Fever stalks UP

Battling Japanese encephalitis virus, Gorakhpur now has a new enemy: enterovirus
Fever stalks UP


It’s four months now. Baba Raghav Das Medical College (BRDMC) in Gorakhpur has been brimming with children. Most are unconscious. Many have drip needles pierced through their skinny arms and legs. Their parents line the hospital corridors, eating, sleeping, weeping and some even defecating.

A stink fills the air in the corridor that leads to the epidemic ward of the hospital where critical children are kept on ventilators. Each bed is shared by two or more children. Seven wards in eastern Uttar Pradesh’s biggest referral hospital for brain fever cannot accommodate the patients pouring in.

On half a bed lies eight-year-old Saurabh. Suffering from high fever for the past 10 days, he was shifted to the hospital’s intensive care unit after he lost consciousness.

In the past four months, brain fever has claimed lives of 426 children in eastern Uttar Pradesh. Seven districts in the region—Gorakhpur, Kushinagar, Maharajganj, Deoria, Basti, Sant Kabir Nagar and Siddharth Nagar—have been battling brain fever for the past three decades. More than 1,000 children succumbed to the disease in 2005. The government, which had identified Japanese encephalitis as the cause of the epidemic, launched two vaccination programmes in 2006 and 2010. It failed to control brain fever. Following the recent outbreak in Gorakhpur, Union health minister Ghulam Nabi Azad visited the district and said brain fever due to Japanese encephalitis virus had been controlled. “Enterovirus is causing most deaths now.” Enterovirus attacks the brain and permanently destroys its cells, killing the patient through multiple organ failure or leaving him physically or mentally handicapped.

The model village
  Since 2003, Holiya village in Kushinagar has seen five deaths and four cases of handicap due to Acute Encephalitis Syndrome (AES).

In 2007, 15-year-old Sanju survived the viral infection but could not recover fully. She was unable to move her limbs, her speech was impaired and she would scream for no reason. After months in hospitals, she can now walk. But her arms are still stiff and speech is affected.

Another victim is Shailesh, a standard III student. Like Sanju, his arms are also twisted and speech is impaired. His ability to learn and understand in the classroom is poor. He often cries in school.

People in the village figured out how to fight the disease. They got rid of stagnant water, opened clogged drains and spread awareness.

In the battle to save their children, they improved the methods of sanitation and hygiene with help from R N Singh, a paediatrician from Gorakhpur. They collected water from handpumps sunk by government. This water, when stored in buckets, covered with white cloth and kept under the sun for six to eight hours becomes good for drinking. “The ultra violet rays of the sun kill the virus,” says Singh.

Parents were also asked to make their children wear full sleeves clothes, use mosquito nets at nights and ensure they did not go near paddy fields. With these basic preventive measures, Holiya did not get any case of AES this monsoon.
Doctors get confused while diagnosing whether brain fever is caused by Japanese encephalitis virus or enterovirus. Initial symptoms of both are similar—high fever, vomiting, unconsciousness and seizure. Both are mostly seen in children because of their low immunity. The only symptomatic difference is that the fever caused by enterovirus stretches up to 15 days as against Japanese encephalitis which lasts about a week.

That’s why doctors have classified all brain fevers under Acute Encephalitis Syndrome (AES).

Enterovirus has taken over Japanese encephalitis virus since 2006. “Till 2005, 30 per cent samples tested positive for Japanese encephalitis virus in Uttar Pradesh. This has been only six per cent following the vaccination programme,” says K P Kushwaha, head of BRDMC’s paediatric department. He has been instrumental in highlighting the prevalence of enterovirus. Lab tests by Sanjay Gandhi Post-Graduate Institute of medical sciences in Lucknow and National Defence Lab in Gwalior confirmed this.

NIV non-committal

Despite this, scientists at the National Institute of Virology (NIV), the apex body to test pathogens in the country, are reluctant to say enterovirus afflicts the state more than Japanese encephalitis virus. The reason perhaps is its own test results. NIV conducts two tests to detect the virus. The first tests the cerebrospinal fluid (CSF), that is the fluid of the spinal cord, as the virus reaches the brain through it. The second tests rectal swabs. For three consecutive years NIV tested CSF and rectal swabs of brain fever patients. Results showed a big disparity. The rectal swab showed 15.4 per cent positive cases in 2008, 34.5 per cent in 2009 and 43.7 per cent in 2010. But CSF, the more credible test, showed positive in two per cent cases in 2008, 1.8 per cent in 2009 and 2.3 per cent in 2010.

“We are not sure if the enterovirus found in the gastro track is the one which reaches the brain,” says Ashok Pandey, scientist at NIV, Gorakhpur. Not all enteroviruses can penetrate the multiple protective layers of the brain. There is a possibility that the brain fever is caused by other viruses, he adds.

The situation is grim because there is neither a vaccine nor any treatment for enterovirus, says R N Singh, a paediatrician in Gorakhpur. To develop a cure, scientists must identify the virus prevalent in the region. “This is difficult as there are a hundred viruses under the enterovirus group,” says Milind Gore, officer-in-charge of NIV. In 2007, NIV identified two enteroviruses—EV 76 and EV 89. A team from the Centres for Disease Control and Prevention, Atlanta, confirmed their presence in a paper published in 2009. But they are not sure if these cause brain fever.

The way out

Given the high cost, time-consuming procedures and a stringent licensing procedure, government has made little investment in research. “The only way out now is prevention,” says Singh. While mosquito bites transfer Japanese encephalitis virus to the victim, enterovirus enters the body through contaminated water. Singh has adopted Holiya, a village in Kushinagar district (see ‘The model village’), where improved sanitation and hygiene have shown results.

In absence of a cure, doctors at BRDMC joined hands with the administration and non-profits to control the disease. Sanjay Kumar, district magistrate of Gorakhpur, recently formed the Japanese Encephalitis Control Society. It aims to educate people about safe drinking water and cleanliness by screening documentary films and conducting street plays. For the survivors of AES, who suffer from neurological and physical disability, the administration plans to build a special home in the 19 blocks of Gorakhpur commissionary. One such centre will also be at the district level.

While the administration holds the key to eradicating the disease by ensuring a clean environment, it is scientists who need to work overtime to identify the viruses so that a cure can be found.

Down To Earth