Ignoring the science behind encephalitis deaths

Without accepting the link between endemic scrub typhus and brain inflammation, the U.P. govt. is unlikely to tackle the medical emergency

Rinki Singh, 31, holds a photo of her daughter Aarushi, 6, who died in the ICU of BRD hospital.

Sometime last week, dozens of seriously-ill children at Gorakhpur’s Baba Raghav Das Medical College Hospital were starved of oxygen from the ventilators that were keeping them alive. News reports say this happened because the hospital didn’t pay its oxygen vendor.

This image of babies being suffocated because someone didn’t get their cash is an obscene one.

Unusual suspect

But the story of why the babies were in the hospital in the first place is equally worrying — it’s one of medical researchers not looking beyond the obvious while investigating the three-decade old scourge at Gorakhpur.

Even though this recurring epidemic has killed over 5,000 people since 2010, its primary cause wasn’t identified until early this year. Now, researchers have learnt that a majority of the children being admitted to BRD have scrub typhus — a mite-borne disease endemic in U.P. Because they weren’t treated during early stages of the disease, the scrub typhus triggered brain inflammation, which can be very hard to cure.

This means that some of the children at the hospital didn’t have much of a chance anyway — a fact the Yogi Adityanath government is citing as a defence of its incompetence.

The confused history of research into the Gorakhpur pestilence begins in 1978, when the epidemic first broke out. Within a few years, doctors at the sentinel hospital confirmed that the outbreak of encephalitis, or brain inflammation, was mainly due to the Japanese encephalitis (JE) virus. Today, researchers suspect that Japanese encephalitis wasn’t the only cause even then. Scrub typhus was hiding in the encephalitis burden during the seventies as well.

Wrong approach

Why did it take so long to pinpoint scrub typhus? First, because we were too focused on the usual suspects to look beyond them. Over the past few decades, organisations such as the National Institute of Virology and the National Centre for Disease Control, visited BRD Hospital repeatedly and ran lab tests for dozens of pathogens known to cause encephalitis, such as enteroviruses, the chikungunya, herpes simplex and dengue viruses, and the malaria parasite.

 

But researchers like Govindakarnavar Arunkumar of the Manipal Institute of Virus Research, who first found scrub typhus in BRD’s encephalitis wards, say this was the wrong approach.

The scientists should have studied the symptoms of each patient in detail, logging data such as the length of fever before encephalitis, and involvement of organs other than the brain, like the liver and the spleen.

These symptoms would have revealed that the epidemic wasn’t due to typical viruses, but the scrub-typhus bacterium that is not known to trigger encephalitis outbreaks.

Instead, the focus remained on lab testing, allowing the disease to continue killing, unseen.

Deaf to data

The second lapse was that the U.P. administration wasn’t listening to the scientists, who were finding that the Gorakhpur outbreak had changed over the years. Once Japanese encephalitis vaccinations began in 2007, incidence of this disease at the hospital fell to less than 20%, but encephalitis cases kept coming. It was obvious to researchers that something other than Japanese encephalitis was at work.

For a brief period, doctors at BRD suspected that enteroviruses, a class of viruses to which the poliovirus belongs, were the top cause for the epidemic. But research didn’t bear out this suspicion either. Yet, even today, the Yogi Adityanath government is talking of poor sanitation as the reason behind the pestilence at the hospital (enteroviruses spread through contaminated water). And while pushing Japanese encephalitis vaccination campaigns is crucial, as the government is doing, this won’t make a dent in the hospital’s burden.

The government can’t ignore the science for a number of reasons. First, it’s going to take a miraculous effort by the government to weed out scrub typhus in the State. Most patients who develop fever, the first sign of scrub typhus, go to private healthcare practitioners and not government hospitals. So, these private practitioners, many of whom aren’t medically qualified, must be targeted in training programmes. Unless they suspect scrub typhus in children and treat it before it advances to encephalitis, children will keep coming to BRD. The hospital will be able to do precious little then.

The real danger is that if the government ignores scrub typhus, children will continue to die, and we’ll never know if the science pointing to scrub typhus bears out. Dumping the hypothesis without testing it fully is the most criminal thing the administration can do. But Yogi Adityanath’s statements raise the very real fear that this will happen.

(Priyanka Pulla is a freelance science and medical journalist.)