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LATEST NEWS UPDATES | Children deaths in Gorakhpur: A dissolving faith, an enduring mystery -Pritha Chatterjee

Children deaths in Gorakhpur: A dissolving faith, an enduring mystery -Pritha Chatterjee

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published Published on Sep 23, 2013   modified Modified on Sep 23, 2013
-The Indian Express


In Gorakhpur, small successes in understanding - and conquering - the killer disease of children are undercut by a wily virus and administrative bottlenecks

Gorakhpur: On August 18, five-year-old Vishal spent the evening playing with friends in Vanjhai village in Gorakhpur district's Bhathat block. He came home irritable, with a slight fever. His mother and grandmother gave him a little milk and sent him to bed. They were not worried, because Vishal, like most children in the village, was "protected".

Three years ago, Vishal had been given two shots, separated by four months, of "jhatki teeka", or the Japanese Encephalitis (JE) vaccine. The first shot, given in August 2010, was part of the child's immunization schedule; the second, in December of that year, in a massive campaign across Uttar Pradesh and parts of Bihar, to ensure the vaccine reached all "left out" children.

Vishal's mother, who had seen children dying in their village during the monsoon - deaths long attributed to the dreaded JE virus - was assured that her son was protected.

So, when Vishal woke up the next morning with a jhatki - convulsions with a yellowish frothing at the mouth, fists clenched and eyes shut tight, seemingly unable to hear his mother's cries - the family went to the local fakir, hoping he would rid the boy of the spirits they believed had attacked him.

A day later, when Vishal was struck by another convulsion, his uncle took him on his motorcycle 15 km away to Gorakhpur town, ignoring the women's protests that he already had "jaadui" protection and needed no more medicines. The boy was admitted to the Nehru Hospital in BRD Medical College, where he died the next day.

Vishal's bewildered grandmother still can't understand why the boy had to die. "Usko to teeka laga tha. Do-do teeka laga tha, toh phir jhatki kyon aaya?" she whispers over and over again.

Vishal's was one of the five confirmed JE cases in Gorakhpur this year. The adjoining districts saw another 20 cases. Besides one deceased girl whose family had persistently refused vaccination, all the dead children had been given the protective shots.

***

In Nehru Hospital, two or three children share a bed and overworked doctors struggle to attend to cries that break out almost every minute from all parts of the epidemic ward. In the adjoining ICU, two skinny children are on ventilator support, multiple IV lines in their small bodies, with cardiac monitors beeping every now and then as a fresh emergency hits their vitals.

Since January 1 this year, over 1,000 children have been admitted to the hospital and 258 have died, with the same classic symptoms - high fever, convulsions, altered sensorium, rigidity in the limbs and nausea - now associated with Acute Encephalitis Syndrome (AES). Only 61 of these children were found to be JE positive.

A total 226 admissions and 59 deaths have been from Gorakhpur, and 248 cases and 43 deaths from Kushinagar. These have been the two worst affected districts this year. In all of this, Gorakhpur has seen five JE cases and Kushinagar eight.

***

Until the mid-2000s, it was JE that was considered the annual mysterious killer of children and early teens in the Purvanchal belt of eastern UP and Bihar. Now, a decade later, it has been crossed off as a "minority disease" by scientists. The doubts over JE which started arising from 2006, and saw some vindication in 2009, have been confirmed "to a great extent" now.

Of 1,000 samples of cerebrospinal fluid (CSF) collected from children admitted between April and December last year to Gorakhpur's BRD Medical College, 100 isolates for organisms called Entero Viruses (EV) - specifically the human EV 89 and EV 76 types - have been identified by the National Institute of Virology (NIV) field station in Gorakhpur. A 10 per cent positivity is considered a huge success for CSF samples. These viruses spread through contaminated water, and can cause symptoms similar to JE, and are covered under the umbrella of diseases that constitute AES. The JE virus, which causes similar symptoms and is also included under the category of AES diseases, has a completely different route of transmission: it is hosted in pigs, water birds and other livestock, and is carried to humans by mosquitoes.

