Acute Encephalitis Syndrome Reduction through Promotion of Environmental Sanitation and Safe Drinking Water Practices

The rising number of AES cases in the country is mainly due to rapid and unplanned urbanization, poorly developed towns, and villages are void of safe sanitation, drinking water facility and behaviour change communication to promote good sanitation practices. According to NVBDCP a total 12,578 cases were affected by AES in 2017, a rise over 243 percent since 2010 AES outbreak of encephalitis in India. It is evident that large proportion of AES cases in Uttar Pradesh are caused by a bacterium called scrub typhus (5),(7) or bush typhus followed by Japanese Encephalitis virus. This, in turn, was linked to environment and living conditions around people tested positive with AES. Uttar Pradesh carried the largest AES burden in India for a long time possibly due to various reasons; socio-political, environmental and economic conditions. (10,11).

Tackling AES through Community led Water Management and Sanitation in Kheri, Uttar Pradesh: Lakhimpur Kheri is one of the largest Terai land District in state of Uttar Pradesh. It consists of 15 Blocks and comes under Lucknow division and, often in news due to flood conditions and JE/AES outbreak in monsoon seasons(9),(10),(11). It is one of the highly cultivated zone because of alluvial soil texture and irrigation facilities mediums are available e.g. rivers, canals, wetlands and motor pumps etc. The agricultural crops in practice are sugar cane, paddy, wheat, pulses, mustard and vegetables. Agriculture being primary occupation of the people in the region(8). The poor women(4) are often working in the farm field along with their children having much chances of exposure to vectors of the AES disease like chiggers are source of fatal scrub typhus lives inside the ears of rodents (17) and found on bushes(7). Water birds, pigs are host of JE virus, moreover paddy field is breeding ground for the mosquitoes Culex family (mainly Culex tritaeniorhynchus) and, if they bites on human body may cause JE illness. The poorest community residing in rural (2), peri-urban setting are more prone to getting AES as they hardly practice the safe hand washing with soap before cooking and eating food and, are not aware of significance of getting drinking water from a safe source like India marka-2 type hand pump, piped water supply and/or store it properly for later use (5). Therefore they drink contaminated water unknowingly and are habitual to live in a poor sanitation condition. Children and women are the most affected group lacking the safe sanitation, especially in monsoon seasons and/or flood conditions in terai belt of Lakhimpur Kheri (12),(13)(14). The AES case rise is high during July to November every year mostly in the flood affected Blocks. Table-1 and figure-4 is showing the spot mapping of AES cases block wise in the district. Those blocks are repeatedly facing the monsoon flood crisis every year, same time they have had the higher number AES cases as well(15),(16). Out of the total 15 blocks in the Kheri district the AES cluster found in most flood affected blocks i.e Phoolbehar, Ramiabehar, Isanagar, Bijuwa, Dhaurahara and Lakhimpur. In the figure-4, Red star is indicating the district hospital, green star indicating the blocks with encephalitis treatment centre, red points are marked for AES cases in year 2018, black points are marked for AES cases in year 2019, green points are marked for AES cases in year 2020. After visiting the each household with AES case in year 2018, 2019 and 2020, It was observed that the affected community is residing in locality of the poor environmental sanitation conditions and, are void of access to safe drinking water. It is evident through analysis of AES case line-list of integrated disease surveillance programme unit (IDSP) Kheri for past three years that 80 percent AES cases are directly linked with the water management and sanitation(18),(19).

Table-1 : Block wise AES cases in 2018-19-2020 Lakhimpur Kheri

Some corrective measures have been taken by the government of Uttar Pradesh to improve sanitation by the involvement of municipal body in the urban areas and Panchayati Raj Institutions in the rural areas. There require more efforts to revise the state water policy and sanitation infrastructure development in order to achieve the SDG-6. Development actors working on water and sanitation can play important role to intervene in-between the target community to engage them and help to create an aware society with the help of communication behavior change strategy. In order to increase the utility of the agricultural by-product and waste management in terms income generation for the poorest community, there must be provision of public private sector partnership with efforts of the state government and ensure the technology transfer between the farmers group on appropriate subsidy as they could adapt scientific farming. It shall be beneficial for the environment (26) as well increase the income of small farmers including women farmers. Strengthen the government system to address the water and sanitation issues in the most affected area primarily and later on cover all blocks to reduce AES cases through improved water management and good sanitation. Women play productive as well as reproductive role in the society, therefore they must be given utmost importance and have access to water and sanitation facility. Frontline workers (FLWs) like ASHA, Aganwadi workers, ANM’s role is crucial to educate the rural and urban women about the management of drinking water, personal hygiene and sanitation, and, routine immunization including JE vaccination to avoid encephalitis due to Japanese Encephalitis Virus. Capacity building of health workers and FLWs as they could educate the women of the poorest community, chlorinated drinking water, upgraded sanitation, hand washing with soap, Infant and young child feeding practices to reduce malnutrition and improve immunity of the children and family at large against water/vector borne diseases.

