Anshuchoudhary28 at 21:47, 10 March 2026

2026-03-10T21:47:06Z

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{{short description|Outbreak of acute encephalitis syndrome in India}}
{{use dmy dates|date=June 2019}}
{{Infobox event
| title = 2019 Bihar encephalitis outbreak
| image = Bihar district location map Muzaffarpur.svg
| image_size =
| image_alt =
| caption = Location of Muzaffarpur district in Bihar
| duration =
| date = {{start and end dates|df=yes|2019|06|01|2019|09|20}}
| venue =
| location = [[Muzaffarpur district|Muzaffarpur]] and adjoining districts, [[Bihar]], India
| coordinates = 
| also_known_as =
| type = [[Encephalitis]]
| cause = Unclear
| outcome =
| casualties1 =
| casualties2 =
| casualties3 =
| reported deaths = 161
| reported injuries =
| reported missing =
| reported property damage =
| burial =
| inquiries =
| notes =
}}
In June 2019, an [[outbreak]] of [[acute encephalitis syndrome]] (AES) occurred in [[Muzaffarpur district|Muzaffarpur]] and the adjoining districts in [[Bihar]] state of [[India]] resulting in deaths of more than 150 children, mainly due to [[hypoglycemia]]. In subsequent months more cases and deaths were reported. The cause of outbreak is unclear. Malnutrition, climate, hygiene, inadequate health facilities, and lack of awareness are considered as contributing factors. The lychee fruit toxins are also cited as plausible cause of AES.

== History ==
Outbreaks of [[acute encephalitis syndrome]] (AES) have occurred previously in the northern regions of [[Bihar]] state and eastern regions of [[Uttar Pradesh]] state of India. The first case of AES in Muzaffarpur district was recorded in 1995.<ref name=":6">{{Cite news|url=https://indianexpress.com/article/explained/acute-encephalitis-syndrome-low-blood-sugar-bihar-5785453/|title=Explained: What causes AES? What makes Bihar so vulnerable?|date=2019-06-18|work=The Indian Express|publisher=Indian Express Group|oclc=70274541|language=en-IN|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618052246/https://indianexpress.com/article/explained/acute-encephalitis-syndrome-low-blood-sugar-bihar-5785453/|archive-date=18 June 2019|url-status=live}}</ref><ref name="np" /><ref>{{Cite news|url=https://www.indiatoday.in/india/story/bihar-encephalitis-deaths-what-nitish-kumar-may-learn-from-yogi-adityanath-govt-1550323-2019-06-17|title=Bihar encephalitis deaths: What Nitish Kumar may learn from Yogi Adityanath govt| vauthors = Dutta PK |date=2019-06-17|work=India Today|publisher=Aroon Purie|issn=0254-8399|archive-url=https://web.archive.org/web/20190617093439/https://www.indiatoday.in/india/story/bihar-encephalitis-deaths-what-nitish-kumar-may-learn-from-yogi-adityanath-govt-1550323-2019-06-17|archive-date=17 June 2019|url-status=live|access-date=2019-06-18}}</ref> There were 143 deaths in 2013, 355 in 2014, 11 in 2015, four in 2016, 11 in 2017 and 7 in 2018.<ref name=":6" /><ref name=":5">{{Cite news|publisher=Indian Express Group|oclc=70274541|url=https://indianexpress.com/article/india/heat-lack-of-nutrition-awareness-add-to-aes-bihar-kids-toll-over-100-5785552/|title=Heat, lack of nutrition, awareness add to AES, Bihar kids toll over 100|date=2019-06-18|work=The Indian Express|language=en-IN|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618042855/https://indianexpress.com/article/india/heat-lack-of-nutrition-awareness-add-to-aes-bihar-kids-toll-over-100-5785552/|archive-date=18 June 2019|url-status=live}}</ref> In most recent years, the death toll had remained under 20.<ref name="np" />

