Malkangiri: One of the more remote and nondescript districts of Odisha, Malkangiri hogged the national limelight on June 29, 2008, when 38 commandos of the elite Andhra Pradesh Greyhounds were massacred by insurgents affiliated with the banned CPI (Maoist) party in a daring ambush. After more than eight years, the same district returned to the headlines of national dailies, and again for all the wrong reasons.
In the last five weeks, 56 children aged one to five – without exception all tribals – have died of Japanese encephalitis (JE), a vector-borne viral fever that attacks the brain. Fifty-six is the official count of institutional deaths; there are many more likely to have died in their villages or en route to hospitals. JE has spread to six out of the seven blocks of the district in a quiet epidemic, and the district administration has been caught unprepared.
The sadder part is that the district is endemic to the disease and has a known history of recurring bouts of JE with alarming regularity. In 2012, 38 deaths were reported due to JE, whereas in 2014 the figure was 24. This year, the toll already stands at 56. As more than 50 children are still under treatment and new cases are being registered everyday, the death toll is poised to increase. In Malkangiri, the problem is not JE alone but the administrative apathy in dealing with it as well.
Lack of preparedness
Despite the fact that JE is endemic to Malkangiri, the preparedness has been lacking at all levels. The first death was reported on September 9 and, by the end of the month, more than thirty children died. However, the district had only one paediatric specialist at the district headquarter hospital. Encephalitis always refers to the inflammation of brain tissues. But the district headquarter hospital does not have an MRI machine nor even a CT scan machine. And the only machine used for fogging that was available with the municipality was highly inadequate because of the lack of skilled manpower.
Medicated mosquito nets were not distributed beforehand. There was no prospective plan for segregating or culling of host animals, in this case pigs. Earlier in the year, malaria hit the Bondaghati, with a large number of casualties among the Bonda tribals, a particularly vulnerable tribal group. But learning from experiences does not naturally come to policymakers, it seems.
As the death toll rose, the knee-jerk reactions of the government didn’t suffice to contain the epidemic. Teams of medical doctors, including the director of health, the joint secretary of the department of health, were mobilised. But not a single neurospecialist was roped in – nor were equipment essential for treatment of brain diseases made available. After one month since disease’s outbreak, an order was placed for fogging machines but they are yet to arrive. And there continues to be no plan to deal with host animals.
The district administration is yet to submit a proposal for the culling of pigs and the department of fisheries and animal resources is yet to provide any direction or declare any compensation schemes. At some places, the administration has segregated the pigs in enclosures at a distance of a few of kilometres from the villages. But the enclosures are not netted and Culex mosquitos, the carriers of JE, have been known to be able to fly up to a distance of 12 kilometres.
A prequel to panchayat elections?
The state government has announced that cooked food will be provided to the anganwadi centres in the two worst affected blocks to enhance the immunity of children. As a result, 35,000 children in 470 anganwadi centres and 6,000 lactating mothers will be served hot food twice a day along with other nutritional supplements. But a question remains: Can immunity improve overnight? How is this step going to help contain the epidemic?
The panchayat elections are going to be held in February 2017, and such a populist measure is bound to get favourable views for the ruling party – along with covering the apparent failure of the state government in responding to the outbreak. The distribution of mosquito nets among the children admitted to hospitals is also considered a good initiative to prevent JE from spreading from affected children to other non-affected paediatric cases inside the hospital. However, nobody has paid attention to the fact that human beings are dead hosts and cannot spread the disease.
Furthermore, no action plan has been made by the municipal authorities to remove the pigs in and around the district headquarter hospital. Six weeks after the first death was reported, medicated mosquito nets are being distributed. The distribution pattern of the nets is also skewed such that nets were being distributed to concentric epidemic zones but not to the areas from which cases are yet to be reported. And now, new JE cases are being reported from the latter areas.
Insensitive health administration
The district health administration has collapsed in the face of JE. And to cover up their tracks, health administrators have been resorting to half-truths. The first is to under-register the toll due to JE and ascribe the rest to having been due to acute encephalitis syndrome (AES).
