Did Litchis kill over 100 children in Bihar?

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As the number of fatalities from an Acute Encephalitis Syndrome (AES) epidemic continues to increase in Bihar’s Muzaffarpur district, there seems to be no happy ending to this “National Horror Story”.

Muzaffarpur, a district of  Bihar, has hogged domestic and global headlines this week for all the wrong reasons. The death toll touched 117 on Thursday morning. As per the last released data, the government-run Sri Krishna Medical College and Hospital (SKMCH) recorded a total of 98 fatalities while 19 kids died at the city’s Kejriwal Maternity Hospital, owing to the vector-borne disease. This number was from 8 am on Thursday.

Caught unaware and grossly under-prepared for this epidemic, the state and central governments have now initiated an all-out attempt to control it, even as kids are still being taken to hospitals.

Terms like ‘Chamki Bhukar’, ‘Litchi Havoc’, ‘Deadly Litchi Toxin’ , ‘Killer Encephalitis’, that are being used to report this epidemic point to the dismal methods of investigating  disease in our country. For, it only serves the purpose of headlines.

The cyclic return of Acute Encephalitis Syndrome (AES) or Chamki fever to one of India’s poorest and most malnourished states, Bihar, resulted in 309 kids being hospitalized in Muzaffarpur in June 2019.

Although more than 100 kids have already been healed and discharged from Sri Krishna Medical College and Hospital (SKMCH), the death of 98 kids in the hospital after a four-year gap requires a four-part inquiry into the outbreak inquiry: identification, causation, confusion, and malnutrition.

  • Identification

The features of AES define it as a group of clinically comparable neurological manifestations induced by various viruses, bacteria, fungi, parasites, chemicals or toxins, etc.

Dr. TJ John, former Chairman of the Indian Pediatrics Association (IAP) and Emeritus Professor of Virology at the Christian Medical College in Vellore, called AES “a meaningless term” because “any brain disease in the kid may be called AES.”

He said to the media, “AES is a term used by untrained health workers to say that a child has some brain disease like convulsion, unconsciousness, etc. But when a doctor examines the child, he must conclude which kind of AES disease it is: encephalitis (virus causing brain inflammation), meningitis (swelling of the protective membranes covering the brain and spinal cord), encephalopathy (broad term for any brain disease that alters brain function or structure) or cerebral malaria (severe neurological complication of infection with Malaria)”.

Dr. John said that when a health worker refers to a situation called AES, a doctor must figure out the correct disease between these four primary classifications. One of his many issues is the doctor’s casual usage of the word AES.

  • Causation

Union minister Harsh Vardhan visited SKMCH in Muzaffarpur on Sunday to review the situation.

After finding no fault in the lack of facilities at the hospital, he extended his assistance to the doctors for their effectiveness in coping with the crisis and also promised to set up a “multidisciplinary institute” to “define the reason behind the disease.”

In Muzaffarpur, despite extensive research by specialists from the National Center for Disease Control (NCDC), New Delhi and the Center for Disease Control (CDC), Atlanta (USA), there are two competing epidemic theories: one, triggered by heat stroke, and two, triggered by local fruit toxin, litchi.

The litchi hypothesis was forwarded by Dr. Vipin Vashishtha, a member of the group that researched the epidemic in Muzaffarpur with NCDC and CDC between 2011 and 2013.

He said, “Whether it is a litchi toxin or some mixed illnesses, the deaths have a strong relation with litchi cultivation”.

Indeed, after 2014, the study supplied by two specialist teams to the government had helped to decrease the number of AES instances in Muzaffarpur.

Dr. John, who was also part of an expert group that recognized the epidemic, said that in the pre-Monsoon season between 4 a.m. and 7 a.m., malnourished kids who ate litchis and went to sleep without a meal fell ill.

This research officially developed a relationship between hypoglycemia or low blood sugar observed in kids who sleep hungry with poor nutrition and methylene cyclopropyl-glycine (MCPG), a toxic substance discovered in litchis that impacts the brain owing to undernourishment.

But in 2019, this entire narrative has changed.

  • Confusion

Dr. Gopal Shankar, the acting HOD of the SKMCH, discredited previous theories, claiming that deaths occurring due to “ acclimatization failure in children” are instead caused by “environmental factors” such as poor rainfall in the area and the heat wave.

He said, “Earlier people thought that an outbreak is caused by a virus. But it is a case of heat stroke causing these deaths. In the years 2005, 2011, 2013, 2014 and 2019, when temperature and humidity were recorded over consecutive days at more 38 degrees Celsius and 50 percent respectively, the epidemic had been at its worse with over 700 dying in 2014 alone”.

Dr. Shankar added that there is fluctuation in temperature and humidity in other areas of northern India, and the evenings are cooler, but the humidity in Muzaffarpur rises at night, making it worse than the day, particularly for kids.

He added that the only solution for this epidemic was rainfall. “When it rained a few days ago, the next day there was a decrease in the hospital’s amount of AES patients. Now the numbers are increasing when it hasn’t rained,” he said.

Refuting the litchi hypothesis, Dr. Shankar asked if during the years when there were no AES instances in Muzaffarpur, had individuals stopped eating litchis. He added, “Sick children also do not have symptoms of abdominal pain to prove the litchi theory”.

Interestingly, in a journal article in 2014,Dr.Vashishtha had presupposed the return of the AES epidemic where he argued in favor of the dismal state of the Muzaffarpur outbreak investigation.

He described that investigation as “five blind people describing an elephant” and said, “The problem is, each team starts with a fixed mindset and looks for some ineffective pathology behind every outbreak. There is a lack of coordination and synchronization of efforts, and ultimately they waste their energy either duplicating the efforts of others or pursuing a different approach unmindful of other’s accomplishments”.

  • Malnutrition

Speaking to a media channel, Dr. Arun Shah, a resident of Muzaffarpur and former president of IAP in Bihar, who was part of the Epidemic Advisory Task Force, said, “The human angle has always been ignored. It is criminal to say that the deaths are not a case of AES. These deaths have had the same symptoms from the past two decades. Poor, malnourished children stay hungry and they pick up to eat anything they find in the gardens like litchis. The government in Bihar is trying to divert the issue of malnutrition instead of taking it up seriously.”

He added that the “time-lapse factor” or time taken to reach a primary health center (PHC) is also a problem for the needy, and sometimes the accessibility of treatment.

Adding, “Children suffering from fever and convulsion early in the morning are brought to health centres after 6-8 hours. Some children are safe because they reach on time, while the rest attempt to make it to the nearest government hospital, thus reducing the chance of survival.

Those who survive are so poor that they cannot go to the physiotherapist. The government is insensitive not to look after these children.”

According to Dr. Shah, the deaths occurred in 2019 even after his team gave the government guidelines not to allow children to go out a lot in the summer, to provide them with a meal before sleep, and to prepare supplies and training for PHCs to provide intravenous glucose in the event of an attack.

On Monday, the National Human Rights Commission (NHRC) sent notices to the Ministry of Health and Bihar government about children’s growing fatalities in Muzaffarpur.

India’s apex rights body has sought a report on “not just vaccination, but all precautionary measures like cleanliness and hygiene.” The NHRC has noted that the epidemic is a case of the victim children and their families being violated by human rights.

The rights panel in a telling statement said, “The state appears to have failed to protect the young innocent lives”.

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