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In June 2019, an
outbreak In epidemiology, an outbreak is a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season. It may affect a small and localized group or impact upon thousands of people across an entire ...
of acute encephalitis syndrome (AES) occurred in
Muzaffarpur Muzaffarpur () is a city located in Muzaffarpur district in the Tirhut region of the Indian state of Bihar. It serves as the headquarters of the Tirhut division, the Muzaffarpur district and the Muzaffarpur Railway District. It is the fourth ...
and the adjoining districts in
Bihar Bihar (; ) is a state in eastern India. It is the 2nd largest state by population in 2019, 12th largest by area of , and 14th largest by GDP in 2021. Bihar borders Uttar Pradesh to its west, Nepal to the north, the northern part of West ...
state of
India India, officially the Republic of India ( Hindi: ), is a country in South Asia. It is the seventh-largest country by area, the second-most populous country, and the most populous democracy in the world. Bounded by the Indian Ocean on the ...
resulting in deaths of more than 150 children, mainly due to
hypoglycemia Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose be ...
. In subsequent months more cases and deaths were reported. The cause of outbreak is unclear. Malnutrition, climate, hygiene, inadequate health facilities, and lack of awareness are considered as contributing factors. The lychee fruit toxins are also cited as plausible cause of AES.


History

Outbreaks of acute encephalitis syndrome (AES) have occurred previously in the northern regions of
Bihar Bihar (; ) is a state in eastern India. It is the 2nd largest state by population in 2019, 12th largest by area of , and 14th largest by GDP in 2021. Bihar borders Uttar Pradesh to its west, Nepal to the north, the northern part of West ...
state and eastern regions of
Uttar Pradesh Uttar Pradesh (; , 'Northern Province') is a state in northern India. With over 200 million inhabitants, it is the most populated state in India as well as the most populous country subdivision in the world. It was established in 1950 ...
state of India. The first case of AES in Muzaffarpur district was recorded in 1995. There were 143 deaths in 2013, 355 in 2014, 11 in 2015, four in 2016, 11 in 2017 and 7 in 2018. In most recent years, the death toll had remained under 20.


Outbreak

In June 2019, an outbreak of AES occurred in 222 blocks of
Muzaffarpur Muzaffarpur () is a city located in Muzaffarpur district in the Tirhut region of the Indian state of Bihar. It serves as the headquarters of the Tirhut division, the Muzaffarpur district and the Muzaffarpur Railway District. It is the fourth ...
and the adjoining districts in Bihar. As a result of the outbreak, total 154 children died in first three weeks of June 2019. A total of 440 cases of AES were admitted to hospitals in these three weeks. At least 85 children of them died at the Sri Krishna Medical College and Hospital (SKMCH), the largest state-operated hospital in Bihar, while at least 18 children died at the Kejriwal Matrisadan, a trust-run hospital, in these weeks. Most of them were aged between 1 and 10 years. In subsequent months of July, August and September; at SKMCH; 30, 18 and at least 12 cases were reported. Total 647 cases of AES including 161 deaths were reported between 1 June and 20 September 2019.


Syndrome

The term acute encephalitis syndrome (AES) was coined by the World Health Organisation in 2008. The symptoms of AES include an acute onset of fever and associated clinical neurological manifestations such as mental confusion, disorientation, delirium, convulsions, or
coma A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions. Coma patients exhi ...
. Early symptoms include headaches and vomiting, along with sudden
hypoglycemia Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose be ...
(drops in blood sugar levels), but may lead to coma, brain dysfunctions, and inflammation of the heart and lungs. Those that survive AES may have long-term neurological weaknesses. The severe hypoglycemia can cause death. The syndrome is locally known as C''hamki Bukhar'' in Bihar.


Cause

The cause of the outbreak is unclear. AES can be caused by different microorganisms including virus, bacteria, fungi, parasites and spirochetes, as well as chemicals and toxins. AES mostly affects children below 15. In India, AES was chiefly associated with Japanese encephalitis virus (JEV) before 1975. The JEV cases and outbreaks became more frequent and endemic regions developed between 1975 and 1999. After 1999, non-JEV cases and outbreaks of AES were increasingly reported caused by other viruses including Chandipura virus (CHPV),
Nipah virus Nipah virus, scientific name ''Nipah henipavirus'', is a bat-borne virus that causes Nipah virus infection in humans and other animals, a disease with a high mortality rate. Numerous disease outbreaks caused by Nipah virus have occurred in Sout ...
(NiV), and
enterovirus ''Enterovirus'' is a genus of positive-sense single-stranded RNA viruses associated with several human and mammalian diseases. Enteroviruses are named by their transmission-route through the intestine ('enteric' meaning intestinal). Serologic s ...
es. After 2012, it is observed that the cause shifting to JEV. Initial examination shows little sign of the JEV or other viral routes in the affected children. A study by
AIIMS Patna All India Institute of Medical Sciences Patna (AIIMS Patna), previously Jaya Prakash Narayan All India Institute of Medical Sciences (JPNAIIMS), is a medical college and medical research public institute located in Phulwari Sharif, Patna, Bi ...
found the presence of enterovirus. High temperature, humidity, malnutrition, poor hygiene and lack of awareness are known aggravating factors of AES. Cases of AES tend to occur during the country's monsoon season. In June 2019, the temperature in Muzaffarpur had remained above and the rains were delayed which might have aggravated the situation. It was the second-longest heatwave in the region. Poverty and malnutrition is widespread among children in the region. Malnourished children lack a buffer stock of sugar as glycogen in the liver which puts them at higher risk of hypoglycemia. Awareness campaigns were carried out in March–April 2019 but were not conducted later due to the
2019 Indian general election General elections were held in India in seven phases from 11 April to 19 May 2019 to elect the members of the 17th Lok Sabha. Votes were counted and the result was declared on 23 May. Around 912 million people were eligible to vote, and voter ...
s. The local administration was not watchful due to the few cases of AES in recent years. The region is the largest producer of lychee fruits in India. A 2014 study published in Lancet found that the
methylene cyclopropyl acetic acid Methylene cyclopropyl acetic acid (MCPA) is found in lychee seeds and also a toxic metabolite in mammalian digestion after ingestion of hypoglycin. Overview Methylene cyclopropyl acetic acid (MCPA) is a compound found in lychee ('' Litchi chinen ...
and hypoglycin A found in unripe lychee (''Litchi chinensis)'' fruit can cause hypoglycemia and cited them as plausible cause of AES outbreaks. A diet heavy on unripe lychee fruits without having an otherwise full meal later in the day may put malnourished children at risk of hypoglycemia. Others disputed the findings citing the unlikeliness of very large consumption of unripe lychee fruits, lack of cases in healthy, well-nourished children and many other pediatric illnesses causing hypoglycemia. Health officials reported that most of the victims suffered severe hypoglycemia. The hospitals and primary health centres lacked the required facilities to treat children.


