Krishnankutty, 62, lifted the tip of his thorthu (towel) on his shoulders to wipe the tears welling up in his distraught eyes. He pointed to the bed in the drawing room where his ailing wife Ammini lay. “She was in hospital for nearly 21 days after being diagnosed with hepatitis A. For six days, she was on ventilator support,” his voice choked with emotions.
It was only last week that they returned to their modest one-storey home in Choorathodu ward in Vengoor panchayat, in Kerala’s Ernakulam district after she was discharged from a private hospital in Aluva. “She is so fatigued, she is still not able to get out of bed on her own,” said the daily-wage worker, as his wife raised her hand for assistance to turn over. Vengoor, with its tiled-roof houses and lush green surroundings, is located about 45 kilometres east of the district headquarters in Kakkanad.
The 58-year-old homemaker was among nearly 35 diagnosed with hepatitis A in a span of four weeks. While trying to console Krishnankutty, 52-year-old Peter P.V., ward member, said he had never witnessed a health crisis of this magnitude in the area. Neither had the rest of the residents in four other wards of the panchayat (Edathuruth, Vengoor, Vakkuvally and Kaippilly). Officials of the Government Community Health Centre in Vengoor alerted the authorities to a possible hepatitis A outbreak on the evening of April 18.
The first confirmed case
The viral infection was first confirmed in a 23-year-old man and a resident of Kaippilly ward. He had sought treatment in a private clinic and was later referred to the Government Taluk Hospital in Perumbavoor town some 11 km away. Three more people from Kaippilly ward with fever sought treatment at the outpatient wing of the community health centre in Vengoor on April 18.
From a single case on April 18, the number of confirmed hepatitis A cases went up to 54 in just 12 days before climbing to nearly 190 cases as on May 10. Over 220 cases have been reported as of the third week of May. People from around 120 families in the five wards were hit by the outbreak.
The water channel along the Pulachira paddy field in Choorathodu, which directs the water from the Periyar Valley Irrigation Project to the pumping station of the Kerala Water Authority in Vengoor, Ernakulam. | Photo Credit: THULASI KAKKAT
Jolly Raju, 51, of Kaniyattupeedika in Vakkuvally, became the first casualty as she succumbed to the infection at the Government Medical College, Ernakulam, on May 7. Karthiyani M.C., 51, of Kariyampurathu, Choorathodu died while under treatment at the Government Medical College, Kottayam on May 19. K.K. Sajeev, 48, of the nearby Mudakuzha panchayat, succumbed to the infection on May 1. Nearly 30 people currently remain under treatment in various government and private hospitals in Ernakulam and Kottayam, according to the Department of Health.
Water woes
On the day the outbreak was detected, officials of the community health centre received reports of people with fever and vomiting from Vakkuvally ward. A report prepared by the centre on April 18 indicated that a common source of infection may have triggered the spike in cases. An email sent by the health authorities to the Kerala Water Authority (KWA) on the evening of April 18 indicated that supply of contaminated water from the pumping station of the authority in Choorathodu may have triggered the outbreak.
Inspections by health officials found that the upkeep of the pumping station and its premises was not up to the standards required. Water samples were collected by the Health department on April 18 from a pond near the station, which had been set up to collect water drawn from the canals linked to the Periyar Valley Irrigation Project of the Department of Irrigation.
The chira, as it is known locally, also helped in recharging the well that acted as the main water source for the drinking water project. The tests conducted at the Government Regional Public Health lab in Ernakulam showed that the maximum probable number (MPN, the statistical estimate of the number of coliform-group organisms per unit volume of sample water) was 1,600/100 ml, indicating faecal contamination at the source. For bathing in a river, the desirable level of faecal coliform is 500 MPN per 100 ml or lesser, according to the Central Pollution Control Board. For drinking water source without conventional treatment but after disinfection, the maximum probable number per 100 ml must be 50 or less.
Health workers and volunteers with hepatitis A awareness leaflets at Vengoor, Ernakulam. | Photo Credit: THULASI KAKKAT
Quoting the inferences drawn in the assessment by the Health department, panchayat chairperson Silpa Sudheesh suspected that the lack of disinfection of the well water at the Choorathodu pumping station using chlorine could have resulted in the spread. “It was the responsibility of the pump operator to ensure chlorination at source,” she said.
KWA denies charge
The KWA has not yet accepted the alleged lapses in chlorinating the drinking water source. “The chlorination was carried out as per the norms and recorded in the logbook maintained at the pumping station. Chlorination is done on the well water and not on the water in the nearby pond. The Health department had collected the water samples from the pond and not the well,” alleged a senior official of the authority’s office in Kuruppumpady near Vengoor.
