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Indian Pediatr 2014;51: 936 |
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Encephalitis Outbreaks in Muzaffarpur: Five
Blind Men Describing an Elephant!
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Vipin M Vashishtha
Consultant Pediatrician, Mangla Hospital and Research
Center, Shakti Chowk, Bijnor, UP, India.
Email: [email protected]
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The President, Indian Academy of Pediatrics (IAP), needs to be
complimented for showing his concerns for the recurring outbreaks of
acute encephalitis syndrome (AES) in different parts of the country,
particularly in Muzaffarpur, Bihar [1]. He has rightly highlighted the
role of pediatricians in disease surveillance through the Academy’s
portal, IDsurv.
However, the Academy is capable of going much beyond
merely reporting of the cases. We have the expertise to lead
investigations and offer solutions regarding diagnosis and management of
these ‘mystery illnesses’. Already, few IAP members are involved in the
investigations of the ongoing recurring outbreaks in Muzaffarpur in
their own individual capacity. The Infectious Disease Chapter of IAP
should come forward and contribute to ongoing investigations. It can
organize brain storming sessions on the problem involving all the
stakeholders, including State and Central agencies. The local
pediatricians, usually the IAP members, are keys to the success of this
endeavor. In fact, the Government of India is short of technical advice
on many issues pertaining to outbreak investigations and usually depends
on multiple agencies – some of their own and some from outsides – for
solving the mystery and instituting preventive measures, which
ultimately do not go beyond recommending mass vaccination against
Japanese encephalitis in affected areas [2].
Outbreak investigation in India is in a dismal state.
Once an outbreak is spotted, usually by the media, the regional and
central investigating teams arrive, carry out field survey, collect few
biological samples, perform virological investigations, and if no
organism is identified, label the outbreak to be caused by an
unidentified viral agent [3]. The problem is each team starts with a
fixed mindset and looks for some infective pathology behind every
outbreak. There is lack of coordination and synchronization of efforts,
and ultimately they waste their energy either duplicating the efforts of
others or pursuing a different approach unmindful of other’s
accomplishment. Individual experts start investigating these outbreaks
according to their own areas of interests. For example, in an outbreak
of AES amongst children in Andhra Pradesh, India in 2003, the virology
group concluded it to be an outbreak of acute encephalitis caused by
Chandipura virus [4] and the neurology team claimed the outbreak was
caused by a neurovascular stroke called as "epidemic brain attack", not
by any encephalitis [5]. Similarly, in Muzaffarpur outbreaks, one group
claimed it to be caused by heat stroke, and another hinted towards a
toxin contained in the litchi, a locally grown fruit [1]. The
current scenario is bit murky and resembles like five blind people
describing an elephant.
The need of the hour is to adopt a fresh systematic
approach with an open mindset. Every effort must be made to characterize
the clinical entity, whether it is an encephalopathy, encephalitis or a
multisystem disease. Thorough clinical, biochemical, histopathological
and microbiological investigations, and autopsies must be performed to
reach at a correct clinico-pathological diagnosis. Second stage of
investigations should consist of proper epidemiological investigations
to identify any risk factor. Based on these investigations, further
studies that may include detailed toxicology can also be planned. The
team should include epidemiologists, pathologists, neurologists,
toxicology experts, public health experts and pediatricians. They should
report to one designated authority spearheading all these teams. It is
definitely possible to crack the mystery behind these recurring
outbreaks and put an end to the prolonged ordeal of innocent children.
References
1. Yewale VN. Misery of mystery of Muzaffarpur.
Indian Pediatr. 2014;51:605-6.
2. Travasso C. Indian health ministry orders
encephalitis vaccination in select districts after more than 500 deaths.
BMJ. 2014;348:g4209.
3. Kumar S. Inadequate research facilities fail to
tackle mystery disease BMJ. 2003;326:12.
4. Rao BL, Basu A, Wairagkar NS, Gore MM, Arankalle
VA, Thakare JP, et al. A large outbreak of acute encephalitis
with high fatality rate in children in Andhra Pradesh, India, in 2003,
associated with Chandipura virus. Lancet. 2004;364:869-74.
5. Rao PN, Kumar PA, Rao TA, Prasad YA, Rao CJ,
Rajyam PL, et al. Role of Chandipura virus in an "epidemic brain
attack" in Andhra Pradesh, India. J Pediatr Neurol. 2004;2:131-43.
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