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Rajesh Kumar Srivastava v. Shri A.P.Verma And Others - CONTEMPT APPLICATION (CIVIL) No. 820 of 2002  RD-AH 21029 (13 December 2006)
Court No. 30
CIVIL MISC. CONTEMPT PETITION NO. 820 OF 2002 (JE/6)
Rajesh Kumar Srivastava - Applicant
Shri A.P. Verma and others - Respondents
Hon'ble Sunil Ambwani, J.
1. Present, Shri S.M.A. Kazmi, learned Advocate General, U.P. assisted by Shri J.K. Tiwari, learned Standing Counsel; Dr. Ashok Nigam, Additional Solicitor, General of India; Shri K.C. Sinha, Assistant Solicitor General of India; Shri Mahendra Bahadur Singh, learned Standing Counsel, Central Government; Shri Jayont Banerji, amicus curiae and Shri Ashok Srivastava, observer; Dr. V.K. Nigam, Joint Director, Communicable Diseases, Programme Officer, J.E. Swasthya Bhawan, Lucknow; Dr. Ramesh Chandra, Acting State Entomologist, U.P. Lucknow; Dr. A.K. Upadhyay, Prof. Social and Preventive Medicine, B.R.D. Medical College, Gorakhpur.
2. In this contempt petition pending on an application of Shri Rajesh Kumar Srivastava, a noted journalist, for monitoring the directions issued by Hon'ble Supreme Court in D.K. Joshi's case (2000) 5 SCC 80 for identifying, apprehending and prosecuting unqualified and unregistered medical practitioners, the court had taken notice of inadequate medical care available to rural areas and specially in eastern U.P. The court noticed outbreak of Japanese Encephalitis (JE) a viral diseases striking thousands of children since 1978 killing about 6000 and paralyzing equal numbers.
3. The J.E. is a viral disease which infects animals and birds as amplifying hosts and then humans. It is transmitted by mosquitoes and in human cases causes inflammation of the membrane around the brain. The disease spreads around paddy fields in rural areas. With the expansion of irrigation in semi-arid areas the flooding of fields at the start of cropping cycle, leads to an explosive build up of the mosquito population. This causes circulation of virus to spill over from the usual host (birds and pigs) to human population. The disease is caused by flavivirus that affects the membrane around the brain. The fatality rate is as high as 60% among those with disease symptoms, 30% of whom suffer from lasting damage to central nervous system. It occurs mainly in young children as the older children and adults, already infected, acquire immunity. It is mostly spread in South East Asia for last 20 years. It was also reported in Arkot district in Tamilnadu, in Srilanka, and is endemic in eastern U.P. since 1978, affecting about 4 districts with epicenter at Gorakhpur.
4. In the year 2006, the J.E. again struck along with Cox Sackie (C.S.) virus. There is some dispute about the number of deaths estimated at about 1000. The State, however, admitted 146 deaths at Nehru Hospital, B.R.D. Medical College, Gorakhpur alone between April 1 to September 1, 2006, out of 664 admissions, in which 50% cases were reported to be each of J.E. and C.S. virus.
5. The Court found that the State Government is not taking adequate measures to contain the disease. The preventive steps were taken only after the disease took toll of thousands of children in eastern U.P. The outbreak of the disease in 2005 with 1411 admitted deaths caused some concern, on which the State Government undertook vaccination drive in 07 out of 34 affected district. The State did not do enough in training the medical and para medical staff and to strength the infrastructure in hospitals, except adding a few beds in B.R.D. Medical College. The Medical and Health Department did virtually nothing for surveillance, research, increase of infrastructure in the 34 districts hospitals, and for rehabilitation of thousands of surviving children suffering mental disorders.