Government response

The Chief Minister of Bihar
Nitish Kumar Nitish Kumar (born 1 March 1951) is an Indian politician, who is serving as Chief Minister of Bihar since 22 February 2015, having previous held the office from 2005 to 2014 and for a short period in 2000. The leader of the Janata Dal (Unit ...
announced an
ex gratia (; also spelled ''ex-gratia'') is Latin for "by favour", and is most often used in a legal context. When something has been done ''ex gratia'', it has been done voluntarily, out of kindness or grace. In law, an ''ex gratia payment'' is a payme ...
payment of to the next of the kin of the children who died from AES. He also visited the hospital and ordered the expansion of the hospital. The union minister of health Harsh Vardhan visited and announced the set-up of 100-bed pediatric ward at the SKMCH as well as five virology laboratories in Bihar. He also announced the upgrade of the
India Meteorological Department The India Meteorological Department (IMD) is an agency of the Ministry of Earth Sciences of the Government of India. It is the principal agency responsible for meteorological observations, weather forecasting and seismology. IMD is headquart ...
’s observatory in Muzaffarpur for better study of climate. Seven pediatric
intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...
s are being established. The interdisciplinary team consisting of experts from
Indian Council of Medical Research The Indian Council of Medical Research (ICMR), the apex body in India for the formulation, coordination and promotion of biomedical research, is one of the oldest and largest medical research bodies in the world. The ICMR is funded by the Gove ...
,
National Institute of Mental Health and Neurosciences The National Institute of Mental Health and Neuro-Sciences is a medical institution in Bangalore, India. NIMHANS is the apex centre for mental health and neuroscience education in the country. It is an Institute of National Importance operates ...
,
National Institute of Malaria Research The National Institute of Malaria Research (NIMR), New Delhi, is one of the research institution of Indian Council of Medical Research under Department of Health Research, Ministry of Health & Family Welfare, Government of India, established in ...
;
National Institute of Nutrition The National Institute of Nutrition (NIN) is an Indian public health, nutrition and translational research centre located in Hyderabad, India. The institute is one of the oldest research centres in India, and the largest centre, under the India ...
,
National Institute of Virology The National Institute of Virology in Pune, India is an Indian virology research institute and part of the Indian Council of Medical Research (ICMR). It was previously known as 'Virus Research Centre' and was founded in collaboration with the ...
;
National Institute of Epidemiology The National Institute of Epidemiology (NIE) is a medical research organisation located in Chennai, Tamil Nadu. NIE conducts research including interventional studies, disease modelling and health systems, conducts epidemiological investigations ...
and All India Institute of Medical Sciences, New Delhi was formed and sent to Bihar to study the syndrome and establish the cause. The
Supreme Court A supreme court is the highest court within the hierarchy of courts in most legal jurisdictions. Other descriptions for such courts include court of last resort, apex court, and high (or final) court of appeal. Broadly speaking, the decisions of ...
ordered the Bihar government to file an affidavit to show the competence of medical facilities and other hygiene conditions in the state in the wake of the deaths. The
National Human Rights Commission A human rights commission, also known as a human relations commission, is a body set up to investigate, promote or protect human rights Human rights are moral principles or normsJames Nickel, with assistance from Thomas Pogge, M.B.E. Smi ...
(NHRC) sent notices to the
Ministry of Health and Family Welfare The Ministry of Health and Family Welfare is an Indian government ministry charged with health policy in India. It is also responsible for all government programs relating to family planning in India. The Minister of Health and Family Welfar ...
and the Bihar government over the deaths and asked for a report in four weeks.


Aftermath

Total 872 cases of encephalitis including 176 deaths were reported in Bihar in 2019.


See also

*
2017 Gorakhpur hospital deaths Many child deaths occurred at the state-run BRD Medical College hospital in Gorakhpur city of Uttar Pradesh, India in 2017. As of 2 September 2017, 1,317 children had died at the hospital in 2017. The 2017 deaths attracted national attention in ...
*
Eluru outbreak In early December 2020, an acute neurological disease broke out in Eluru, a city located in the southern Indian state of Andhra Pradesh. The first case was reported on 5 December, with hundreds more falling ill and one person dying over the n ...


References

{{DEFAULTSORT:Bihar encephalitis outbreak 2019 disease outbreaks 2019 disasters in India Encephalitis History of Bihar (1947–present) Disease outbreaks in India Muzaffarpur June 2019 events in India 2010s in Bihar