When Bina Bora, 60, a resident of Ouguri in Assam’s Jorhat district, started throwing up, running a temperature and complained of a headache in the last week of June, her family rushed her to the mini-primary health centre in the area.

Ouguri, which is part of the Bhogamukh administrative block, has been at the centre of an acute encephalitis syndrome outbreak. At least 13 cases have been detected in the last two months in the block. Eleven villages in Ouguri revenue circle, with a population of slightly more than 10,000, has accounted for almost all of them.

Acute encephalitis syndrome is a condition of brain inflammation caused by both bacterial and viral infections. It is accompanied by fever, headaches, seizures, disorientation and vomiting in people, and if not treated quickly can result in death. The Japanese encephalitis virus has been responsible for most cases of acute encephalitis syndrome in India and South Asia.

When a blood test was run on Bora, she tested positive for Japanese encephalitis.

There is no specific treatment for Japanese encephalitis, but given the high fatality rate, patients require hospitalisation, supportive care and treatment of symptoms by ensuring rest and administering fluids, pain relievers and medication to reduce fever.

The outbreak in Jorhat is part of a larger outbreak in the state. As of July 31, 1,404 people in Assam have been diagnosed with acute encephalitis syndrome in Assam this year, 424 among them have tested positive for Japanese encephalitis. About 119 people have died of acute encephalitis syndrome of which 58 had Japanese encephalitis infections.

Bora, incidentally, had been vaccinated against Japanese encephalitis in February 2014. In fact, out of the 12 people who were detected to be infected by Japanese encephalitis in Bhogamukh, 11 had been vaccinated. And they are not the only ones.

Bina Bora

Almost 28% of people in the state who have been infected by Japanese encephalitis had been vaccinated, said Dr Parashee Choudhury, senior medical and health officer at the state’s Infectious Disease Surveillance Program. “There is definitely a problem there too. We need more research to say what exactly is wrong.”

Assam is the only state where children in all its districts are being given the Japanese encephalitis vaccine as routine immunisation, which is part of India’s universal immunisation program. The state began administering the vaccine to children for the first time in 2006 in Sibsagar district, and has since gradually expanded the coverage to other districts.

According to state government data, almost 80% of all children under 15 have been vaccinated as of December, 2016.

In 2014, Assam also became the first state to administer the Japanese encephalitis vaccine to adults. The adult vaccination programme has covered 18 districts as of now, according to state government data reviewed by Scroll.in. However, the exact number of people vaccinated has yet to be compiled.

While there is consensus among doctors that the immunisation intervention has been crucial, most acknowledge that there are gaps in the vaccination system. Those who have received vaccinations should not succumb to infections. However, the government’s own data over the years confirms that is not the case.

Doctors in the region suspect that the cold chain to transport the vaccines to remote areas may have been compromised at some places. “By the time, the vaccine reaches a remote village in Sibasagar and Jorhat, where there are practically no roads, it is possible that their efficacy decreases because it is difficult to maintain a cold chain for such a long time,” said a government doctor who did not want to be identified.

The doctor added that the vaccine provided immunity only against Japanese encephalitis. She said: “There are so many other viruses that can be responsible for acute encephalitis syndrome like the West Nile, but more often and then they don’t even get detected and we never get to know what actually caused the symptoms.”

Vaccination leading to fewer deaths?

However, Assam’s extensive vaccination drive, doctors and public health experts contend, has at least brought down the case fatality rate in patients suffering from Japanese encephalitis. The death toll from Japanese encephalitis, data suggests, has come down marginally since 2014.

(AES: Acute encephalitis syndrome; JE: Japanese encephalitis)

“The mortality rate has come down because of the vaccine,” said Dr Labnaya Baruah, a retired government doctor in Sibasagar district that neighbours Jorhat. Sibasagar has been a hotbed for Japanese encephalitis for decades.

“Also, if you notice the trend, more adults are getting affected than children,” said Baruah. “That is because almost all children are vaccinated these days.”

While immunisation interventions in the encephalitis endemic districts of Dibrugarh, Jorhat and Sibasagar have helped arrest the spread of the virus to a large extent, most doctors and health workers in the region admit there is a long way to go.

Chinks in the vaccination story

The adult vaccination program introduced in 2014, in particular, has suffered many setbacks because of widespread rumours that the Japanese encephalitis vaccine led to impotency.

“This is primarily because there is very little faith in the public health system”, said Suneel Kaul, a public health professional who operates out of rural lower Assam. “In many tribal areas here, teams that come to administer the vaccine were almost lynched. Any immunisation drive has to be preceded by a lot of communication.”

The failure is evident in areas where the outbreak has been severe. For example, the Baghchung administrative block in Jorhat district, has had 20 acute encephalitis syndrome cases, out of which 15 have been Japanese encephalitis. Five people with Japanese encephalitis and one person with acute encephalitis syndrome not caused by the Japanese encephalitis virus have died – all adults who had never been vaccinated.

