. The virus exists in a transmission cycle between mosquitoes, water birds and animals. The disease is predominantly found in rural and suburban settings, where humans live in closer proximity to these vertebrate hosts. JEV is transmitted mainly during the warm season, when large epidemics can occur.
Year after year the poor hygienic status, water scarcity and the increase in number of the rodent population help to maintain the virus population in the community.
The immunity status of children is very low thereby making children more susceptible to this.
What can be done to prevent these outbreaks?
Health care providers need to address at the primary level.The preventive measures are directed at reducing the vector density by fogging , control of the mosquito breeding areas by the primary level health care workers and educating the public in taking personal protection against mosquito bites using insecticide and mosquito nets. The reduction in vector mosquitoes breeding places needs eco-management, as the role of insecticides is limited. Pig and animals should be be kept away (4-5 kms) from human dwellings. Locally practising physicians should be made aware about the increasing cases of the infectious diseases to detect at an early stage . Government needs to address the increase in demand for emergency medicine services such as urgent and ambulatory care .
Expanded surveillance activities should be carried out.
The best way to prevent viral encephalitis is to take precautions to avoid exposure to viruses that can cause the disease. Wash hands frequently and thoroughly with soap and water, particularly after using the toilet and before and after meals.
Make sure they practice good hygiene and avoid sharing utensils at home and school. Keep your own and your children’s vaccinations current. Before traveling, talk to your doctor about recommended vaccinations for different destinations.Live attenuated SA-14-14-2 vaccine against Japanese encephalitis (JE) was introduced in the routine immunization under Universal Immunization Program in the 181 endemic districts of India. Recently, the Government of India has announced the introduction of one dose of JE vaccine for adults in endemic districcts
Protection for young children
Insect repellents aren’t recommended for use on infants younger than 2 months of age. Instead, cover an infant carrier or stroller with mosquito netting.
For older infants and children, repellents with 10 to 30 percent DEET are considered safe. Products containing both DEET and sunscreen aren’t recommended for children
Children, the elderly, and those with a weak immune system are most vulnerable.So they are affected more.
What is considered timely intervention for treatment?
Timely intervention is getting a medical opinion as early as possible hen you get any of these signs, Proper health education and supportive care management can give a better outcome at the early stage.
Fatality cannot be exactly assessed, but we can assume around 10 - 30 per cent, because it varies with the virus, age, immune factors. Encephalitis is a serious neurological condition and unfortunately, despite improvements in specific and more supportive treatments such as excellent intensive care management, it still has a high mortality (death) rate.Some forms of encephalitis are more severe than others. For example, herpes simplex encephalitis (HSE) has a mortality rate of up to 30 per cent even with specific anti-viral treatment, and 70-80 per cent without the treatment.
Most children recover completely. In a smaller proportion of patients with severe illness, they may end in coma or death. In some cases the survivors may have:
• Persistent fatigue
• Weakness or lack of muscle coordination.
• Personality changes.
• Memory problems.
• Hearing or vision defects.
• Speech impairments.
Are vaccinations an effective way to combat this?
Nowadays encephalitis due to measles, mumps and rubella have been nearly abolished with vaccinations, now what we are getting are due to recently detected viruses like JE, Chandipura virus, nipah virus, for which vaccination only available for JE. The elimination of smallpox and the use of vaccines against mumps, measles, and rubella have reduced the incidence of encephalitis, especially in children.
Is it correct to say that children who survive may end up with neurological weaknesses?
No, many people who survive, recover without any much deficits. However, those who have severe disease may end up with some neurological consequences.
Social media reactions
As the death toll increases in the Indian state of Bihar due to an encephalitis outbreak, panic has gripped the state and the issue is being widely talked about online.
Many shared images from hospitals filled with ill children and distressed parents.
Twitter user @MukulAdhikary5 posted a picture and wrote: “A child showing symptoms of Acute Encephalitis Syndrome (AES) being shifted to a hospital in Muzaffarpur.”