== Outbreak ==
In June 2019, an outbreak of AES occurred in 222 blocks of [[Muzaffarpur district|Muzaffarpur]] and the adjoining districts in Bihar.<ref name="np">{{cite news | url = https://nationalpost.com/news/world/could-the-humble-litchi-fruit-be-behind-a-mysterious-sickness-that-has-killed-nearly-100-children-in-india | title = Could the humble litchi fruit be behind a mysterious sickness that has killed nearly 100 children in India? | first1=Joanna| last1=Slater| name-list-style = vanc | date = 17 June 2019 | access-date = 17 June 2019 | work = The National Post |issn=1486-8008}}</ref><ref>{{Cite web|url=https://reliefweb.int/report/india/india-acute-encephalitis-syndrome-aes-bihar-dg-echo-media-echo-daily-flash-17-june-2019|title=India - Acute Encephalitis Syndrome (AES) in Bihar (DG ECHO, media) (ECHO Daily Flash of 17 June 2019) - India|website=ReliefWeb|date=17 June 2019 |language=en|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618091839/https://reliefweb.int/report/india/india-acute-encephalitis-syndrome-aes-bihar-dg-echo-media-echo-daily-flash-17-june-2019|archive-date=18 June 2019|url-status=live}}</ref>

As a result of the outbreak, total 154 children died in first three weeks of June 2019.<ref name=":12">{{cite journal | vauthors = Ghosh S, Raghunath M, Sinha JK | title = Recurring acute encephalitis syndrome outbreaks in Bihar, India | language = English | journal = Lancet | volume = 394 | issue = 10202 | pages = 914 | date = September 2019 | pmid = 31526729 | doi = 10.1016/S0140-6736(19)31811-2 | doi-access = free }}</ref> A total of 440 cases of AES were admitted to hospitals in these three weeks.<ref name=":5" /> At least 85 children of them died at the [[Sri Krishna Medical College and Hospital]] (SKMCH), the largest state-operated hospital in Bihar, while at least 18 children died at the Kejriwal Matrisadan, a trust-run hospital, in these weeks.<ref name=":5" /><ref name=":10">{{Cite web|url=https://www.ndtv.com/cities/bihar-encephalitis-outbreak-kills-over-125-children-with-107-dead-in-muzzaffarpur-2054896|title=Nitish Kumar Visits Encephalitis Ground Zero, "Go Back" Cry Protesters|website=NDTV.com|url-status=live|archive-url=https://web.archive.org/web/20190618091840/https://www.ndtv.com/cities/bihar-encephalitis-outbreak-kills-over-125-children-with-107-dead-in-muzzaffarpur-2054896|archive-date=18 June 2019|access-date=2019-06-18}}</ref> Most of them were aged between 1 and 10 years.<ref name=":2">{{Cite news|url=https://www.indiatoday.in/india/story/encephalitis-toll-reaches-83-in-bihar-s-muzaffarpur-1549820-2019-06-16|title=Encephalitis toll reaches 84 in Bihar's Muzaffarpur|date=16 June 2019|work=[[India Today]]|access-date=17 June 2019|url-status=live|archive-url=https://web.archive.org/web/20190617051842/https://www.indiatoday.in/india/story/encephalitis-toll-reaches-83-in-bihar-s-muzaffarpur-1549820-2019-06-16|archive-date=17 June 2019|publisher=Aroon Purie|issn=0254-8399|oclc=321350054}}</ref><ref>{{Cite news|url=https://www.indiatoday.in/india/story/encephalitis-fever-bihar-1550297-2019-06-17|title=Encephalitis: Death toll reaches 100 in Bihar|date=17 June 2019|work=India Today|access-date=17 June 2019|url-status=live|archive-url=https://web.archive.org/web/20190617083113/https://www.indiatoday.in/india/story/encephalitis-fever-bihar-1550297-2019-06-17|archive-date=17 June 2019|publisher=Aroon Purie|issn=0254-8399|oclc=321350054}}</ref><ref name=":1">{{Cite web|url=https://www.ndtv.com/india-news/muzzafurpur-bihar-encephalitis-outbreak-kills-100-children-heatwave-kills-40-in-one-day-2054405|title=100 Children Die Of Encephalitis In 16 Days In Bihar's Muzaffarpur|website=NDTV.com|url-status=live|archive-url=https://web.archive.org/web/20190617083117/https://www.ndtv.com/india-news/muzzafurpur-bihar-encephalitis-outbreak-kills-100-children-heatwave-kills-40-in-one-day-2054405|archive-date=17 June 2019|access-date=17 June 2019}}</ref>

