Next early detection rates have to increase by increasing suspicion index amongst the community and increasing sensitivity of screening criteria. Thirdly, by appropriate standards of procedure (SOP) based response pre-hospital in the home and during retrieval and decreasing distance to final management to achieve decrease in response time affects the most important determinant of outcome. Finally, follow-up and management of disabled has also to be factored into the strategy of a comprehensive response.
The crux of any strategic planning is that the normal to infected, infected to diseased, infected to carrier and diseased to disabled or dead arms have to be weakened and the disabled rehabilitated just allocating resources doesn't off burden the system from its responsibility to mount a sufficient response.
Science should inform policy and programming
AIIMS Patna, Epidemic Investigation Unit thus initially mounted a time place person distribution investigation of the 2012 epidemic.
The data was collected on tablets or mobiles from the residence of patients of AESJE during 2012 and later during 2013, 14 and 15 on a well-designed pilot tested data collection instrument. The position of mobile in terms of latitude and longitude was transmitted from the residence of patient to the database on the server through the net. Historical Data was obtained by the courtesy of the UP Government of 2009 and 10 and latitude and longitude values were found and fed into the data through addresses using Epi-info map software.
Perusal would reveal that the number of cases remained nearly constant over the years though JE positives decreased from 12 to 6 percent between 2009 and 2011. The proportion affected across districts was also similar suggesting that populations were not developing any immunity against the unknown agent of AES though vaccination against JE were probably causing decrease in JE.
The epidemic is limited in the south by the river Saryu though it crosses the Gandak into Muzzafarpur on 7th May 2012 to get 2 cases, spreads north to it on 27th and gets into a full blown epidemic by 13th June, the daily rate crossing 50 cases per day, starts subsiding by 15th June and by 7th July the original rates of about 5 per day have returned. This is premonsoon. The later post monsoon curve beginning 27th July, peaking around 1st September and subsiding near 19th November, is contributed by Gorakhpur. Not crossing the river Saryu, sparing areas south to it and then river Ganges, after Chapra, sparing Patna suggests that it is limited by the fast flowing midstream of these rivers. It crosses the Gandak because it is weakened pre-monsoon. The post monsoon spurt in Gorakhpur is perhaps because of the contamination of surface water sources due to flooding of rivers or use for toilet, bathing etcetra. The spread lends force to waterborne transmission through feco-oral contamination and thus preventable by a. using the midstream to prevent horizontal transmission.
We need to use deflectors to deflect mid-stream, wash of faecal-contamination and thus prevent the horizontal west to east transmission of disease. These relatively low cost interventions were recommended but not implemented by the UP, Bihar or Central Governments.
However, an intensive health awareness drive concentrating with use of soap hand wash in Muzzafarpur decreased the numbers from 1347 in 2014 to 64 in 2015. In contrast the numbers in Gaya where the epidemic mimics Gorakhpur post monsoon, there was no campaign and the numbers remained the same. It is suggested that measures to prevent feco-oral water borne transmission on the north banks of Saryu and Ganges rivers may prevent 1000 deaths, 3000 disabled and 5000 acutely taken sick from this 37 year old devastating encephalitis epidemic in under 15 year olds.
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