‘No Room For Complacency Despite Fall in JE Deaths,’ Monalisa Goswami
Rifa Deka was in conversation with the Commissioner & Secretary, Health & Family Welfare, Government of Assam to discuss the current situation of Japanese Encephalitis (JE) in Assam in the backdrop of the Covid-19 pandemic. JE has claimed 34 lives in Assam as of 25th July 2020.
What is Acute Encephalitis Syndrome (AES) and Japanese Encephalitis and which are the areas worst affected by the disease in Assam?
These are a group of vector-borne diseases that are transmitted by Culex mosquitoes. Japanese Encephalitis is a disease that affects the central nervous system. It is very difficult to treat a patient once the virus affects a person’s brain, which is why the fatality rate by this particular disease is very high. Natural hosts of this viral disease are water birds (pond herons and cattle egrets) and pigs play an amplifier host. These birds sit on pigs and infect pigs which maintain prolonged viraemia, which is the duration of the presence of the virus in their blood. JE cannot be transmitted through human to human contact and humans are the dead-end of the cycle. Culex mosquitoes bite at dawn and dusk.
In Assam, the highest number of deaths has been recorded in Barpeta district from where 20 cases have been found and 6 deaths have been recorded. 3 deaths have been reported from Sivasagar, Sonitpur, Kamrup (Rural) and Morigaon districts whereas 2 deaths each have been reported from Sonitpur, Jorhat, Darrang and Dibrugarh districts of Assam.
As of today, Assam has 225 cases of Acute Encephalitis Syndrome or Japanese Encephalitis and 34 deaths have been reported from the state.
What is the root cause of AES/JE and similar vector-borne diseases in Assam? Could you tell us what preventive measures are being taken to ensure that people are safe from this?
Floods and stagnant water, as we know, are breeding grounds for these mosquitoes (Culex) that spread the viral disease. Although pigs are said to amplify the disease, we have noticed that in districts such as Nagaon and Hojai, where some JE cases have been identified, have no piggeries. This means that these mosquitoes are breeding in paddy fields where water had accumulated due to rains.
Infrastructure in many districts is a challenge which also leads to waterlogging, then there are the floods; all this leads to a rise in JE cases around the time between July and September.
Control rooms have been set up and officials are regularly visiting places and field workers have intensified surveillance. Use of ITBNs which are Insecticide Treated Bed Nets are given to people to keep them safe from mosquitoes.
Fogging is done regularly to kill adult mosquitoes and larvicides are used to kill the larvae; otherwise, if only fogging is done, then the larvae turn into a pupa and the pupa into mosquitoes in a few days and we are back to square one. So, both are important and done regularly and simultaneously.
We are also going to suggest breeding of Guppy and Gambusia Fish, which are currently being bred in certain areas, on a wider scale in water tanks and ponds, or any other place where water accumulates. These fish are known to feed on larvae; however, it is most useful in the elimination of Anopheles larvae of malaria spreading mosquitoes.
At a time when the state is busy battling the novel coronavirus disease, how is the health department preparing to deal with an increase in AES/JE cases in Assam?
We are personally taking stock of the situation and ensuring testing and immediate treatment if anybody shows symptoms of AES/JE. The mortality rate by JE is very high as compared to COVID-19; at close to 15%. We have set up various District Task Forces to ensure that even those at the grassroots get benefitted with whatever it is that we have facilitated for their treatment.
District Task Forces comprise the Veterinary, PHE, Deputy Commissioner, Police, Education, etc, who all play a vital role in the implementation of our plans in a more inclusive manner. Regular routine immunization is on and we will resume adult vaccination after this JE season.
Do people voluntarily come forward to get themselves treated or is there fear among them? What happens if a person does not get proper treatment?
One problem that we have noticed is that when a person starts to show symptoms of JE which usually involve fever, disorientation, tremors, hypertonia or loss of coordination, villagers tend to take the patient to a ‘bez’ rather than a Primary Healthcare Center (PHC) or a nearby hospital. Sensitization and awareness campaigns play a major role here for which our workers are going down to the grassroots level and informing people of the dangers of such fatal diseases. In many cases, almost 25% of JE patients end up with lifelong physical disability if they are not treated well which is why it is very important to give the right treatment to the patient.