The councillors in the affected wards are in no mood to accept the authority’s position. Baiju Paul, councillor representing Vakkuvally ward, which had reported the highest number of cases (over 70), said that only those who used the piped water were infected. “The report by the community health centre had clearly indicated it. There are families that do not have the KWA piped connections as they depend on wells for drinking water. They have not been affected,” he said.
Experts speak
Public health experts pointed out that the ability of this virus to remain viable (alive) for several weeks in dirt or sewage propagates its spread. “This virus enters the human body through faecally contaminated food and water. It reaches the liver and within two-three weeks, it causes symptoms that include fever, loss of appetite, nausea, and jaundice. The virus starts appearing in a patient’s stool two weeks before the symptoms appear. People with prior infection or those who took the hepatitis A vaccination have lifelong immunity. They will not get the disease,” said Rajeev Jayadevan, Chairman, Research Cell of the Kerala State branch of the Indian Medical Association.
“Among all hepatitis viruses, this is one of the least severe. Some patients have no symptoms, but play a role in spreading the virus to others. The vast majority recover without complications. A small percentage go on to get severe disease and among them, a few have fatal outcomes, he said, adding that deaths occur primarily among people over 40 or those who have certain underlying health conditions. “People living with liver disease which may or may not be known, are at a higher risk of severe outcomes,” he said.
Magisterial inquiry
The lack of clarity about the reason behind the outbreak prompted the district administration to order a magisterial inquiry. Ernakulam District Collector N.S.K. Umesh said he had entrusted Shyju P. Jacob, Revenue Divisional Officer and Sub Divisional Magistrate, Muvattupuzha to hold an inquiry under Section 176 (1) of the Code of Criminal Procedure into the case. An order issued by him on May 16 stated that the report had to be submitted within two weeks.
The inquiry will cover the cause of the death and the factors that resulted in the outbreak of hepatitis A. It will ascertain whether there were any lapses on the part of those responsible (at various levels), besides recommending measures to avoid such incidents in the future. “The report will also recommend the relief that could be offered to the family of the deceased,” said Umesh.
Superchlorination plans
A multi-pronged remedial plan has been activated to contain the outbreak. Superchlorination (dosing of a water with a high dose of chlorine) has been done at all water sources, including ponds and wells in the affected wards. The KWA has been told to continue super chlorination at the tanker and the well at the pumping station in Choorathodu. Health workers are holding fever surveys, besides creating awareness to use only boiled water. The workers at eateries and those involved in the sale of fresh juices or drinks like buttermilk have been told to ensure hygiene and compliance with the food safety norms. Umesh said that the leaks reported in some of the pipelines of the KWA have been rectified. “Accredited Social Health Activists are holding house visits as part of the remedial plan,” he said.
Amidst the medical event, the families are staring at a financial crisis impacted by prolonged hospitalisation. A report prepared by the Tahsiladar of Kunnathunadu on May 10 said that each patient had to spend an average ₹60,000 to ₹1 lakh for medical expense.
For people like Chandran, 54, a rubber tapping worker, the expenses have gone through the roof. A resident of Kaippilly, he is now shuttling between two private hospitals in Ernakulam where his daughter Anjana, 28, and son-in-law Sreekanth, 36, are under treatment. “Anjana has been on ventilator support for over 20 days in a private hospital in Kochi city, while her husband is in a hospital near Aluva, nearly 19 km away. Though her liver condition was returning to normal, her condition deteriorated after she had fever five days ago. We have incurred about ₹15 lakh for her treatment alone,” he said, trying hard to hide the pain. An engineering graduate, Anjana was getting ready to join a company at Infopark, Kochi, when she fell ill.
“She was staying with her husband a kilometre away from our home. Their house was linked to the drinking water supplied from the pumping station in Choorathodu. We are getting water from a well under the MLA scheme for nearly 60 families,” Chandran explained, hoping he could go back to work that earned him a daily wage of ₹600. “The doctors have told us that both of them may need prolonged treatment and we are clueless about how to meet the rising expenses,” he said.
With the government yet to take a call on extending relief, the panchayat has initiated a fund collection drive to help those in need. “We are reaching out to the public and the response has been positive. The panchayat has also submitted a request to the government for help, especially for the families of patients who have exhausted all their earnings to meet medical expenses,” said Sudheesh. As the wait for help continues, Krishnankutty waits for his wife to be able to manage alone, which will enable him to return to work and repair their lives scarred by this unexpected health crisis.
