Perpetually ill-prepared

Inept response as mystery fever grips Uttar Pradesh

By Pranay Lal
Published: Friday 31 January 2003

-- (Credit: Pranay Lal / CSE)it was in October 2002 that media reports surfaced about children succumbing to a mysterious infectious fever in Saharanpur town of western Uttar Pradesh (up). The disease struck neighbouring districts too. Within the first two weeks the toll reportedly mounted to 100 in the area. The local administration first denied that there was an outbreak and then dismissed it as an annual occurrence.

The National Institute of Communicable Diseases (nicd), the nodal body for epidemiological research, was not even aware of the development till the media reported it. The institute's team has till now confirmed Japanese encephalitis (je) in three of the samples collected. Even this has been contradicted by one of its own entomologists. "We have still not detected the cause," says team leader Awadesh Kumar.

It is noteworthy that the real reason behind the Saharanpur epidemic figuring prominently in the news is the rivalry between two medical officers -- chief medical superintendent (cms) V P Bhatnagar and chief paediatrician Gopal Krishna. Information about the disease was apparently leaked to settle personal scores. Meanwhile thanks to the authorities' ostrichism, the disease has neither been classified nor notified.
Preventive mechanism missing Today when a child is admitted to a government health centre with symptoms such as high fever, convulsions and vomiting, chloroquine is promptly administered on the assumption that the disease is malaria. This is the "protocol", reveal doctors. If it fails, broad-spectrum antibiotic is given. This does not work in most cases of mystery fevers, because doctors and pathologists are clueless about the type of organism.

These systemic shortcomings can be traced to the lack of focus on new infectious diseases in India's health policy of 1963 and its draft policy of 2001. Apart from malaria, other diseases receive scant attention. Even now, more weight is lent to therapeutic interventions than outbreak prevention. When precautions are taken, they do not have a scientific basis. "Strict protocols of 'what, how and when' samples should be prepared and collected," points out N S Deodhar, ex-director of All India Institute of Hygiene and Public Health in Kolkata.
Afflictions anonymous According to Krishna, "The death of one child every day is common in any children's emergency ward. Hence Saharanpur's mystery fever cannot be classified as an epidemic." The fact is that at least four other districts of up -- Muzaffarnagar, Meerut, Bulandshahr and Bijnore -- were affected.

Surprisingly, nicd does not have a classical definition for an outbreak or epidemic. It only acts on requests received from state administrations and evinces nothing more than an "academic" interest in fevers and outbreaks. States, on their part, are wary of declaring an epidemic as it can cause panic. Further, the state health department has the onerous task of preventing epidemics by spraying insecticides and dispensing medicines.

In Saharanpur, nicd was looking only at viruses -- that too vector-borne and related to je. Going by the institute's poor track record (not even one new virus identified from a rash of mysterious fevers over 20 years), it cannot be relied upon to get to the bottom of the Saharanpur epidemic.

"Early detection is possible only if bodies like nicd are made autonomous," feels nicd director K K Datta. But would this help control diseases?
Need to delve deeper While they often come up with knee-jerk reactions, nicd and local administrations have seldom conducted long-term epidemiological studies. In Saharanpur, for instance, if the disease recurs every year, why have the authorities not analysed records of mortality and morbidity? A look at the victims' profiles reveals that girls were mostly in the age group of 4-8 years and boys were between 6-12 years of age. This data can come in handy because "many viral diseases show disparity in infection in males and females, especially among children", opines Chris Newton, virologist, University of Leicester.

The absence of evidence in Saharanpur has led to many agencies sowing seeds of doubt. The Industrial Toxicology Research Centre, Lucknow, went to the extent of claiming that a pesticide was killing the children. Even as the up town awaits nicd's verdict (expected around January 25, 2003), new mysterious fevers have reared their head across the country.

In Karnal, Haryana, just before the onset of winter at least 15 to 20 children die of Japanese encephalitis. Sadly these victims are considered a part of the natural cycle of the disease. Vinod Khosla, deputy director, entomology division, district health services, Chandigarh, says it is impossible to vaccinate each child. And the civil surgeon of Karnal, H B D Arora, seems to have become comfortably numb: "If 15-20 kids die of Japanese encephalitis every year, it is an acceptable loss."

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