6. The court was deeply concerned and took suo motu notice of the emergent situation. Whenever basic human right of citizens, which include right to health guaranteed under Article 21 of the Constitution of India, are violated, the Court has a constitutional duty to step in and to direct immediate remedial steps. By order dated 5.9.2006 (JE/1) the Court directed the Principal Secretary, Medical and Health, U.P. and the Director General, Medical and Health, U.P. to appear in the court on 12.9.2006 with a detailed report with regard to steps taken in the matter and to publish a white paper for containing the outbreak of the diseases to be widely circulated in news papers in eastern U.P. so that their claims may be verified.
7. Shri Arun Kumar Misra, Principal Secretary, Medical Health and Family Welfare, U.P.; Shri S.K. Raghuvanshi, Special Secretary, Medical Education, U.P.; Dr. (Mrs.) B. Nath, Director General, medical health & Family Welfare, U.P. and Dr. Kamal Sahni, Director General, Medical Education, U.P. Lucknow and Dr. O.P. Pathak, Director, Vector Borne Disease, U.P. Lucknow and Prof. (Dr. ) Kamal Prasad Kushwaha, B.R.D. Medical College, Gorakhpur appeared on 12.9.2006. The State Government represented by Shri S.M.A. Kazmi, learned Advocate General accepted the fact that the eastern U.P. is facing medical emergency. He provided a summary of the steps taken by the State Government to meet the crisis. The information furnished by him is contained in the order dated 12.9.2006 (JE-2) in para 8 and 9:-
8. Shri S.M.A. Kazmi, learned Advocate General has submitted a report in which, the steps taken to meet the crisis have been detailed. A summary of these steps, as provided by the Advocate General, is as follows;
"National level expert meeting on 29 & 30 December 2005 to formulate Action Plan for 2006.
Action Plan sent in March, 2006 to all concerned authorities of Divisions & Districts Commissioner, Additional Director of health, District Magistrates & Chief Medical Officers.
Intensive training drive (Capacity building)-
March, 2006- Training of Trainers (TOT)
March & April, 2006- Training of Medical Officers of JE affected districts in JE clinical management.
June, 2006- Training of Staff nurses & paramedical staff.
No specific treatment for JE cases but supportive & symptomatic treatment schedule made available to districts & followed accordingly.
Medicines required for JE treatment sent to PHC, CHC, District Hospitals.
Medicines worth Rs. 10.00 lakh provided to BRD Medical College, Gorakhpur
J.E. Test Kits provided to BRD Medical College, Gorakhpur & others district hospital labs.
Testing facilities available in
BRD Medical College, Gorakhpur
District Hospital, Gorakhpur
District Hospital, Raebareli
Regional Lab., Swasthya Bhawan, Luckn
Ten doctors, six staff nurse, 3 laboratory technicians & 3 other class IV employee provided to BRD Medical College.
Adequate budget & insecticide provided to districts for intervention measures.
Control Room established at each district & operating 24 hours
Case Fatality Rate ( CFR ) during 2006 is very low (15.88%) in comparison to 2005 (24.27%) and 2004 (20.10%) due to better case management.
Vaccination done in 6836506 children of 1015 years in 07 districts during May/June, 2006 and 81458 children of 105 years in one district-Basti (Inter-epidemic period)
Other Departts coordination needed.
Community involvement to avoid man-mosquito contact of most importance for which BCC campaign being carried out to generate awareness among community."
9. Shri Kazmi has also given a list of 35 doctors in the districts of Basti; Deoria; Gorakhpur; Kushi Nagar; Lakhimpur Khiri; Maharajganj; Sant Kabir Nagar and Sidhartha Nagar, trained by experts including Professor T.N. Dhole of the Department of Microbiology, S.G.P.G.I. Lucknow in March-April 2006. He has also provided a ''Protocol for Management of Children Suffering from JE' prepared by Department of Pediatrics, B.R.D. Medical College, Gorakhpur.
