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Situation in Gorakhpur's BRD medical college hospital is past the stage of prevention

Only this June, NITI Aayog painted a grim picture before UP Chief Minister Yogi Adityanath of the state’s health parameters.

Updated: Aug 21, 2017, 01.07 PM IST
Over 98 lakh children across Uttar Pradesh were vaccinated against Japanese encephalitis in the past three months.
Over 98 lakh children across Uttar Pradesh were vaccinated against Japanese encephalitis in the past three months.
It’s not unusual to find two children with a deadly viral infection sharing a bed in the 210-bed paediatric wing of Gorakhpur’s Baba Raghav Das Medical College hospital, especially in “Ward No 12” that’s meant for 110 encephalitis patients. The wing is usually filled up to twice its capacity. Add to this a couple of attendants for each child overcrowding the ward and contributing to the spread of infection, non-functional air-conditioning and a lack of doctors to cater to the steady stream of admissions and it’s not surprising that BRD hospital’s paediatric wing reports one of the highest mortality rates in the country.

The country woke up to the tragedy of child deaths at BRD hospital, western Uttar Pradesh’s only major health facility, on August 11 after 30 deaths over two days, allegedly due to disruption of oxygen supply for a couple of hours over outstanding dues of Rs 68 lakh. However, 34 more children died on August 14 and 15 – even after all the attention on the hospital – implying the issue is far bigger and intrinsic to the state’s failing health parameters.

Acute encephalitis syndrome (AES), caused by various reasons including contaminated drinking water, results in 500-650 deaths at the hospital every year. UP reported 152 AES deaths as of August 13, a majority at BRD hospital, and 1,208 cases of AES. Last year, UP reported 621 deaths from 3,919 cases of AES. Although the incidence of AES is high in five states including Assam and Tamil Nadu, UP reports the maximum deaths from the disease.

Children are most susceptible to AES as they have lower natural immunity, said doctors. It is fatal in case early treatment is not available and at least 20 per cent of children with AES die, according to them.

Only this June, NITI Aayog painted a grim picture before UP Chief Minister Yogi Adityanath of the state’s health parameters. The government thinktank cited the National Health Family Survey of 2015-16 to show UP had one of the worst infant and child (under 5 years) mortality rates in the country at 64 and 78 deaths per 1,000 live children, respectively. This was even worse in rural UP, where child mortality was as high as 82 per 1,000. The presentation by NITI Aayog CEO Amitabh Kant said there were only 0.7 doctors in UP for every 1,000 people and total bed density was 1.5 for 1,000 people. The state’s 29 districts figured among the 100 worst in the country requiring transformation on health parameters. Premature children dying in the neonatal ward of BRD hospital as well as other major UP hospitals due to non-AES causes was extremely high, too, exemplifying the situation.

The primary concern for the state, however, is AES, the biggest killer. The syndrome is difficult to diagnose because it has a multitude of causes, said doctors and researchers. There is a vaccine for Japanese encephalitis, one of the major causes of AES. However, there is no cure and the only option that medical practitioners have is to provide “supportive” care to help patients tide over the symptoms, they said.

“The only sure-shot method for stopping mortality by AES is by prevention. Gorakhpur is past the stage of prevention, so the only solution would be to get the children to the hospital quickly so that they can get supportive treatment,” said Raghuram Mallaiah, director and head of the department of neonatology at Fortis La Femme, the woman and child arm of Fortis Healthcare in New Delhi. There needs to be good medical and nursing care and properly equipped wards to manage these people, he said.

Encephalitis is a condition that causes inflammation of the brain. Hundreds of bugs could cause AES, said Mallaiah.

“A lot of times, the diagnosis itself is difficult and the only way we can do it is through a tap from the spinal cord… Even then, the exact virus may be difficult to isolate. Most of the treatment would be empirical – we presume it is a form of viral encephalitis. You can give them anti-viral medication but the chances of them making a huge deal of difference are very low,” Mallaiah said.

According to him, most affected children should get better unless they have reached the hospital very late. “Then there’s not much you can do because the virus would have spread to other parts of the body as well,” he said. Hence, district health centres are crucial.

