The litchi link?
In Bihar, authorities failed at several levels in preventing deaths due to encephalopathy
Why in news?
- In the outbreak of acute encephalitis syndrome (AES) in Bihar, which has witnessed close to 350 cases and 103 deaths, most of these deaths have been attributed to hypoglycaemia, or low blood sugar.
What causes AES?
- AES is a broad term involving several infections, and affects young children. The syndrome can be caused by viruses, bacteria or fungi.
- In India, the most common cause is the virus that causes Japanese encephalitis (JE). Health Ministry estimates attribute 5-35% of AES cases to the JE virus.
- In Bihar, the Directorate of Health Services (DHS) claimed that the JE virus had caused only two of the AES cases this year (this assessment came at a time when the total cases were 342).
- The syndrome is also caused by infections such as scrub typhus, dengue, mumps, measles, and even Nipah or Zika virus.
- The combination of AES with hypoglycaemia is unique to Muzaffarpur, Vietnam and Bangladesh.
- Hypoglycaemia is not a symptom but a sign of AES.
- In Bihar, convulsions in children (which is AES) are found in combination with hypoglycaemia. This hypoglycaemia is caused by malnourishment and lack of proper diet.
- With 98% of AES patients in Bihar also suffering hypoglycaemia, doctors are attributing deaths to the latter.
- Six years ago, a two-member team invited by the State government suspected that a toxin (methylenecyclopropylglycine, MCPG, also known as hypoglycin A) naturally present in litchi fruit was responsible for the mysterious deaths; a large Indo-U.S team confirmed it in 2017.
- The two-member team found that undernourished children who ate the fruit during the day and went to bed on an empty stomach presented with serious illness early the next morning.
- In 2014, the team saved 74% of sick children through a simple intervention — infusing 10% dextrose within four hours of the onset of illness.
- The recommended prevention strategy — making sure that no child goes to bed without eating a meal — adopted from 2015 ensured a sharp drop in the number of children falling sick.
- It is appalling that this year the government failed to raise awareness on this strategy.
- Worse, some doctors came up with alternative explanations for the illness and even pointed to the heat wave.
What makes this region so vulnerable?
- The first AES case was recorded in 1995 in Muzaffarpur. Eastern UP too sees frequent outbreaks.
- There is no fixed pattern, but a year with high temperature and scanty rain usually witnesses high cases.
- Malnutrition is high in both states, and malnourished children are prone to infection.
- Ministry of Health and Family Welfare data show UP and Bihar together account for over 35% of child deaths in country.
- National Family Health Survey-4 data show that in 2015-16, 48% children aged less than five in Bihar were stunted — the highest in India.
- A team from the Centers for Disease Control, Atlanta, and Christian Medical College, Vellore, has concluded that heat, humidity, unhygienic conditions and malnutrition, unique to these areas, together contribute to the rise in AES.
- Incidence is higher in litchi fields around which malnourished children live.
- While the most common causes of acute encephalitis syndrome are traced to a bacteria or a virus and it takes at least a few days before presenting serious symptoms and deaths, the toxin in litchi causes serious problems overnight.
- While well-nourished children who eat the fruit remain unaffected even if they go to bed on an empty stomach, the under-nourished ones are at grave risk.
- Blood glucose falls sharply causing severe brain malfunction (encephalopathy), leading to seizures and coma, and death in many cases.
- This is because under-nourished children lack sufficient glucose reserve in the form of glycogen and the production of glucose from non-carbohydrate source is blocked midway leading to low blood sugar level.
- This causes serious brain function derangement and seizures.
- While 5% dextrose infusion serves the purpose in cases of general low blood sugar, children suffering from acute hypoglycaemic encephalopathy can be saved only by infusing 10% dextrose within four hours of illness onset.
- Recovery is rapid and complete if 10% dextrose is infused within the golden hours. Infusing a higher concentration of dextrose is necessary to completely stop the attempt by the body to produce glucose from non-carbohydrate source.
- If encephalopathy was indeed the cause of death, this simple medical intervention could have saved many lives.
- Dextrose infusion could have been done even as children were being transported to hospitals in ambulances.
- The failures were at the stages of both prevention and care.
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