8. The Court noticed that the State Government had published a short information book of Dr. M.L. Khatloia, Additional Director and State Programme Officer on 21.3.2005 giving the statistics and steps taken to contain Viral Encephalitis (VE) in which the State Government reported that JE has become endemic in U.P. It surfaced in 1978 and has affected 28 districts. In the year 1988 largest number of 4484 patients were reported out of which 1413 died. In the year 1991 the same kind of epidemic was noticed. It again took menacing proportion in the year 2005. The Chief Minister of the State sent a letter on 8.5.2006 to the Prime Minister reminding him of the discussion held at Lucknow on 1.9.2005. The Chief Minister apprised the Prime Minister that JE had affected 34 districts killing 1411 patients and requested for importing 66.54 lacs vaccine under a programme with Central Government in January 2006 and requested for giving top priority to the import.
9. Learned Advocate General agreed with the Principal Secretary, Medical and Health and Director General, Medical and Health, Government of U.P. to take some more effective measures for prevention and control. Shri Radhay Shyam Misra, Former Vice Chancellor, Gorakhpur University and Chairman of ''Samarpan Sansthan' an NGO was allowed to intervene through Shri Satish Trivedi, Senior Advocate. It was suggested that a nodal centre be established on permanent basis to monitor JE/CS or other viral infections. The Director General, Medical Education informed that the State Government had released Rs. 2 crores in last financial year for establishment of ''Clinical Research and Epidemic Ward of B.R.D. Medical College' and that in current year, the State Government made a provision of Rs. 7 crores out of which Rs. 276.22 lacs was released on 12.4.2006 for ''Viral Research Centre and Epidemic Ward' for which constructions are under progress. The Court noticed that there is no Viral Research Centre in U.P. and that it takes long time to get reports from the National Institute of Virology, Pune to identify the outbreak of strains. There is no effective surveillance and that apart from B.R.D. Medical College having only 94 beds in pediatric ward, the district hospitals in the 34 affected districts do not have adequate medical facilities. There is no rehabilitation centre for the children who survives the infections. The court directed the State Government to prepare and submit a detailed plan on 27.9.2006.
10. The report submitted by the State Government on the next date is sumarised in para 3 and 4 of the order dated 27.9.2006 (JE/3) as under:-
"3. The first part of the report prepared by the Medical Education Department, Government of U.P. highlights the efforts made by the State Government for establishing ''Viral Encephalitis Ward' and an ''Intensive Care Unit,' the equipments in B.R.D. Medical College, Gorakhpur; supply of medicines for viral encephalitis by the State Government; establishment of Viral Research Centre and an Epidemic Ward for which Rs. 4.76 crores has been released in the year 2005-06 and the building of Research Centre and Epidemic Ward is under construction and is likely to be completed by December 2006; the posting of additional number of medical officers, the meeting held on September 12, 2006 and the proposal regarding establishment of Rehabilitation Centre. It further reports that the Director, S.G.P.G.I., Lucknow has been requested to prepare a detailed project report for ''Viral Research Centre' comparable to the status of ''National Institute of Virology, Pune'. The Advocate General has also placed the letter written by Chief Minister, U.P. to Prime Minister and Minister of Health, Government of India requesting for their intervention in establishing a ''Virology Research Centre' in U.P. of the level of National Institute of Virology, Pune.
4. The second part of the report submitted by Principal Secretary, Medical Health & Family Welfare, Government of Uttar Pradesh, Lucknow, details the efforts for supply of vaccine and technical input in 41.22 lakh doses of the vaccine for the children in five districts of Bahraich, Shravasti, Gonda, Balrampur and Basti; reservation of 10-20 beds in all the Government Hospitals in endemic districts; preparation of separate wards in district hospital Saharanpur, Ram Manohar Lohia Hospital, Lucknow and Pediatrics Hospital Medical College, Allahabad. It also reports that surveillance and MIS system is being strengthened by imparting training for capacity building. The Additional Chief Medical Officers; Medical Officers of CHCs and PHCs and para medical staff of JE affected 34 districts are to be trained for prevention and control; lab diagnosis; clinical management and rehabilitation of the patients. The ''JE Command Control Committee' is being constituted to monitor and coordinate the activities, and a ''J.E. Steering Committee' is being constituted at state level under the chairmanship of Secretary, Medical, Health & Family Welfare with the Director General, Medical Education as Member Secretary and Special Secretary, Medical Education and Special Secretary, Finance as its members. It is further reported that instructions have been sent to the districts to report JE cases on a ''Standard Reporting Format,' and for regular entomological surveillance through Medical & Health and Animal Husbandry Departments. A teem of experts is proposed to be sent to South Asian countries where the disease has been eliminated. To assist the court, Mr. Jayont Banerji, Advocate has been appointed as Amicus Curiae @ Rs. 10000/- per month as honorarium."