There is no test kit available in the district to diagnose JE cases. The blood samples are sent to the regional medical lab at Bhubaneswar for testing. It takes a week’s lead time to get the diagnosis report. Most times, an affected child succumbs to the disease before her blood-report even arrives. And health officials only confirm those cases whose blood-reports have arrived. Other cases are, for the time being, being sidelined as due to AES.
This act of minimising the death toll due to JE is not limited to the absence of blood reports. Any deaths that occur during the shifting of patients to the district hospital is not registered as a JE death. It has also been alleged that children with acute JE have not been admitted to the hospital. Finally, any deaths occurring in the hinterland with clinical symptoms similar to JE have not been investigated. Such unethical practices are being followed to reduce the number of institutional deaths. No wonder then that there were at least 23 LAMA (left against medical advice) cases as well.
Vaccination is the only way to prevent JE. However, Odisha has not been in the central government’s JE immunisation program. On October 7, 85 families – including businessman and government officials – got their children vaccinated by procuring vaccines under private medical advice. This created a row all over Odisha. The state government sought an opinion from A.C. Dhariwal, the director of the National Vector-Borne Disease Control Programme (NVBDCP) regarding the vaccination. He replied, inter alia, “… during transmission period, there is a possibility that vaccination may be perceived as the cause of JE cases occurring naturally in the endemic area by the community and the immunisation programs [are] set back.”
The reply’s tone is dangerous. According to the JE-AES prevention control guidelines prepared by NVBDCP, there are a large number of subclinical JE cases in endemic areas. The ratio of the incidence of the disease to unapparent infections varies between 1:250 and 1:1,000. The chances of unapparent or subclinical infections becoming clinical infections is randomly distributed among the population. Now, according to Dhariwal, if a vaccination drive is done during the transmission stage, there is a fair chance that a subclinically infected child receives the vaccine.
The vaccine requires a specific span of time in which to generate the desired level of antibodies. In this period, if the subclinical infection evolves into a clinical infection, there are chances that some will allege that the disease surfaced because of the vaccine. And such allegations will be a setback to the government policy of immunisation. A successful implementation of government policy is more important than life-saving measures. So, can vaccines be administered during the transmission stage?
There are two kinds of vaccines: the live attenuated vaccines and the inactivated virus vaccines. For example, OPV drops contain live but attenuated (i.e. weakened) polioviruses whereas the injectable polio virus vaccines contain an inactivated form of the viruses. Unlike the live attenuated virus vaccines, the inactivated virus vaccines do not contain any viruses. The virus itself has been made irrelevant by various techniques and only its outermost protein cover remains intact. This protein cover helps trigger the production of antibodies to prevent the disease.
The benefit of an inactivated virus vaccine over the live attenuated virus vaccine is that the former can be administered during an ongoing outbreak. The Indian Academy of Paediatrics prescribes the administration of inactivated virus vaccines during the transmission season as well as during epidemics. A Hyderabadi company launched an inactivated virus vaccine for JE in 2013 that is today readily available in the market. The vaccine schedule includes two doses in a gap of four weeks.
However, when some people in Malkangiri and its neighbouring districts got their wards vaccinated privately, the state government put an embargo on the sale of vaccines in the district. The drug controlling authorities have raided pharmaceuticals and seized their stock. The government has also taken a stand that nobody can administer vaccines privately either. The Supreme Court has interpreted that the right to healthy life is subsumed under Article 21 of the constitution. Not allowing parents to get their wards vaccinated by their own arrangement interferes with it.
Like every other epidemic, JE’s has a lifespan of six to eight weeks and it will run its natural course. But have we learnt our lessons? Will we be better prepared for the next round of transmissions in the future?
Note: The reference to the Bonda tribals as a “primitive group” was drawn from the earlier Census of India classification of ‘Primitive Tribal Groups’. These groups are now known as ‘Particularly Vulnerable Tribal Groups’. The oversight at the time of publication is regretted.