In subsequent months of July, August and September; at SKMCH; 30, 18 and at least 12 cases were reported. Total 647 cases of AES including 161 deaths were reported between 1 June and 20 September 2019.<ref>{{Cite web|url=https://www.downtoearth.org.in/news/health/acute-encephalitis-syndrome-strikes-north-bihar-again-2-children-dead-66844|title=Acute Encephalitis Syndrome strikes north Bihar again, 2 children dead|website=www.downtoearth.org.in|language=en|access-date=2020-01-04}}</ref>

== Syndrome ==
The term [[acute encephalitis syndrome]] (AES) was coined by the [[World Health Organization|World Health Organisation]] in 2008.<ref name=":0">{{cite journal | vauthors = Ghosh S, Basu A | title = Acute Encephalitis Syndrome in India: The Changing Scenario | journal = Annals of Neurosciences | volume = 23 | issue = 3 | pages = 131–133 | date = September 2016 | pmid = 27721580 | pmc = 5043220 | doi = 10.1159/000449177 }}</ref> The symptoms of AES include an acute onset of fever and associated clinical neurological manifestations such as mental confusion, disorientation, delirium, convulsions, or [[coma]].<ref name=":0" /><ref name=":3">{{cite journal | vauthors = Joshi R, Kalantri SP, Reingold A, Colford JM | title = Changing landscape of acute encephalitis syndrome in India: a systematic review | journal = The National Medical Journal of India | volume = 25 | issue = 4 | pages = 212–20 | date = July–August 2012 | pmid = 23278779 | url = https://www.researchgate.net/publication/234030375 }}</ref> Early symptoms include headaches and vomiting, along with sudden [[hypoglycemia]] (drops in blood sugar levels), but may lead to coma, brain dysfunctions, and inflammation of the heart and lungs. Those that survive AES may have long-term neurological weaknesses.<ref name="bbc">{{cite web|url=https://www.bbc.com/news/world-asia-india-48610932|title=Encephalitis in India kills more than 90 children|date=17 June 2019|work=[[BBC]]|access-date=17 June 2019|archive-url=https://web.archive.org/web/20190617123938/https://www.bbc.com/news/world-asia-india-48610932|archive-date=17 June 2019|url-status=live}}</ref> The severe hypoglycemia can cause death.<ref name=":7">{{cite journal | vauthors = Shrivastava A, Kumar A, Thomas JD, Laserson KF, Bhushan G, Carter MD, Chhabra M, Mittal V, Khare S, Sejvar JJ, Dwivedi M, Isenberg SL, Johnson R, Pirkle JL, Sharer JD, Hall PL, Yadav R, Velayudhan A, Papanna M, Singh P, Somashekar D, Pradhan A, Goel K, Pandey R, Kumar M, Kumar S, Chakrabarti A, Sivaperumal P, Kumar AR, Schier JG, Chang A, Graham LA, Mathews TP, Johnson D, Valentin L, Caldwell KL, Jarrett JM, Harden LA, Takeoka GR, Tong S, Queen K, Paden C, Whitney A, Haberling DL, Singh R, Singh RS, Earhart KC, Dhariwal AC, Chauhan LS, Venkatesh S, Srikantiah P | display-authors = 6 | title = Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study | language = English | journal = The Lancet. Global Health | volume = 5 | issue = 4 | pages = e458–e466 | date = April 2017 | pmid = 28153514 | doi = 10.1016/S2214-109X(17)30035-9 | doi-access = free }} {{open access}}</ref> The syndrome is locally known as C''hamki Bukhar'' in Bihar.<ref name=":1" /><ref name=":12" /><ref>{{cite journal | vauthors = Sunderam S, Kumar D | title = Recurring Outbreaks of Acute Encephalitis Syndrome Cases in Bihar: A Conundrum for Experts and Health System | journal = Indian Journal of Community Medicine | volume = 44 | issue = 4 | pages = 403 | date = 2019-10-01 | pmid = 31802811 | pmc = 6881881 | doi = 10.4103/ijcm.IJCM_342_19 | doi-access = free }}</ref>

