Thursday, August 17, 2017

AES Update: This is not the time for a “blame game”

The recent tragic deaths of children due to encephalitis in Gorakhpur medical college have hit the headlines in the last few days. These deaths also generated a lot of debate on the issue. Unfortunately much of the debate centered on “finger pointing”. This is not the time for a “blame game”.

This is not the first outbreak of acute encephalitis syndrome (AES) in the region. Many such outbreaks have been occurring for several years now and each epidemic has taken a heavy toll of lives.

By now there should have been a state of the art hospital to manage AES patients. There should have also been a research facility to examine why the area is vulnerable to AES, establish effective surveillance systems, plan a response plan, predict future outbreaks etc.

This is the time to look to the future and not talk of the past or even the present outbreak. Drawing from the lessons of the past years, we must be able to anticipate such local outbreaks and be ready to respond to them systematically and in a timely manner to contain them. A research center focusing on AES will help to identify early warning signals for such impending outbreaks.

Anticipation and preparedness will enhance efforts to control and prevent future outbreaks of AES. All stakeholders have equally important roles to play in prevention of any epidemic.

Some key points on AES

·         Encephalitis is inflammation of the brain parenchyma. It presents clinically as neurologic dysfunction (altered mental status, behavior, or personality; motor or sensory deficits; speech or movement disorders; seizure)
·         Viruses are the most commonly identified infectious causes of encephalitis. Around 10% cases may be due to Japanese encephalitis, scrub typhus and herpes simplex each. Enterovirus and other viruses also cause AES. Bacteria, fungi, and parasites may also cause encephalitis. In many cases of encephalitis, the etiology remains unknown despite extensive evaluation.
·         The WHO’s guidelines for JE surveillance recommend syndromic surveillance for JE meaning that all AES cases should be reported (NVBDCP, 2009).
·         The NVBDCP 2009 guidelines on management of AES have recommended classification of a suspected case as follows:
o    Laboratory-confirmed JE: A suspected case that has been laboratory-confirmed as JE.
o    Probable JE: A suspected case that occurs in close geographic and temporal relationship to laboratory-confirmed case of JE, in the context of an outbreak.
o    Acute encephalitis syndrome (due to agent other than JE): A suspected case in which diagnostic testing is performed and an etiological agent other than JE virus is identified.
o    Acute encephalitis syndrome (due to unknown agent ) A suspected case in which no diagnostic testing is performed or in which testing was performed but no etiological agent was identified or in which the test results were indeterminate.
·         The incidence is highest among infants <1 year. 
·         Status epilepticus, cerebral edema, fluid and electrolyte disturbance, and cardiorespiratory failure are some of the complications of AES.
·         ICU care is essential for patients with severe encephalitis (i.e., those with seizures, cardiorespiratory compromise, coma, or severe neurologic compromise) with close cardiorespiratory monitoring and careful attention to neurologic status, fluid balance, and electrolyte status.
·         Prognosis of viral encephalitis depends upon the age of the patient, neurologic findings at the time of presentation and the etiopathogen.
·         The case fatality and morbidity is very high among various viral encephalitis especially in JE or enterovirus encephalitis.
·         Survivors of childhood encephalitis should be monitored for long-term sequelae.
·         Scrub typhus encephalitis: Curable with doxycycline or erythromycin if diagnosed early. Look for fever, rash, local black eschar in the legs with enlarged, lymph nodes.
·         Japanese encephalitis: Mortality is 20% in the best of the centers. Preventable by vaccination.
·         Herpes simplex encephalitis: Can be diagnosed due to temporal lobe localization and can be managed with antivirals.
·         Lichi encephalitis is manageable with intravenous glucose.
·         Enteroviral encephalitis has limited therapeutic options. Intravenous immunoglobulin (IVIG) is often administered despite a lack of convincing evidence for efficacy.
·         All children who present with suspected encephalitis should be treated with acyclovir pending viral studies.
·         Empiric treatment for bacterial meningitis pending bacterial cultures also may be warranted if bacterial meningitis cannot be excluded.
·         Empiric treatment with doxycycline or erythromycin should be given till scrub typhus is ruled out.
·         Prevention strategies include hand hygiene, appropriate management of pregnant women with active herpes simplex virus lesions, routine childhood immunizations, JE vaccine, traveling immunizations, and insect control and avoidance measures. Control of culex mosquito.
·         All children who are hospitalized with encephalitis should be placed on airborne, droplet, and contact precautions at the time of admission, pending identification of a pathogen.

Dr KK Aggarwal

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