Children in the tribal district of Malkangiri in Odisha have been dying in mysterious circumstances since September-end, and medical experts were none the wiser. More than 100 children have died, and initially the local health authorities blamed Japanese encephalitis (JE), a mosquito-borne viral disease endemic to the region. 

In 2012, JE claimed 38 lives, whereas in 2014 the number was 24. But in 2016, the toll crossed the 100 mark in just three months. This sudden spurt in number was alarming and experts were hard-pressed to explain it.

Despite local health authorities labelling JE as the killer, a committee of experts headed by Dr Jacob John was appointed to investigate the deaths. Dr John is a veteran virologist who once spearheaded the polio eradication campaign in India. He had previously identified the cause of sudden deaths of children in Bihar’s litchi belt in 2014 and 2015: a toxin in litchi was creating a fatal brain sickness, especially when consumed on an empty stomach.

After camping in Malkangiri for two days and gathering information from the ground, Dr John concluded that these deaths were caused by encephalopathy and not encephalitis.

He homed in on the raw beans of a common plant called Cassia occidentalis, which the children were eating. The toxicity of these beans is well known, especially to vets, who have seen many animal deaths caused by them. “I just found their effect in human beings and gave it a name,” says Dr John.

The diagnosis was an exercise in information gathering and analysis. The expert team called a meeting of local doctors, and sought a detailed description of how the cases proceeded: the children usually turned up with severe convulsions and died in a day. “But that was too quick for JE in which brain gets damaged only by the second week of infection,” says Dr John.  

Nevertheless, the patients’ brain were indeed damaged, as the convulsions indicated. The next step would have been to investigate the condition of the patients’ muscles and liver. Only problem: there were no patients for testing.

Luckily, some local doctors had preserved blood samples, which were tested for liver enzymes. “Instead of having a normal level of 40, the samples showed 4,000. So the liver was severely damaged. Again muscle enzymes were tested and the levels were sky-high. All this showed a second pattern which the Odisha doctors had missed. It was not just the brain damage, but liver and muscle too,” explains Dr John.

Moreover, sources reveal that only a few tests were done in the district for JE. Though some cases were indeed of JE, some were not, as they were based on false readings of symptoms.

When urine samples were tested for toxins, five out of five samples showed signs of the toxin anthraquinone, which is found in Cassia occidentalis. The plant grows in abundance in these parts, and children are known to eat the beans. So in the absence of a virus, Dr John surmised that a plant toxin was a possibility, as with the litchi deaths in Bihar and AES (acute encephalitis syndrome) in Saharanpur, Uttar Pradesh.

Confusion in diagnosis is not infrequent. Quite often, sudden deaths of children, accompanied with seizures, have been labelled AES.
In the 2000s, Dr John had found cassia beans as the cause for deaths of children in repeated outbreaks of AES in Saharanpur. He had found that the symptoms which looked like those of encephalitis were actually of acute hepatomyoencephalopathy caused by the cassia beans. 

A few years ago, many JE deaths were reported in Gorakhpur, Uttar Pradesh. But not all of them were JE. Many were suspected to be scrub typhus, which affects the brain in the second week much like JE. A final diagnosis is still awaited.

The Malkangiri incident raises questions which have no answers. Why the country does not have a public health department staffed with qualified public health personnel?

The reason, says Dr John, is that our medical curriculum does not offer public health as an option at all. And even if it were to offer a course, the people who qualify would be jobless as there is no public health department to employ them. “They would find jobs only in NGOs, WHO or foreign countries,” he adds.
                                                    
                                                          Interview with Dr Jacob John, veteran virologist

                                                    “Medical curriculum does not teach outbreak investigation”

When an outbreak happens, who is supposed to investigate the causes and suggest the solution?

Outbreak investigation is the union government health department’s responsibility. Healthcare belongs to the state government health department. This is a bad division of responsibilities. 

What should be the ideal mechanism for investigation?

The public health department, which we don’t have, ought to be the agency to investigate and control outbreaks. India believes that all disease can be treated – so public health is felt unnecessary.

Are there clinicians and virologists who are helping the government in investigation?

The National Centre for Disease Control is the main agency. The National Institute of Virology, Pune, does some outbreak investigations. The National Institute of Epidemiology, Chennai, likewise. When asked, AIIMS and some medical colleges will chip in.

Is something lacking in medical education that we don’t have enough people to identify diseases correctly?

Outbreak investigation, especially of diseases of unknown nature, is not in medical curriculum but only in the public health curriculum. I learned it by myself.

Who were the other experts and institutions who worked with you at Malkangiri?

Dr Madan Mohan Pradhan, state vector borne disease control programme officer, was insisting that there were non-JE cases with high mortality; Dr Arun Kumar of Manipal Virology Centre who has conducted a fever surveillance project in Koraput district had noticed that many Malkangiri children had an encephalopathy disease and both of them helped identify Cassia occidentalis in Malkangiri. Dr Mukul Das of the Indian Institute of Toxicology Research, Lucknow, detected anthraquinone of cassia in the urine samples of a few children.

Do we have a directory of plant toxins and other possible causes for diseases?

The classical poisonous plants are well known – some are used for suicides, like oleander and jatropha. The cassia one was discovered by Saharanpur investigators, a team that I put together, all volunteers, who worked at no cost.

Menon is a freelance journalist

(The story appears in the January 16-31, 2017 issue)