Chenemai Saikia, 55, died of from the disease on July 11. Members of her family said that no one in the family went to get vaccinated because they were scared. “We did know that they were giving some injection, but we did not know what exactly,” they said. “So, we did not go.”

Chitra Karmakar, the daughter-in-law of Chumchumi Tanti, 60, who died on April 25, said her no one in the family had heard of any vaccination: “We work in the tea garden, we were not told anything there.”

Raja Ahmed, 22, who was diagnosed with a Japanese encephalitis infection in June, and suffered several seizures, claimed he was not in town when the immunisation drive was underway in February 2014. “I was at my aunt’s place then, and since I didn’t know anyone there I was apprehensive about taking the injection,” he said.

Doctors who treated Ahmed at the Jorhat Medical College said that he had been lucky to have survived.

Raja Ahmed

Areas like Sibasagar, Jorhat and Dibrugarh are vulnerable to Japanese encephalitis due to their geography. “Just look around the area,” said Baruah. “There are all these wetlands, plus so many people breed pigs. And then there are egrets everywhere. The whole area is like a heaven for mosquitoes to breed. No vaccination drive can offset all of these factors.”

Pigs and wild water birds like egrets, which abound in upper Assam, are known to act as hosts to the culex mosquito – the vector that transmits the Japanese encephalitis virus to humans. But while, the animals and birds are hosts for the mosquitoes, stagnant water helps them breed.

Egrets at Ouguri

Failing infrastructure

With geographical peculiarities working against the local population, there is very little in terms of a second line of defence when the vaccination fails to immunise people. Assam’s health infrastructure in remote areas is almost non-existent.

Take Ouguri for instance. When Bora fell ill, her family brought her to the mini-primary health centre – a second tier health facility under the block primary health centre that caters to smaller populations. The mini-primary health centre is the only medical facility in the area and Dr Bhaskar Jyoti Saikia, who manages the centre, is the only doctor for 10,000 people in the area.

With the threat of encephalitis looming large in the area and Bora displaying quite a few early symptoms of the disease, Saikia wasted no time in collecting her blood sample. However, that was the easy part. The test kit that to detect Japanese encephalitis was only available at Jorhat Medical College in Jorhat town. Although barely 40 kilometres away, getting to the town was problematic.

Ouguri, on the edge of Jorhat and Sibsagar district, is located on the banks of the river Jhanji, a south bank tributary of the Brahmaputra. The village is protected from the river by a dyke and the only way to reach Ouguri from either of the two districts is by taking the road on top of the dyke. The recent incessant rains had made large stretches of the road unmotorable.

Since the health centre has no vehicle at its disposal, Bora’s family and Saikia pitched in to rent one that could transport the blood sample to the medical college. Bora finally got her tests results based on which Saikia treated her to a full recovery.

Disease surveillance can help pre-empt outbreaks but the state surveillance system [what does it consist of] is also not adequate, claim public health professionals. “The entire surveillance system has been weak for a while now,” said a person with an international health non-profit organisation that works closely with the Assam government. “So, irrespective of vaccination programs, cases of JE will keep emerging from time to time.”

Choudhury of the Infectious Disease Surveillance Program countered claims of the encephalitis surveillance program being not sturdy enough, even as she admitted that the programme did not have enough manpower.

“Every district reports each case of JE to the National Vector Borne Disease Control Programme office in Guwahati,” she explained. “And if there is a new case in any area with no history, our people go there immediately, collect blood samples, and are always on alert.”

Mosquito control (or not)

Meanwhile, community health workers have alleged that the government has been complacent about mosquito control measures because the outbreak in 2016 was less severe than the preceding years. In both Baghchung and Bhogamukh – the most severely affected areas in Jorhat – the government did not spray mosquito repellents. Such spraying or fogging is important in areas prone to mosquito-borne infections.

“Whatever [fogging] has happened has happened after people started dying,” claimed a health worker. “By then, the damage was already done. There seems to be a shortage of even DDT this year.” Dichlorodiphenyltrichloroethane or DDT is still used as to control mosquitos in many parts of the country.

Residents echoed similar concerns. Rupumoni Bora of Bhogamukh said the health department usually sent teams to encephalitis affected areas with insecticides for people to wash their mosquito-nets in preparation for summer. No team went to Bhogamukh this year.

“Nobody has come till date,” Bora said on Friday. “Locally, we have organised awareness camps with the help of the health centre, but no help has come from the district.”

However, Choudhury contested the claim. “I have personally ensured that fogging took place in high-risk areas in the various districts,” she contended. “So, accusations that we were not prepared are not true.”

All photos by Arunabh Saikia.

This reporting project has been made possible partly by funding from New Venture Fund for Communications.