These findings have been heartening for scientists who were initially reluctant to accept the EV theory due to contradictory results between rectal swabs and CSF samples - considered the more direct evidence of brain tissue - until 2011. From 2008-11, while rectal swab samples showed a 15- 44 per cent positivity for EVs, CSF samples from the same patients showed positivity rates of between 1.8 per cent and 2.3 per cent.

Dr Milind Gore, director of NIV Gorakhpur, who has headed the station's activities since 2006, said, "There were initial doubts that the virus strands which we were identifying in the rectal swabs were not traversing to the brain tissue, since we could not collate them in the CSF samples. To counter this theory, in 2012, we only tested for CSF samples and put them through rigorous testing, and we have managed to identify 100 isolates of enteroviruses. For us, it's a huge boost, since it's coming from hard primary evidence."

The first doubts about JE started after deaths continued despite exhaustive mass immunization campaigns, and lab results provided no concrete answers. In 2006, despite JE vaccinations, 700-800 seizures were reported, and over 150 children died. Most of these children had received JE vaccination. The mystery remains to be fully explained.

***

This year, six per cent of cases are JE positive, and about 10-15 per cent EV - which leaves the vast majority of cases still undiagnosed. "We are trying to identify the causative agents in all samples, but there are other factors that need to be considered. The causative agent is the most active in the CSF samples only within the first 2-3 days of onset. A majority of children are coming to us late, and hence we are losing out on identifying the pathogens there," said Dr K P Kushwaha, principal and head of the department of paediatrics at BRD Medical College.

Unlike bacteria, viruses need active cell lines to multiply for scientists to examine them. "Earlier we were using only one such cell line, now we are hoping that more viruses will multiply in our laboratories. We have identified isolated cases of measles and herpes viruses, but not in considerable numbers. We are trying to lay our hands on something more, but so far we have not been successful," Dr Gore said.

He adds that even in the best diagnosed international outbreak situations, only about 50 per cent of cases are actually diagnosed. "Considering that, we can say EVs have solved at least some of the mystery, though not all of it."

***

As scientists and doctors struggle to get a handle on the three-decade-old disease, many complain that the clinical and administrative management of the outbreaks remains flawed.

In Gorakhpur, the hub of the management of the disease, representatives of the only medical college in the area and district authorities cannot agree on several things.

The hundreds of AES cases that are finding their way into government records are coming only from the one medical college and district hospitals in the area. The disease is still to be officially declared a notifiable disease like other common viral diseases like dengue - where every case has to be reported.

Said Dr Kushwaha, "All the patients who are coming to us are referrals from private hospitals, and by the time they are coming here, they are already so critical that in the majority of the cases it is too late for us to do anything. Why can't private hospitals report these cases early?" He said this year, only 10 per cent of patients are direct entrants, the rest being referrals from private centres. "The government is losing out on precious data due to this mismanagement."

But district health authorities say there is no monitoring of medical college treatment records, and inflated figures are presented, the definition of AES itself being flawed.

CMO of Gorakhpur Dr M P Singh said, "The unwritten protocol the medical college seems to be following is that any patient who comes with the symptoms of fever, nausea and altered sensorium is declared AES, without waiting for laboratory results. Later, if any of these patients tests positive for malaria, typhoid or meningitis, the case records are not changed. They just put it down as AES with any of these other diseases. This is an absurd situation, where eventually you are diagnosing the disease, but still declaring it as AES."

Dr Singh said that last year, of the eight cases that the medical college declared JE positive, repeat tests on six showed only three to be actually positive. Cases are being reported round the year - 18 cases came in April, many of children under the age of one year.

"How can a child below the age of one have AES which they say is from EVs? A child that young only has mother's milk, so what is the source of contaminated water?" he asked. He said district health authorities had, after "umpteen reminders", managed to access treatment records of deceased patients this year, and were studying them.

The medical college, overwhelmed by the number of patients and the shortage of doctors, has other concerns.

"In 2010, the government had sanctioned immunoglobulin injections which cost over Rs 1 lakh for every patient, but which, in a trial at AIIMS, were found to reduce mortality in AES. In our experience, we found it helps where there are cardiac complications in non-JE AES cases. Later, however these injections were discontinued because the government found it difficult to manage the costs," said Dr Kushwaha.