Others like user @RishiKNagar posted update about the epidemic: “India: 36 children died in Bihar’s Muzaffarpur district in the last 24 hours. 133 children are admitted to hospitals due to suspected Acute Encephalitis Syndrome (AES). The doctors said many of the deaths were due to hypoglycaemia, a condition caused by very low level of blood sugar.”
This is not the first time India has had an emergency related to encephalitis. In the past, the infectious disease has taken lives of many in Uttar Pradesh and Bihar.
Twitter user @Sinha_Nagmani questioned why precautions have not been taken to avoid such tragedies in the first place: “Kids death of encephalitis in Bihar or anywhere in India. Why do we wake up after massive causalities? Planning may also be done prior, these cases always occur during rainy season in Bihar and reasons are also known but... I wish people start early and be proactive.”
Tweep @rahulvats199 had similar concerns over the reoccurring issue: “Alarming! ... Every year during summer time, especially in the season of luscious fruit litchi, AES outbreak gets reported and takes the lives of children in the district.”
Parents in UAE react
We asked Indian parents in the UAE if they were aware of the issue and what precautions they take when travelling to the home country during summer break.
Acute Encephalitis Syndrome outbreaks
In India, AES outbreaks have become a routine in summer in and around flood-prone north Bihar districts, where the disease is locally known as “Chamki Bukhar” or “Mastishk Bukhar”.
It is a severe case of encephalitis transmitted by mosquitoes.
According to doctors, high temperatures during summer, along with humidity more than normal, is considered to be an ideal situation for the outbreak of AES. It is characterised by high fever, inflammation of the brain, vomiting, nausea, and unconsciousness.
Indian mother Chitra Bhatia, 37, is aware of the disease and says she is extra careful while travelling to India during monsoons. She said: “I try to keep my six-year-old son indoors as much as possible if I am visiting India during the rainy season.”
But, that’s not it. Just before travelling to India, she makes sure her children are given flu shots. Chitra, who also has a six-month-old baby, takes enough water from Dubai to last her children till they reach home in Mumbai. She said: “Once we reach, I give them water that has been boiled and cooled.”
To avoid diseases that spread through mosquito bites, she uses insect repellents. She also added: “I dress the children in clothing that covers their arms and legs. And, we avoid being outside at dawn and dusk, when mosquitoes are most active.”
During summers, Chitra said the family uses air conditioning if available.
UAE-based mum, Amrita Vidyarthi, 38, avoids travelling in extreme weather altogether. Additionally, she said: “Appropriate clothing is essential to keep the children from feeling too hot or too cold. I mostly prefer fully covered clothes when we go out in India to avoid insect bites and use insect repellant creams.”
Amrita said one of her main concerns is hygiene in public toilets, including malls and diseases spread by mosquitoes and other insects. She said: “Sometimes you have to travel to India irrespective of disease outbreaks. So I don’t always do research on this, such as AES but I take care of hygiene. I prefer bottled water, however, if we are visiting someone, I don’t have an option. As for food, I avoid giving children street food and give them freshly cooked food at home.”
Immunity and shots
Amrita ensures her children get annual flu shots. However, Jaishree Jaiswal, another Indian mother based in Dubai takes her preparation a step further. Not only does she read up about health-related news in India before travelling, but also, always takes her daughter to the doctor to find out what vaccination needs to be taken. She said: “Last time we travelled there was dengue, so I read about what preventive actions I could take. I found out that neem oil and neem leaves keep mosquitoes away. We even called the local municipality to spray medicines to keep the mosquitoes away.
“I give importance to vaccinations and herbal medicines and keep myself updated with home remedies to tackle such situations.”
Jaishree, who is a 46-year-old tutor in Dubai said that her preparations begin a month or two in advance from the scheduled date of travel. She said: “I start giving my daughter supplements such as B12 and omega-3 to boost her immune system, a month or two before we travel. If the child’s immune system is strong, chances are they will be safe from diseases.”
Additionally, Jaishree who travels mostly to Nagpur and Mumbai, tries to make sure her daughter drinks only boiled and clean water and keeps her from eating street food from road-side hawkers.