A new outbreak of Japanese encephalitis killed several scores of children in the eastern state of Odisha in 2016.
The Japanese Encephalitis Virus (JEV) is a mosquito-borne flavivirus which has a particularly impactful presence in Asia, where it is the leading cause of viral encephalitis. The World Health Organization (WHO) estimates that there are 68,000 clinical cases a year worldwide, and between 13,600 and 20,400 deaths. In south-east Asia and the Western Pacific, 3 billion people are believed to be vulnerable to infection. This is across 24 countries where transmission of JEV is considered endemic.
The Centers for Disease Control and Prevention (CDC), a U.S. Federal agency, identifies India as a JEV risk area. It states that the highest rates of human infection in the country are reported from the states of Andhra Pradesh, Assam, Bihar, Goa, Haryana, Karnataka, Kerala, Tamil Nadu, Uttar Pradesh, and West Bengal.
In Odisha – the eleventh most populous of India’s 29 states – the rising death toll among children from JE in the district made headlines frequently in the autumn of 2016, especially in the Malkangiri district. On October 16, The Hindu reported that 52 children had died over the previous five weeks. By the end of the month, NDTV reported that the number of deaths had reached 61 and stated that the disease had “affected around 100 villages spread over six of the seven blocks in the district.” At the beginning of November, The Indian Express reported that the toll had risen to 81.
It is, however, unclear as to how many of these deaths can be attributed to JEV and related conditions such as acquired encephalitis syndrome (AES). An article by Basudev Mahapatra published by Village Square at the end of December – by which point 103 children had died in the district – quoted Dhanurjay Mohanta, the district headquarter hospital’s (DHH) malaria officer as postulating 37 child deaths of the 103 total due to JE. The remainder seems the norm for the district. As stated in the article
“Having a population of 80,000 under-five children, Malkangiri sees the death of over 1500 children every year. So, on an average, more than 100 children die every month in the district. “Even though there was no JE or AES outbreak last year, the number of deaths of children between September and November 2015, remained the same as in 2016,” said Mohanta, suggesting that there was no excess mortality this year.”
The article then went on to suggest that malnutrition played more of a role in the number of deaths:
“With seven out of every 10 children happen to be underweight in Malkangiri, according to the 2014 Annual Health Survey report, the district ranked third in the country among 100 districts having the highest prevalence of malnutrition among children under the age of five.
Nearly 33.4% of children being under the wasting category, infant mortality rate in Malkangiri for the 2015-16 remained 53 per 1,000 child births, according to sources in the district unit of NRHM. “Child mortality in the district is primarily ruled by malnutrition,” an NRHM official said on condition of anonymity.”
As well as malnutrition, the blame has been assigned variously to pig rearing, monsoon rains, and mismanagement of the crisis by the state government. As with any public health climacteric such as this, it is likely that there is no one cause, but rather a compound of causative factors.
The initial response of state officials – which some described as delayed – was to segregate pigs and humans and relocate pig farms, as pigs are considered the disease’s “natural amplifier and reservoir host.” The Hindustan Times also reported that officials attributed the outbreak to “water accumulations in the paddy fields” serving as “good breeding grounds for the carrier mosquitoes”, after the monsoon season.
However, a number of commentators have laid the blame squarely at the doorstep of the government itself. The HT quoted Bijay Mohapatra, a leader of the Bharatiya Janata Party (BJP), as accusing the Central Government (run by his own party) of failing to dispatch an adequate supply of JE vaccines. The Quint concurred whilst also stating that the cases “exposed the dark realities of the state of healthcare in Odisha”, identifying severe staffing shortages and inadequate facilities. It noted that the district has just one paediatrician. The Times of India accused the government of failing to learn its lessons after an outbreak of JE in 2012.
In his article for Village Square, meanwhile, Mahapatra wrote of the “state of disarray” of a number of government programmes designed to ensure that children and pregnant women are properly nourished. Given that malnourished children are more susceptible to infection with any number of conditions – and given the aforementioned high rates of malnutrition in Odisha’s young – it is reasonable to suppose that there is a direct correlation. What is certain is that a more substantive effort needs to be made to rectify this problem. That a JE vaccine, albeit a controversial one, has already been developed and is simply not available to Odisha’s citizens makes the death toll from the disease all the more galling. “These deaths…should not be happening in the India of 2016”, concluded Mahapatra – and he’s right.