Programme for Appropriate technology in Health (PATH) organization is implementing AES project in 11 most affected districts of Uttar Pradesh. At Lakhimpur Kheri District PATH organization has introduced Encephalitis Treatment Model (ETCs) in 11 high risks blocks and main objective of ETCs to decrease the morbidity and mortality of AES cases through ensuring prompt treatment, early oxygenation and referral. The project is providing technical support to the government of Uttar Pradesh to establish ETCs at government hospitals for the treatment of AES case, and sensitize the community by involvement of FLWs about preventive measures against AES illness(20)(21). It shall be given utmost importance to protect the community from exposure to vectors of AES disease in a holistic way by engaging the multi-stakeholders like health, education, agriculture, animal husbandry, panchayat raj institutions, rural development, urban development and municipality, and, public health engineering department (PHED). These allied departments shall act in coordination under supervision of the district magistrate and work to control the vectors of AES diseases, ensure early referral of cases to nearest ETC, oxygenation and prompt treatment. Other than this, Integrated activities to prevent AES (28) are includes bush cutting, fogging and anti larval activity at the society places, chlorination of drinking water, India Marka-2 type hand pump installation in between the poorest community not having access to piped water supply, demonstration and training of compost making for the small farmers and other sustainable income generation activities for the women group along with health education programme for the children(27), youth and behaviour change communication in-between the target community. Public private sector partnerships, CBOs, NGOs, Educational Institutions, PRIs and local volunteers can play important role in implementation of above said activities and ensure the sustainability of AES reduction programme from Terai land in Uttar Pradesh and other regions worldwide (24),(25).

Conclusion: This article is based on field research study and I report for the first time that number of AES cluster through spot mapping is high in the blocks where flood conditions(22),(23) occurred every year causing water logging problem, contamination of drinking water and adversely affect the environmental sanitation. It is necessary to improve the water management practices amongst the community through an sustainable model of empowerment on environmental sanitation. Such kind of environmental sanitation intervention shall be community led and, also involve the development actors in same field, public private sector partnerships for the agricultural waste management and employment generation, capacitate allied government departments and fix their liability at policy level to meet the expected outcome (29). In order educate, aware and engage the women group and turn them as activists to reduce AES through improved environmental sanitation and water management. This way an aware community is adapt to good sanitation practices like hand washing with soap, manage agricultural waste and livestock waste into compost making, manage drinking water and grey water to prevent vector borne diseases as well as protection against COVID-19 pandemic.

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Acknowledgements: I’m thankful to national vector borne disease control programme (NVBDCP), government of Uttar Pradesh and PATH organization for their great efforts and new initiatives to reduce the number of AES cases through integrated preventive measures and establishment of encephalitis treatment centres in the 18 high risk districts of Uttar Pradesh. I am also thankful to IDSP unit Kheri for their support in research work related to acute encephalitis syndrome.

Author Information:

SEMRAI, Gola Gokarannath, Lakhimpur Kheri, Uttar Pradesh, India ( 262802).

Email: mukesh.envo@gmail.com

Contact No: +91 979-598-3487

Date of Birth: 15/07/1978

LinkedIn account: https://www.linkedin.com/in/mukesh-kumar-shukla-4325287a

Mukesh Shukla has his expertise in child health, nutrition, WASH and biodiversity conservation. Currently working as District Coordinator in Program for Appropriate Technology in Health (PATH) at Lakhimpur Kheri, U.P. India. Earlier he worked as Nutrition and WASH Expert for Nutrition Smart Village project in Chhatarpur, M.P. and worked as Project Officer in Centre for Environment Education, India for river biodiversity conservation education programme. Recently he structured an independent project on the topic of community led water management and sanitation, health education programme.