Draft National Policy on Health2015 includes Japanese Encephalitis, but will it ensure better outcomes for JE?
Etiological enquiries into acute encephalitis in north India have dominated headlines in academic and research circles for a long time now, but a systematic response to health care access and delivery issues is only now being treated as a priority at the highest level.
In India, a much-needed political push has been seen with the recently announced Draft National Health Policy, 2015 that covers almost all issues of concern that are of relevance to the country’s massive healthcare system. What is heartening for those working in the area of infectious diseases and within that vector-borne diseases like Japanese Encephalitis specifically, has been the Policy’s endorsement of the dedicated National Programme for the Prevention and Control of JE/AES. The National programme that was announced by the National Vector Borne Disease Control Programme (NVBDCP) in the year 2012 is clearly aligned with the Government of India’s thinking that assigns JE as a major public health priority.
The Programme provisions for a district-level model action plan including public health measures for containment of JE/AES has been developed in consultation with state and district health authorities in high burden states such as Uttar Pradesh. The plan envisages community-based surveillance, entomological surveillance, vector control, relevant IEC/BCC and capacity building involving community volunteers. Further, the NVBDCP operational guidelines which are quite comprehensive, covers almost all aspects related to JE management.
In addition to envisioning a strong component of intersectoral collaboration, the Programme also recognises the need for good quality data and strong biomedical research. There is increasing conviction that this will help establish better understanding of the disease and its transmission, while stepping up drug discovery and introducing innovations with shorter lag times, aiming to building public health capacity at district levels.
The peril JE in endemic belts of India
Inspite of strong political will and a well thought-out action plan, the confusion on the ground, the blame game between the different agencies and the absence of a coordinated response is leading to dwindling public confidence, especially in places where JE/AES incidence is high.
According to estimates, JE claims hundreds of lives every year and leaves many physically and mentally disabled with the disease being reported in as many as 171 districts, spread across 19 states including Uttar Pradesh, Assam, Bihar, Tamil Nadu and West Bengal.
The spate of media stories around the mystery deaths of hundreds of children in eastern Uttar Pradesh every year has the health system on its toes. The question is not whether the media is alarmist or sensational, rather it over and over again puts the spotlight on the level of preparedness that exists in the district hospitals in the event of a Japanese Encephalitis (JE)/Acute Encephalitis Syndrome (AES) outbreak. This combined with low levels of awareness in the community about JE in general and healthcare access in particular, have been contributing to creating a nightmarish situation for all concerned.
On one end of the spectrum are the victims and their families and an angry, often ill informed media and on the other hand is the district hospital that is made to suddenly shoulder the maximum burden along with the government who scrambles to take remedial measures and responsibility for events on the ground.
Measures such as vaccination against JE, environmental management, larval control, pig control, as well as provision of India Mark II hand pumps and deep wells to counter enteroviral infections, have inspite of being part of health care protocols failed to significantly reduce AES cases and mortality.
It is time we ask ourselves once again as we enter another monsoon cycle, as to what exactly is needed to avert these unfortunate and highly avoidable JE-related deaths.
Manoeuvring implementation challenges – the key to success of health policy on JE/AES
All the systems, guidelines and policies are in place and yet the challenge lies in implementing them and ensuring they reach all vulnerable and at-risk populations. In addition to access to acute care being a major stumbling block in preventing avoidable mortality, an important example of the implementation challenges is making the JE vaccine available to the last mile.
India currently procures 66 million doses of JE vaccine from China and has sought an additional 16 million doses to expand coverage of its ongoing National Programme for Prevention and Control of JE. The development is significant as China is currently one of the major suppliers of the low cost JE vaccine and is supplying to at least seven countries. While India has developed the vaccine indigenously, the government's Rs 3,355 crore immunization programme to control the disease remains dependent on supplies from China.
Supplies were increased in phases as the government rolled out the national programme for the vector-borne disease and started expanding it to cover more districts. However, China’s commitment to other nations as also increase in price has impacted the situation on the ground. Government of India has in the meanwhile intensified its efforts to resolve the issue in its discussions with the Chinese counterparts as it ramps up its immunization programme and assists states in its implementation.
Overcoming the JE vaccine supply shortage issue will be a major step in reducing morbidity, mortality and disability in children and help restore public confidence in JE endemic areas. A stronger multisectoral response will further steer issues related to vaccine safety and security; development of a rational vaccine policy and its effective regulation. Going forward, it must commission a lot more relevant research as also encourage the manufacturing new vaccines, including against locally prevalent diseases; building more manufacturing units to generate healthy competition; guarding against risks of batch failure; and developing innovative financing and assured supply mechanisms with built inflexibility.
Once vaccine supplies are consistently rolled out, a major JE awareness campaign will have to be launched in endemic states and frontline workers educated to guide communities and target groups to access the same. Only then will the National Health Policy’s vision for JE see an actionable impetus on the ground.
JE outbreaks are being reported from previously unknown foci. Further, encephalitis outbreaks of other aetiologies in endemic areas have only added to their complexity. For programme managers, researchers and community health professionals, access to accurate and updated information is key to planning interventions and other relief measures.read more