Re: India Encephalitis 2013; 996 fatalities
Re: India Encephalitis 2013; 996 fatalities
As soon as I saw this post, it reminded me of an earlier ProMED post. It is remarkable how little has changed in the past 8 years.
Published Date: 2005-11-15 23:50:00
Subject: PRO/EDR> Undiagnosed deaths - India (Uttar Pradesh) (02)
Archive Number: 20051115.3342
UNDIAGNOSED DEATHS - INDIA (UTTAR PRADESH) (02)
That post was based on an analysis by Prof TJ John - here's some quotes;
...
The crucial differentiation between encephalitis and encephalopathy is
often not made.
Since Japanese encephalitis (JE) is well known in India,
every outbreak (except the repetitive seasonal ones in specific places) is
first called JE and then as studies find no clear evidence of JE, revised
as viral encephalitis; if no viral infection can be found, then it is left
as a mystery virus or disease. Many doctors do not perform lumbar punctures
(LPs) in sick children even with obvious neurological illness -- I cannot
understand why -- but they say the families might blame the LP and doctor
for any subsequent complications, including death. Moreover, laboratory
support services are grossly inadequate. In my judgement and after careful
review of several pieces of evidence -- including those of a few LPs done
by good pediatricians --
the "mystery disease" is an acute encephalopathy
syndrome closely resembling Reye's syndrome (Ref 1), more likely to be
toxic or multifactorial -- viral infection being quite unlikely.
7. I had requested a friend and colleague in Saharanpore (Bijnor to be
specific) -- Dr Vipin Vashishtha -- to do specific investigations for
Reye's syndrome. Except for the consistent microvesicular fat inclusion
bodies in hepatocytes, most other features -- CSF (cerebrospinal fluid)
without pleocytosis, under pressure due to brain edema, high liver enzyme
levels, low blood sugar, etc. fit with a Reye's-like picture (ref 2); case
fatality 84 per cent and total duration of illness 48 hours or less.
8. There have been many virological studies on similar outbreaks, but in
all of them clinical criteria were vague and epidemiology virtually absent.
In 2 'published' outbreaks (Vadodara and Warangal), measles virus was
detected in CSF or serum and incriminated as the etiolgy of the illness
(ref 3). In one genuine Reye's syndrome outbreak (ref 4), measles virus was
also detected in CSF and declared the etiology (ref 5). However, I do not
find these studies to be completely reliable (ref 6). Curiously, in another
similar recent outbreak, Chandipura virus (Genus vesiculovirus, family
Rhabdoviridae) was declared by virologists as the etiology in a study of 55
children (ref 7). The odd thing is that the very same 55 children were
reported by neurologists to have ischemic brain lesions and encephalopathy
-- but no encephalitis (ref 8,9).
...
My current suspicion is agriculture practice-related
chemical toxicity as the proximate cause of illness -- of the Reye's-like
syndrome with clinical and laboratory features, reminiscent of "Udorn
encephalopathy" (ref 11,12). The vasculitis-ischemic syndrome deserves more
attention and study. Proper epidemiological investigation of every outbreak
is sorely needed. They will certainly provide clues.
...
http://www.promedmail.org/direct.php?id=20051115.3342
Dr John and his colleagues actually put their theory into practice and investigated point sources in Saharanpur, Uttar Pradesh - settling on Cassia occidentalis
Cassia occidentalis poisoning as the probable cause of hepatomyoencephalopathy in children in western Uttar Pradesh. and
Cassia occidentalis toxicity causes recurrent outbreaks of brain disease
in children in Saharanpur (PDF) Large doses of Cassia produced hepatomyoencephalopathy (HME) syndrome which could also be mistaken for Reye syndrome.
Over the course of a couple of years, by weeding out the Cassia plants and providing information to villagers cases dropped by 80% or more.
Disappearance of a deadly disease acute hepatomyoencephalopathy syndrome from Saharanpur
To quote from the final paper linked above;
"There is an urgent need to carry out similar awareness/education campaigns in all other affected districts of western UP and Uttarakhand.
The lessons learnt are that there is no substitute to systematic and professional investigation of any outbreak of unknown cause2–4. This experience deserves wider publicity and public understanding. Healthcare professionals both in private and public sectors should have inquisitive mind and motivation to solve local problems by team approach. Public-private partnership in health sector can help achieving some difficult, unattainable targets. And, media can also play a very important constructive role in raising awareness among general public."
Unfortunately that call remains largely ignored.
