Mysterious ‘fever’ a bigger challenge than Covid

Reports in the media suggest that as many as 11 districts in Uttar Pradesh (UP) are currently in the grip of a ‘mysterious fever’ and suspected cases of dengue. The other suspected causes of fevers in these districts are scrub typhus, leptospirosis, Japanese Encephalitis (JE) which is caused by a virus, and other viral encephalitis. Even malaria or typhoid, endemic in large parts of India, cannot be ruled out. Similar reports have come in from Bihar as well.

A large number of cases have been reported among children in Firozabad, a city with a population of over 6 lakhs near Agra and known for its glass making industry. The population density is over 1000 per km2, which is more than twice the national population density.

Firozabad is on the national highway, which makes it an important stopover for passing transport vehicles. The district includes a large rural belt with rural-urban movement of people in search of occupation. These movements create an ideal environment for spread of febrile illnesses from this epicentre to other parts of the State.

The spate of febrile illnesses has caused panic. There are reports of people fleeing from villages as many, mostly children and young people, reportedly died from the "mysterious fever."

Media reports say thousands of people in Firozabad are bedridden with fever either at home and hospital. Till last week the district reported 71 deaths, tragically 52 of them being children. Yet, only a meagre 185 samples were tested, which yielded 73 positive cases for dengue, 28 for scrub typhus and one for Japanese Encephalitis.

In the 18th century, when told that her French subjects had no bread and were starving, Marie-Antoinette, the Queen of France famously sniffed and said, “Qu'ils mangent de la brioche” (Let them eat cake).

The attitude of our policy makers, in the wake of this public health crisis, has been similar. Despite one of the largest states in the country in the grip of a "mysterious fever", which is apparently killing mostly children and young people, our resources are deployed in mass vaccination for Covid19 which rarely kills children and young people. We are also Quixotically preparing for the paediatric third wave.

To add to the irony, vaccine trials for Covid-19 are being conducted among children with unholy haste. Schools continue to remain closed ostensibly to protect children from a "lethal" virus. The panic among parents has been sustained so that many are waiting for a vaccine for their children before they go back to school.

UP health officials confirmed this thought process by saying that the situation is fast turning ‘Covid like’. What an amateurish comparison! With so many deaths among children and young people from this "mysterious fever," only 185 samples have been tested after a month into this outbreak, compared to lakhs of RT-PCR tests done every day on asymptomatic people, both young and old.

Post-monsoon, dengue is a major public health problem in our country. It is a leading cause of hospitalization and death among children and young people. The death rate can vary from 2% - 20% depending on the severity, access to early diagnosis and treatment. The dreaded dengue hemorrhagic fever with severe fall in platelets and bleeding can be fatal.

The dengue virus is transmitted by bite of aedes mosquitoes, which thrive in artificial water containers. The mosquito, also known as the tiger mosquito is a day biter. There are four serotypes of the virus and previous infection with one serotype does not protect against subsequent infection by a different serotype - in fact this sequential infection with different serotypes makes a person more vulnerable to the dreaded dengue hemorrhagic syndrome.

The second suspect for this "mysterious illness" is scrub typhus with 28 confirmed cases out of the 185 samples tested. This is caused by rickettsia, a small bacterium named after Howard Ricketts, the American pathologist who died of it after discovering it. Scrub Typhus is transmitted by bite of mites which thrive in grassy soils.

Post-monsoon these grassy "mite islands" expand. The cycle of transmission continues in nature between mites and rodents. Children playing on grassy terrain and campers are accidental victims. Scrub Typhus is treated with antibiotics like tetracycline. When treated early, the mortality is 1.6%. In untreated cases the mortality can be as high as 30-35%.

Japanese Encephalitis is a viral infection which can affect the central nervous system. It is transmitted by culex mosquitoes which breed in rice fields. The natural cycle is between mosquitoes and pigs or other animals like cattle and in birds and poultry. The animal and bird hosts do not themselves suffer from the illness (except horses) but act as amplifier hosts, i.e. the virus multiplies in them. The infection does not cause symptoms but can be fatal in children and young adults with a case fatality rate of 20% to 40%. Neurological deficits in survivors are common.

Other diseases such as malaria and typhoid are the other unfinished agenda in our country. Malaria while treatable, can cause rapid deterioration in some cases where fatality can reach 20% even with treatment. Typhoid has a fatality rate between 1% to 4% with treatment, while without treatment the fatality rate can be as high as 10% to 30%. Children and young adults between 5 years to 19 years have the highest incidence.

Leptospirosis is also on the suspected list of probable cause of fevers. It is again an infection which spreads from waste water contaminated by urine of animals which carry the bacterial spirochetes. While it can be treated with antibiotics like penicillin, death rates can vary from 5% to 30% depending on diagnostic and treatment facilities. It is common after monsoon due to water logging through which people may wade and the organisms may enter through skin abrasions or cuts.

In comparison, untreated Covid-19 has a mortality rate of 0.3% across all age groups globally and less than 0.1% in India. In children and young adults, the mortality is lower than 0.05%.

The science and art of public health demands that scarce resources be allocated to diseases with higher public health burden. This is determined by death rates and potential years of life lost.

It would be evident that all the potential causes of "mysterious fever" presently creating havoc in districts of Uttar Pradesh have far higher death rates and potential years of life lost as they all predominantly affect children and young people. Offering mass vaccination against Covid-19 to populations in such predicaments is tantamount to asking them to eat cake when they cannot afford bread!

As Professor Martin Kulldorff, a leading epidemiologist from Harvard University says,"We have to go back to the basic principles of public health that was thrown out the window a year ago. It’s not one disease, public health is about all the diseases, and all the collateral damage."

An editorial in the British Medical Journal, "Covid-19: politicisation, corruption" and suppression of Science," poignantly states, "The stakes are high for politicians, scientific advisers and government appointees. Their careers and bank balances may hinge on the decisions that they make. But they have a higher responsibility and duty to the public. Science is a public good...When good science is suppressed, people die."