A spate of Japanese Encephalitis (JE)-related deaths, especially in children of Gorakhpur, caught the attention of the Indian and Western media in 2010-11. Questions were being asked, the government was under pressure, the health system was overburdened and the media was indulging in misleading and sensational news coverage. The Roadmap to Combat Zoonoses in India (RCZI) Initiative is a multisectoral one that mobilises partners working across human, wildlife and veterinary sectors in the area of zoonoses research, capacity building and advocacy. JE is one of the nine priority diseases that RCZI has been working on. Under the aegis of the Public Health Foundation of India (PHFI), RCZI embarked on a study funded by the International Development Research Centre (IDRC), Canada, in 3 blocks of Kushinagar District of Uttar Pradesh – Padrauna, Kaptanganj and Khadda, with a view to get greater clarity on transmission and other risk drivers. The PHFI/RCZI study on “Identifying Sources, Pathways and Risk Drivers in Ecosystems of Japanese Encephalitis in an Epidemic-Prone North Indian District” was conducted between 2011-14. The findings and recommendations that emerged from the study were shared at the national, district and state levels. An EcoHealth Approach to studying JE in Kushinagar District of Uttar Pradesh The study followed an EcoHealth approach encouraging trans-disciplinarity, systems-thinking, multi-stakeholder participation, equity and environmental sustainability to generate evidence for community-based interventions. It studied the association of ecological, physical, biological and social factors on transmission of JE virus among different host populations in Kushinagar. Given the strong EcoHealth focus of the study, a core group was formed. An epidemiologist, entomologist, veterinary public health specialist and a virologist with a public health background were brought on board. They were instrumental in conducting the study and were referred to as the EcoHealth Research Core Group (ERCG). The trans-disciplinary approach led to identification of key knowledge gaps and generation of important hypotheses for future enquiries. However, the broad base of EcoHealth, which at times chooses ‘breadth’ of enquiry over ‘depth’, was seen as a challenge. The study concluded with findings that reinforced the relevance of the EcoHealth perspective to studying JE in Uttar Pradesh. Going forward, this will be used to form the basis for an interdisciplinary approach to addressing other aspects of JE transmission. It will also help study other diseases that overlap the human-animal-environment interface. More importantly, it will help to identify the linkages between changing agricultural practices, ecological developments, social inequities with disease transmission and health seeking behaviours. Lack of awareness, the biggest stumbling block to diagnosis and timely treatment Kushinagar’s is a largely agrarian economy, where rice, wheat, sugarcane and dals (pulses) are grown. It is a common sight to find sugarcane and rice fields submerged under water through the season. Water logging and pig farming are the two most important predisposing factors for JE virus to thrive. JE is spread by the bite of the Culex species of mosquito which generally breeds in water bodies, like ponds, pools and waterlogged paddy fields. Mosquitoes also pick the virus from pigs and aquatic birds. Local communities have very sketchy information on JE– its causes, prevention and treatment. In monsoon, JE cases increase. Most of its early symptoms are ignored, or at best, treated superficially. As a result, families reach the district hospital, or the Medical College at Gorakhpur late, when the case is quite serious. Affecting mostly children, the saga ends with the child’s unfortunate demise, or survival but with severe neurological defects. The study resulted in a number of creative outputs that emerged based on the findings and interactions that the study team had on the field. These ranged from technical documents, peer reviewed publications, to easy-to-comprehend and yet impactful communication tools that could be used by health workers, householders and school teachers, providing basic information on JE. This 10-minute documentary film, “Lifting the Veil of Silence that Shrouds Japanese Encephalitis” presents facts with interviews featuring a village pradhan, a Dom community member, the local NGO partner Savera, a school teacher, and a health official. It follows a simple narrative capturing the unique features of the location which make it vulnerable to JE. It also highlights, rather poignantly, the helplessness of the local population that accepts illness and loss of life on account of JE as an inevitable part of existence. With awareness and a more responsive health system, much of this can change. The film will be shared at various national and international forums. It will be sent to health institutions and agriculture/veterinary colleges to be used as resource material. It has also been uploaded on the RCZI website (http://zoonoses.phfi.org/) which has a special microsite on JE (http://je.phfi.org/). The PHFI/RCZI team hopes that the powerful medium of audio-visual communication can capture the magnitude of the problem and help mobilise and intensify a collective response that can bring hope to a devastated community. PHFI/RCZI on its part will try to continue the work it initiated as part of the IDRC supported study not just in Kushinagar, but also other JE endemic areas in the country.
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