What new initiatives are being taken by your department to help those infected by the disease? What facilities have been arranged for their treatment?
This year we have taken additional measures apart from the immunization, sensitization, and surveillance that we do each year. We have arranged for special facilities such as transport allowances for patients, free treatment for those suffering from JE, incentives for workers, dedicated help desks in district hospitals, and medical colleges. We have also cancelled leaves of all doctors and medical staff till the end of September.
Transportation is a big problem in Assam, especially during the current flood season, and with restrictions on travelling due to COVID-19. What kind of transportation facilities are being provided to patients and how much allowance is being given to them?
We have instructed all service providers of 108 Mrityunjoy ambulances and 102 Inter-Facility Transfer ambulances to accord high priority to shift AES/JE patients. In case patients have to travel on their own, we have consolidated a transport allowance of Rs 1,000 for them which will be given to those who make their own arrangements to reach the district hospital or medical college.
All superintendents of medical colleges will put in place a mechanism for immediate reimbursement of this amount to AES/JE patients out of the Hospital Management Society Funds which they can claim from the government as reimbursement.
What other measures have been taken by your department to ensure timely treatment of AES and JE patients?
We have directed all medical colleges and district hospitals to earmark certain beds exclusively for AES and JE patients. Treatment of these patients will be absolutely free of cost in all government hospitals inclusive of medicines, consumables, and all other diagnostic facilities.
Hospitals that cause out of pocket expenditure will be charged with disobedience to government orders and will be viewed seriously. Even ICU facilities in these medical colleges and hospitals will be made free for pre-diagnostics and treatment of the disease.
How has community surveillance helped with AES and JE cases? Are the field workers still visiting homes to collect samples or have they been withdrawn due to COVID-19 pandemic?
Surveillance workers are out on the field doing their job and to further strengthen the mechanism of early detection of AES/JE cases through blood slide collection. We have announced a special incentive of Rs 5 per blood slide collected from 1st July till the 30th of September this year, which will be paid to Multi Purpose Workers (MPWs), Auxiliary Nurse Midwives (ANMs) and Surveillance Workers (SWs). This will be paid to them by the end of September this year by their respective District Health Societies.
Have any steps been taken to hasten the process from identification of the disease to treatment of patients since, in most cases, it is delay that leads to the death of a patient?
We have directed all medical colleges and hospitals to set up dedicated help desks to ensure faster delivery of services and so that no time is lost between the arrival of the patient and treatment. These desks will be manned by staff round the clock to ensure that there are no delays of any sort.
In addition to this, as I mentioned earlier, we have cancelled leaves of doctors and paramedical staff, including leaves of surveillance workers, till this season passes. Emergency leaves, however, will be granted but only with prior approval. We will treat absence seriously.
How is the scenario of AES and JE in Assam this year as compared to previous years?
Last year at this point in time, 125 deaths had been recorded from across the state of Assam. This year only 34 deaths have been reported from JE. We have even set up death review committees in various districts to take corrective actions as sometimes a person could be fully treated and recovered of AES or JE and succumbed to co-morbid conditions and the death would be counted as a JE death.
Have the lockdown, COVID-19 pandemic, and floods been posing additional challenges to the state health department in combating problems of vector-borne diseases like JE?
Despite the lockdown, we have been in consultation with districts and have constantly monitored the situation. We have been meeting up via video conferencing and conference calls and have insisted on regular field visits. I myself will be travelling to Barpeta and Nalbari tomorrow to personally take stock of the situation there. Despite a decline in the number of JE cases as compared to previous years in Assam, we do not want to be complacent. We will leave no room for any kind of complacency.
Are any benefits being provided to patients who undergo treatment in private hospitals?
Critical patients suffering with AES/JE who are admitted in the ICUs of private hospitals or nursing homes which are registered under the Clinical Establishments Act will be extended monetary support of up to Rs 1 lakh. To avail this benefit, attendants accompanying the patient may call upon JE Central Room helpline numbers or to the concerned health authorities at the district level.