== Cause ==
The cause of the outbreak is unclear.<ref name=":11">{{Cite news|url=https://www.bbc.com/news/world-asia-india-48610932|title=India encephalitis death toll rises to 103|date=2019-06-18|access-date=2019-06-18|language=en-GB|archive-url=https://web.archive.org/web/20190617145557/https://www.bbc.com/news/world-asia-india-48610932|archive-date=17 June 2019|url-status=live}}</ref><ref name=":13">{{cite journal | vauthors = Chatterjee P | title = No cause identified for death of children in Bihar, India | language = English | journal = Lancet | volume = 393 | issue = 10191 | pages = 2578 | date = June 2019 | pmid = 31258117 | doi = 10.1016/S0140-6736(19)31509-0 | s2cid = 195699211 }}</ref>

AES can be caused by different microorganisms including virus, bacteria, fungi, parasites and [[Spirochaete|spirochetes]], as well as chemicals and toxins. AES mostly affects children below 15.<ref name=":0" /><ref>{{cite journal | vauthors = Chaudhuri A, Kennedy PG | title = Diagnosis and treatment of viral encephalitis | journal = Postgraduate Medical Journal | volume = 78 | issue = 924 | pages = 575–83 | date = October 2002 | pmid = 12415078 | pmc = 1742520 | doi = 10.1136/pmj.78.924.575 }}</ref> In India, AES was chiefly associated with [[Japanese encephalitis|Japanese encephalitis virus]] (JEV) before 1975. The JEV cases and outbreaks became more frequent and endemic regions developed between 1975 and 1999. After 1999, non-JEV cases and outbreaks of AES were increasingly reported caused by other viruses including [[Chandipura virus]] (CHPV), [[Nipah virus]] (NiV), and [[enterovirus]]es. After 2012, it is observed that the cause shifting to JEV.<ref name=":0" /><ref name=":3" /> Initial examination shows little sign of the JEV or other viral routes in the affected children.<ref name="np" /> A study by [[All India Institute of Medical Sciences, Patna|AIIMS Patna]] found the presence of enterovirus.<ref name=":8" />

High temperature, humidity, malnutrition, poor hygiene and lack of awareness are known aggravating factors of AES.<ref name=":13" /><ref name=":4">{{Cite web|url=https://www.news18.com/news/india/litchi-toxins-or-heat-wave-doctors-explain-whats-causing-the-deadly-encephalitis-epidemic-in-bihar-2191335.html|title=Litchi Toxins, Malnutrition or Heat Wave? Doctors Explain What's Causing Deadly AES Epidemic in Bihar|website=News18|date=18 June 2019|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618065240/https://www.news18.com/news/india/litchi-toxins-or-heat-wave-doctors-explain-whats-causing-the-deadly-encephalitis-epidemic-in-bihar-2191335.html|archive-date=18 June 2019|url-status=live}}</ref><ref name=":5" /><ref name=":6" /> Cases of AES tend to occur during the country's monsoon season.<ref name="bbc" /> In June 2019, the temperature in Muzaffarpur had remained above {{convert|40|C|F}} and the rains were delayed which might have aggravated the situation.<ref name=":5" /><ref name=":8">{{Cite web|url=https://indianexpress.com/article/explained/explained-what-is-acute-encephalitis-syndrome-bihar-symptoms-causes-treatment-5779371/|title=Acute encephalitis syndrome (AES) explained: Definition, cause, and its contrary theories|date=2019-06-17|website=The Indian Express|language=en-IN|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190617123944/https://indianexpress.com/article/explained/explained-what-is-acute-encephalitis-syndrome-bihar-symptoms-causes-treatment-5779371/|archive-date=17 June 2019|url-status=live}}</ref> It was the [[2019 Indian heat wave|second-longest heatwave]] in the region.<ref>{{Cite web|url=https://www.aljazeera.com/news/2019/06/india-heatwave-turns-deadly-190618090507114.html|title=India's heatwave turns deadly|date=18 June 2019|website=Al Jazeera|access-date=18 June 2019}}</ref> Poverty and malnutrition is widespread among children in the region. Malnourished children lack a buffer stock of sugar as glycogen in the liver which puts them at higher risk of hypoglycemia.<ref name=":8" /><ref name=":9">{{Cite web|url=https://www.downtoearth.org.in/interviews/health/-it-s-absurd-to-blame-litchi-for-aes-malnourishment-the-real-cause--65130|title='It's absurd to blame litchi for AES, malnourishment the real cause'|website=www.downtoearth.org.in|language=en|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618072313/https://www.downtoearth.org.in/interviews/health/-it-s-absurd-to-blame-litchi-for-aes-malnourishment-the-real-cause--65130|archive-date=18 June 2019|url-status=live}}</ref><ref name=":11" /> Awareness campaigns were carried out in March–April 2019 but were not conducted later due to the [[2019 Indian general election]]s. The local administration was not watchful due to the few cases of AES in recent years.<ref name=":5" />

