Recurring Outbreaks of Acute Encephalitis Syndrome Cases in Bihar: A Conundrum for Experts and Health System.

Sir,

Recent rise in cases of acute encephalitis syndrome (AES) or acute encephalopathy in Bihar and Muzaffarpur, in particular, is not a new mystery for the health system in Bihar; the doctors have been seeing this for the last so many years and are controlling and managing them as per their experience and resources available. Locally, this disease is known as “Chamki Bukhar” which has killed more than 150 children in 2019 till July 4th week, 2019, and two-third cases are from Muzaffarpur district only. This district is a major producer of litchi, and fruits grown here are exported even to foreign countries. The current misery has created repercussions not only in health department but also in other departments, which is not directly linked with contemporary situation.

Although there is lot of hue and cry over litchi and its role has been misinterpreted in the current outbreak, but this luscious fruit is only a triggering factor for acute encephalopathy in malnourished children.[1] Malnourished children have depleted glycogen stored in the liver. Hence, if there is no glycogen reserve, the glycogen breaks into glucose, and when the shortage further increases, even fats start burning. This process produces by-products such as ketones and amino acids which are neurotoxic. Hence, if a child sleeps without food, this whole physiological process gets completed by wee hours of the day, and then the kid gets fever with convulsions and at times s/he loses consciousness. When malnourished kids are exposed to toxins such as methylene cyclopropyl-glycine (MCPG) present in litchi, which is grown in these months, the chemical triggers hypoglycemia, but litchi per se is not the causal factor. However, studies have proved that there is a strong epidemiological association of the disease with litchi fruit.[2] Litchi fruit such as Ackee fruit in Jamaica and other African countries has potential to induce hypoglycemic encephalopathy which may be attributed to MCPG, depending on the other congenial factors.[34] However, many experts in the last 5 years considered this encephalopathy to be a mystery and continue to disapprove or remain unconvinced with the findings of research and public health experts' viewpoint and have their own notions regarding these outbreaks.[5] The governments, both central and state, must accept that malnutrition is the cause. They should not try to run away from their responsibility to deal with malnutrition by putting the onus on poor litchi farmers.

The need of the hour is to establish a robust system of surveillance to capture each and every case of AES such as acute flaccid paralysis surveillance, and AES stewards should be made in the system to tackle the situation efficiently. Although there is an existing system of AES in place, complacency and lack of pro-activeness to manage the outbreaks have resulted in large number of deaths. The awareness level is poor and has to be increased by rein enforcing health education among the masses regarding the food habits, nutrition, and health-seeking behavior. Moreover, nutritional status of the children has to be improved to control the menace to occur in the future.

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Conflicts of interest

There are no conflicts of interest.