This year, hospital authorities have forwarded requests to the state health department for permission to resume these injections.

Meanwhile, caught in the tussle, some long-promised facilities are still to come up - a 100-bed AES ward with 25 new ventilators at BRD Medical College, and 10 ventilator-equipped AES wards in district hospitals. Authorities say another month or so will be required. The 100-bed ward is still to get an oxygen supply system, and ventilators are still to be purchased for district hospitals.

***

Over the last six years, Uttar Pradesh and parts of Bihar, including Gopalganj, Sitamarhi, East and West Champaran and Gaya, which unlike Muzaffarpur saw outbreaks of JE, have witnessed massive JE immunization efforts. From 2006-2010, mass immunization campaigns were carried out for children up to 15 years. When cases with symptoms similar to JE persisted, last year one of the JE vaccines was included in the routine immunization programme for children up to 16-24 months old. This year, since April, a second JE vaccine has been added to the immunization list for children of 9-12 months age.

Despite an over-90 per cent coverage of vaccination, a few JE cases have persisted, mostly in children who have been vaccinated for the disease.

Authorities say no vaccine assures 100 per cent protection, but it definitely controls susceptibility. "We cannot go back to examine the samples since 1978, so we don't know if the cases were confirmed JE. But assuming they were, we have achieved considerable success," Dr Singh said.

There are many who say the problem could also be attributed to wasted vials of the vaccine, and false records of vaccination, considering the strict approach of the authorities. In the single case of JE death in Gorakhpur, where the deceased girl's family refused vaccination this year, the auxillary nursing midwife of the area, who was responsible for immunization, has been suspended.

"The vaccine comes in packs of five vials. Each vial costs about Rs 1,500-2,000, and is viable only for two hours after the whole pack is opened. So our health workers are advised to open the packs only when 4-5 children are present, to ensure there is no wastage. But a lot of times our health workers can't manage this, and the vaccines are wasted. False records are inevitable in some cases like these, to escape administrative action," said a medical officer monitoring the immunization efforts.

A preliminary analysis of this year's vaccine usage in Kushinagar district, the worst hit this year, shows 66 per cent of vaccines were wasted, according to sources.

Agencies like the National Institute of Malaria in Bangalore have travelled to affected districts this year and last year to distribute Gambusia and Guppy fish that eat the larvae of the Aedes Aegypti and Culex Bishnoi mosquito, known vectors of JE. Samples have been collected from pigs to monitor any JE infections in them.

***

Have all these efforts been misplaced? With scientists now establishing EVs to be the main problem, the administration finds itself facing the prospect of managing an entirely new disease. What makes matters worse is that unlike JE, which had a known cause and a targeted vaccine, for the hundreds of types of EVs, there is no vaccine yet.

"Till 2005, we did not know properly what we were up against, we were just assuming it was JE. In the last two years, we have some confirmation that it is largely EVs, with very few cases of JE. All we know about EVs is that they spread through water. So that's our only possible direction to control the outbreak," Rigzian Sampheal, district magistrate of Kushinagar district, said.

Water tables are high in the Terai region where the worst affected districts are located. Local surveys show between four lakh and five lakh locally dug handpumps, known as khechu pumps, which are hardly 30-40 feet deep. Almost no one uses the standard government handpumps which go 100 feet under the surface.

"Drinking water here comes from the first strata of the soil, which can be highly contaminated and is not considered potable," said the chief executive engineer of Gorakhpur Nagar Nigam.

New methods like getting all shops that sell pork to get licences under the Food Safety and Standards Act, and trying to build enclosed piggeries with mosquito nets for pigs, are also being explored.

***

Scientists in laboratories, authorities on the ground and doctors in the hospital continue to struggle, celebrating only small successes. Meanwhile, children continue die, and mothers live in fear, with the promised protection the JE vaccination brought their children fast dissolving.


The Indian Express, 23 September, 2013, http://www.indianexpress.com/news/children-deaths-in-gorakhpur-a-dissolving-faith-an-enduring-mystery/1172834/0


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