[[File:Litchi_chinensis_fruits.JPG|thumb|right|[[Lychee]] fruits, which naturally include toxins related to encephalitis, are suspected to have been a contributing factor in the outbreak.]]The region is the largest producer of lychee fruits in India. A 2014 study published in Lancet found that the [[methylene cyclopropyl acetic acid]] and [[hypoglycin A]] found in unripe lychee (''Litchi chinensis)'' fruit can cause hypoglycemia and cited them as plausible cause of AES outbreaks. A diet heavy on unripe lychee fruits without having an otherwise full meal later in the day may put malnourished children at risk of hypoglycemia.<ref name=":12" /><ref name=":7" /><ref name="np" /><ref name=":4" /><ref name=":8" /> Others disputed the findings citing the unlikeliness of very large consumption of unripe lychee fruits, lack of cases in healthy, well-nourished children and many other pediatric illnesses causing hypoglycemia.<ref>{{Cite web|url=https://thewire.in/health/litchi-hypoglycin-lancet-mcpg|title=Is Litchi the Real Culprit Behind 1995's Mysterious Muzaffarpur Child Deaths?|website=The Wire|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618072324/https://thewire.in/health/litchi-hypoglycin-lancet-mcpg|archive-date=18 June 2019|url-status=live}}</ref><ref name=":8" /><ref name=":9" /> Health officials reported that most of the victims suffered severe hypoglycemia.<ref name="AJ">{{Cite web|url=https://www.aljazeera.com/news/2019/06/encephalitis-kills-100-children-india-bihar-state-190618030756153.html|title=Encephalitis kills more than 100 children in India's Bihar state|website=www.aljazeera.com|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618042910/https://www.aljazeera.com/news/2019/06/encephalitis-kills-100-children-india-bihar-state-190618030756153.html|archive-date=18 June 2019|url-status=live}}</ref><ref>{{Cite web|url=https://timesofindia.indiatimes.com/india/20-more-kids-die-in-24-hours-bihar-encephalitis-toll-hits-93/articleshow/69818146.cms|title=Encephalitis: 20 more kids die in 24 hours, Bihar encephalitis toll hits 93|last=Ramashankar|first=Mr.|date=2019-06-17|website=The Times of India|archive-url=https://web.archive.org/web/20190618080034/https://timesofindia.indiatimes.com/india/20-more-kids-die-in-24-hours-bihar-encephalitis-toll-hits-93/articleshow/69818146.cms|archive-date=18 June 2019|url-status=live|access-date=2019-06-18}}</ref>

The hospitals and primary health centres lacked the required facilities to treat children.<ref name=":5" />

