‘Lack of diagnostic facilities forces doctors to do guesswork’

Dr. Soumya Swaminathan , Director General, Indian Council of Medical Research (ICMR), is a paediatrician and clinical scientist known for her work in tuberculosis. She spoke toThe Hinduabout the recent deaths at Gorakhpur’s Baba Raghav Das Medical College Hospital and the health emergency the area is facing. Excerpts:

ICMR reportedly shared the guidelines for the treatment of scrub typhus, which would have prevented many children from progressing to the Acute Encephalitis Syndrome (AES) condition needing hospitalisation. Would you say that the guidelines were not followed widely by doctors?

Preventing deaths was the aim of developing and disseminating clinical treatment guidelines. But the scenario here isn’t so simple. Our research from 2014 to 2017 shows that 40-60% of AES in this region is caused by scrub typhus infection. There may be other risk factors in this region that make scrub typhus present as AES, which need to be explored. AES is a syndrome and the causative agent of AES is known to vary with season and geographical location.

Of course, early diagnosis is key to controlling patient load and reducing mortality. But we have to understand that this disease itself presents with fever and scrub typhus is not easy to distinguish from any other fever, without good diagnostics. ICMR has provided a clinical algorithm to assist in early diagnosis.

Are doctors in the public sector at all levels aware of the ICMR guidelines on treating children infected with scrub typhus? What is the level of awareness among private doctors? Has the Uttar Pradesh government taken any measures to create awareness about treating children with fever caused by scrub typhus?

A training programme was conducted for doctors and nurses for intensive care management of children at Christian Medical College and Hospital, Vellore, earlier this year. I believe that the Uttar Pradesh government has also worked towards creating awareness among doctors both in the public and private sectors in Gorakhpur and its surroundings. The awareness and educational training programme should not be restricted to government hospitals and we have asked State governments to involve private practitioners also. Our studies show that most patients consult three or four private-care providers before coming to the government hospital.

We should also understand that the lack of good diagnostic facilities hampers early treatment. Besides this, overcrowding — because of the large number of patients coming in during this season — makes patient management cumbersome.

Are the symptoms of scrub typhus infection specific? How early can scrub typhus infection be diagnosed and can it done at the Primary Health Centre level?

Quite often, clinical signs of scrub typhus are indistinguishable from other causes of AES and an accurate laboratory confirmation is essential for accurate and early diagnosis of AES. Currently, without adequate laboratory support, doctors have to make an informed guess.

Many interventions were put in place this year. We are still mid-season in terms of this disease outbreak and it would be too early to come to any conclusion about the overall disease burden. Our team will conduct a comprehensive study of the situation, identify gaps where more research is needed, and make suggestions to improve health outcomes.

Can all the deaths that occurred on Aug 10-11 be directly linked to lack of oxygen supply at the BRD Hospital?

It would be unfair to say that all the reported deaths have occurred due to one reason alone — be it drop in oxygen level or anything else. Once you have sick children on ventilators, some mortality is to be expected. Newborn deaths occur due to a number of reasons. The newborns under treatment will have low birth weight, infections, etc. But to say that newborns kept in an incubator dying a day after birth is due to encephalitis would be wrong.

Do all AES cases need ventilator support?

Ventilatory support is required when patients go into coma and there is breathing irregularities during advanced stage of AES.

Why was there such a long delay in diagnosing scrub typhus as a major cause factor for AES? Has scrub typhus become the predo-minant cause for AES as vaccine for JE became available or was it causing same percentage of AES cases even when there was no vaccine for JE?

Scrub typhus was identified as cause of a large proportion of AES in 2014 and this was further confirmed in 2015 and 2016. Once vaccination for JE expanded, that accounts for < 10% of AES now. The challenges that we face include weak lab diagnostic facilities, which forces doctors to go through guesswork for early diagnosis.