Under Adityanath, the state government has tried to correct the situation. Paediatric deaths at BRD have come down this July and August from last year. A central team of doctors found 134 deaths were reported at BRD for August 1-12 this year compared with 138 deaths a year earlier. The death count at BRD was 200 in July, lower than 292 in the same month last year

Over 98 lakh children across the state were vaccinated against Japanese encephalitis in the past three months. The government is trying to spruce up facilities for treatment of AES at public health centres and community health centres in each district so that people from the 38 worst-affected districts by AES do not have to travel all the way to Gorakhpur’s BRD for treatment.

In a first for the state, a government paediatrician from each district was brought to BRD two months ago for a week-long training on treating AES. The emphasis was on starting treatment early, stopping the virus from reaching unmanageable proportions and saving the child’s life.

Anirban Basu, professor at the National Brain Research Centre in Manesar who has studied AES for years, said there seems to be a difference this year.

“Besides the Gorakhpur incidents, deaths due to AES are far less than the previous years. This could possibly be because of the government push on the Japanese encephalitis vaccination,” Basu said. “Another possibility is that social activities by clinicians in these regions to raise awareness and give urgent treatment to AES patients has also been paying off… It all depends on how quickly you can get them initial supportive treatment.”

While there is no cure, the drug minocycline has shown promise in treating AES symptoms such as inflammation in the brain, according to Basu. Currently, the UP government has prescribed the use of another drug, doxycycline, in AES patients, he said.

A clinical trial on 281 patients in Lucknow in 2012-13 showed “modest” benefits from taking minocycline, according to Rashmi Kumar, head of the department of paediatrics at King George’s Medical University in Lucknow, who conducted the tests.

“Given the number of encephalitis patients every year, even a modest benefit is worth cashing on,” she said. The government is yet to be convinced about the efficacy of the drug. Basu said nobody knows for sure how many bacteria, viruses and fungi are responsible for causing AES.

“From recent evidence, even dengue could cause encephalitis syndrome. In Gorakhpur, the (predominant) encephalitis was at one point Japanese encephalitis alone, but over the years this has changed. Other causes include Scrub typhus and other viruses, bacteria and fungi,” Basu said.

A 2016 Indian Council of Medical Research study suggested mite-borne bacterial disease Scrub typhus – and not Japanese encephalitis – was the cause of a majority of AES cases in Gorakhpur. But why does Gorakhpur have such a high number of deaths?

“Patients come from far-f lung villages. This time, there were reportedly patients from even Bihar,” said Basu. “If you have to transport patients from farflung, remote villages in public transport, they are eventually in a bad shape when they reach the hospital. In bigger cities, when someone is infected, they can reach the hospital on time. That is not the case in these regions.”

If the patient comes early, supportive treatment can start early, according to Mukesh Agrawal, head of the department of paediatrics at KEM Hospital in Mumbai.

“A lot of times, patients who come are severely dehydrated, they have visited 2-3 hospitals already and present symptoms like convulsions. Late detection and treatment is a big factor in these deaths. This is a disease where, at present, no treatment is known. Adequate attention is required to each patient. Most require ventilator support and intensive care beds,” Agrawal said.

The situation is expected to turn for the better in 2019, by when a new 500-bed paediatric wing spread over 12 floors is expected to come up in BRD hospital and an All India Institute of Medical Sciences will start functioning in Gorakhpur. The Centre has sanctioned a full-fledged regional research centre to come up with a vaccine for AES. These measures are expected to take the load off the paediatric department at BRD.

What is most required is a cleanliness campaign – the chief minister himself is expected to kick off one in Gorakhpur on Saturday. An inquiry team was shocked last week when it spotted garbage piled up right outside the paediatric wing, attendants waving hand-fans for children in the AES ward as the air-conditioning was not working and taking a bath outside the ward using pipes attached to taps in the absence of any facility for accommodation.

For a disease that spreads due to contaminated water, the source of infection is present at the ward’s doorstep itself.
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