== Government response ==
The Chief Minister of Bihar [[Nitish Kumar]] announced an [[ex gratia]] payment of {{INRConvert|4|l}} to the next of the kin of the children who died from AES.<ref name=":1" /><ref name=":2" /> He also visited the hospital and ordered the expansion of the hospital.<ref name=":10" /><ref>{{Cite web|url=https://www.thequint.com/news/india/bihar-muzaffarpur-encephalitis-deaths-live-updates-acute-encephalitis-syndrome-outbreak|title=Muzaffarpur Deaths: CM Calls for Hospital Expansion, Toll at 109|date=2019-06-18|website=The Quint|language=en|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618133023/https://www.thequint.com/news/india/bihar-muzaffarpur-encephalitis-deaths-live-updates-acute-encephalitis-syndrome-outbreak|archive-date=18 June 2019|url-status=live}}</ref>

The union minister of health [[Harsh Vardhan (Delhi politician)|Harsh Vardhan]] visited and announced the set-up of 100-bed pediatric ward at the SKMCH as well as five virology laboratories in Bihar. He also announced the upgrade of the [[India Meteorological Department]]'s observatory in Muzaffarpur for better study of climate. Seven pediatric [[intensive care unit]]s are being established. The interdisciplinary team consisting of experts from [[Indian Council of Medical Research]], [[NIMHANS|National Institute of Mental Health and Neurosciences]], [[National Institute of Malaria Research]]; [[National Institute of Nutrition, Hyderabad|National Institute of Nutrition]], [[National Institute of Virology]]; [[National Institute of Epidemiology]] and [[All India Institute of Medical Sciences, New Delhi]] was formed and sent to Bihar to study the syndrome and establish the cause.<ref name=":5" /><ref>{{Cite web|url=https://www.firstpost.com/india/bihar-encephalitis-deaths-harsh-vardhan-constitutes-high-level-multi-disciplinary-team-to-monitor-patients-find-cause-of-viral-disease-6836181.html|title=Bihar encephalitis deaths: Harsh Vardhan constitutes high-level multi-disciplinary team to monitor patients, find cause of viral disease|website=Firstpost|date=18 June 2019|access-date=2019-06-18|archive-url=https://web.archive.org/web/20190618133022/https://www.firstpost.com/india/bihar-encephalitis-deaths-harsh-vardhan-constitutes-high-level-multi-disciplinary-team-to-monitor-patients-find-cause-of-viral-disease-6836181.html|archive-date=18 June 2019|url-status=live}}</ref>

The [[Supreme Court of India|Supreme Court]] ordered the Bihar government to file an affidavit to show the competence of medical facilities and other hygiene conditions in the state in the wake of the deaths.<ref>{{Cite web|url=http://www.millenniumpost.in/big-stories/encephalitis-deaths-sc-directs-centre-bihar-govt-to-file-response-within-7-days-359590|title=Encephalitis deaths: SC directs Centre, Bihar govt to file response within 7 days|date=24 June 2019}}</ref>

The [[National Human Rights Commission of India|National Human Rights Commission]] (NHRC) sent notices to the [[Ministry of Health and Family Welfare]] and the [[Bihar government]] over the deaths and asked for a report in four weeks.<ref name=":4" /><ref name=":5" />

== Aftermath ==
Total 872 cases of encephalitis including 176 deaths were reported in Bihar in 2019.<ref>{{Cite web|date=2019-07-12|title=176 died in Bihar due to Acute Encephalitis this year, 872 cases reported|url=https://www.asianage.com/india/all-india/120719/176-died-in-bihar-due-to-acute-encephalitis-this-year-872-cases-reported.html|access-date=2020-12-09|website=The Asian Age}}</ref>

== See also ==
* [[2017 Gorakhpur hospital deaths]]
* [[Eluru outbreak]]

== References ==
{{reflist}}

{{Disasters in India in 2019}}

{{DEFAULTSORT:Bihar encephalitis outbreak}}
[[Category:2019 disease outbreaks]]
[[Category:2019 disasters in India]]
[[Category:Encephalitis]]
[[Category:Disease outbreaks in India]]
[[Category:Muzaffarpur]]
[[Category:June 2019 in India]]
[[Category:2010s in Bihar]]

2019 Bihar encephalitis outbreak - Revision history

Anshuchoudhary28 at 21:47, 10 March 2026