The story so far: On March 6, Chief Minister Mamata Banerjee informed the West Bengal Legislative Assembly that 19 children below the age of five years have died in State-run institutions due to acute respiratory infection (ARI). Of the 19 children who succumbed, 13 had co-morbidities and six children had no health conditions other than the adenovirus infection, she added. Despite admission of infant deaths, the State claims that there is no evidence of a viral epidemic and the current situation is nothing but a seasonal surge. While officials put mortality figures at 19, unofficial estimates suggest the number of children who have died to be well over 100 between December 2022 and the first week of March, 2023. On Saturday, the West Bengal government set up an eight-member task force to ‘supervise the works related with control of adenovirus and treatment of affected persons’. The State government’s statement said that so far 10,999 acute respiratory infection cases in children have come to the fore.
What is the adenovirus infection?
The Centre for Disease Control and Prevention of the United States government states that adenoviruses are common viruses that typically cause mild cold or flu-like illness and are usually spread from an infected person to others by close personal contact. The virus is transmitted through the air by coughing and sneezing and also by touching an object or surface with adenoviruses on it. While the virus can affect people of any age group, children with low and compromised immunity are at a higher risk. The symptoms of the viral infection, other than common cold or flu-like symptoms, include acute bronchitis, pneumonia, pink eye (conjunctivitis) and acute gastroenteritis.
Shanta Dutta, Director of Kolkata’s National Institute of Cholera and Enteric Diseases (NICED), a unit of the Indian Council of Medical Research (ICMR), said that a recombinant of two strains of adenovirus is causing a spike in viral infections in West Bengal. “It is a recombinant strain of human adenovirus type 3 (HAdV-3) and type 7 (HAdV-7) that is causing the majority of infections. In January, when the serotyping of adenovirus samples was done, the recombinant strain was found in 30% samples and it increased to 40% in February,” Dr. Dutta said. While about 88 human adenovirus (HAdV) serotypes have been found, epidemiologic reports have suggested that nearly all fatal adenoviral diseases in children are associated with HAdV-7. The HAdV-3 strain is said to be more prevalent.
What is the strain prevalent in Bengal?
While the NICED is yet to come out with the outcome of the virulence study on the recombinant strain, doctors claim that it is the recombinant strain which is the reason for the spike in infections and deaths. Sayan Chakraborty, an infectious disease expert at AMRI Hospitals, Kolkata said a recombinant of human adenovirus type 3 (HAdV-3) which is more prevalent and type 7 (HAdV-7) which is more severe has led to morbidities. Dr. Chakraborty said most of the children who have been infected by the virus are less than three years old and were born during the COVID-19 pandemic. Since they were isolated at home, an ‘immunity gap’ has emerged for them and that they are more susceptible to viral infection. Tamal Laha, senior consultant and paediatrician at Apollo Hospitals, Kolkata said that children who are in the age group of six months to preschool are most susceptible to viral infection and suffer from something called ‘immunity lag period’. He added that this is the reason why vaccines are administered to children in this period.
What about Bengal’s health infrastructure?
With the spike in viral infections, children from different districts of Bengal were admitted to two paediatric institutions in Kolkata — Dr. B.C. Roy Postgraduate Institute of Paediatric Science and Calcutta Medical College and Hospital. These referrals were made by district level primary and tertiary care units and in some cases family members brought the children to these facilities directly without any referrals. An advisory issued by the State Health Department on February 28, directed that no paediatric ARI cases should be referred to Kolkata without the knowledge of the medical superintendents of the hospitals. Beds were augmented in these facilities but in February a shortage of beds resulted in two to three children being treated on a single bed. Medical practitioners and even the government point out that the referring of a large number of children without stabilising them or providing oxygen support may have resulted in the deaths of several children.
The government claims that there are more than 5,000 beds in 121 hospitals in the State having facilities for management of paediatric ARI, with 600 paediatricians in place. “There are 2476 SNCU (sick newborn care units) beds, 654 PICU (paediatric intensive care units) beds and 120 NICU (neonatal intensive care units) beds across the State,” the State government pointed out. To deal with the situation, the government announced the setting up of five additional paediatric hubs.
Is there a link between co-morbidities and infant mortality?
Infant mortality in West Bengal stands at 22 per live thousand births and under-five year mortality rate is at 25.4. The figures are better than the national average (infant mortality in India is 35.2 and under-five mortality rate stands at 41.9) but when it comes to nutritional status of children, the State does not fare so well. Children in West Bengal under five years who are stunted (height-for-age) is 33.8% whereas children under five years who are underweight is 32.2%, as per the National Family Health Survey (NFHS)-5. The percentage of children stunted or underweight in West Bengal is almost similar to the national average. When it comes to children in the age group of 6-59 months who are anaemic, West Bengal stands at 69% compared to 67.1% across the country. While referring to co-morbidities, West Bengal government officials and the Chief Minister stressed that many of the children had low birth weight and congenital heart or lung diseases.
Maternal health is also a crucial factor and studies have shown that if a mother is underweight, her child has an increased risk of stunting, wasting and being born underweight. Child marriage is high in several districts of West Bengal; according to NFHS-5, 41.6% women (national average 23.3%) in the age group 20-24 years were married before turning 18 years. There is also a high prevalence of anaemia with 62.3% among pregnant women aged between 15-49 years, compared to 52.2% in the same age group in the rest of the country.
Public health reports suggest that poor maternal health as well as child marriages result in underweight babies and the absence of adequate health infrastructure in districts to treat severe ARI cases in turn creates a vicious circle.