11. Dr. T.N. Dhole made suggestions of two project proposals as under:-
1. Safety and Immunogenic Study of Live-attenuated SA-14-14-2 Japanese Encephalitis Vaccine in children in seven endemic districts of U.P. The objectives of the proposal are:-
To evaluate the safety and reactogenicity of the SA-14-14-2 strain of JE vaccine.
(a) To assess the risk vs. benefits of live attenuated vaccination in children as well as in young adult population who are at high risk.
(b) To determine the magnitude and protective immune response required/necessary for the prevention of disease morbidity and mortality.
2. Encephalitis: Strategies for avoiding frequent outbreaks.
The objectives of the proposal are:
1. Setting up of surveillance center and network with SGPGI.
2. Setting up of a diagnostic laboratory at BRD Medical College, Gorakhpur and SGPGI Lucknow
3. Setting up of JE ward in BRD Medical College for 300 patients.
4. Setting up of small laboratories in all the 31 infected districts."
Dr. Dhole has also expressed concerns about the lack of training institute for health workers, ANMs, Anganwadi workers, vaccinators and technical. According to him, for long term interest a ''Virology Research Institute' or a Centre for Encephalitis/Viral Diseases be set up with a 400 to 500 bedded hospital for supervising and conducting epidemiological assessments and surveillance, for undertaking comprehensive research, diagnosis, treatment and rehabilitation of patients. Further, development and production of vaccines should be a part of such an Institute. As per Dr. Dhole, the campus of the SGPGI is so vast that it can easily accommodate such an institute. The institute should be centrally located (geographically) in the State so that it can be easily accessed by needy persons.
Dr. Dhole also proposed that there should be PHC level monitoring with a doctor trained for treatment to be posted with arrangement of atleast five beds. If required, the patients can be shifted to CHCs having computerized link with the telemedicine department of the SGPGI for advise on the course of action. He proposed that the SGPGI can function as a ''Nodal Centre'. Dr. Dhole was impressed with the work carried out at BRD Medical College. He, however, raised doubts about the utility of the amounts spent by the State Government in the current year by the B.R.D. Medical College."
12. In order to understand the issues and to prepare a long term plan to deal with the surveillance; research; prevention; treatment; and rehabilitation, the State Government was directed to seek expert intervention. The Court directed a meeting to be held on or before 19.10.2006 consisting of following members to prepare a comprehensive action plan.
1. Director General, Medical Education, who shall also be Organising Secretary.
2. Dr. T.N. Dhole, Head of Department of Microbiology, SGPGI as Secretary Coordination..
3. Dr. A.K. Rathi, Consultant Pediatrics, B.R.D. Medical College, Gorakhpur.
4. Dr. Kushwaha, Consultant Pediatrics, B.R.D. Medical College, Gorakhpur.
5. A representative of Ministry of Health and Family Welfare, Government of India.
6. A representative of Indian Council of Medical Research, New Delhi.
7. A representative of National Institute of communicable Diseases, New Delhi
8. A representative of National Institute of Virology, Pune
9. A representative of National Vector Borne Disease Control Programme, New Delhi.
10. A representative of World Health Organisation with its office at New Delhi.
11. A representative of Rehabilitation Council of India, New Delhi.
12. Shri Jayont Banerji, Amicus Curiae, High Court as an invitee member.
13. Shri Radhay Mohan Misra, Ex Vice Chancellor, Gorakhpur University, Gorakhpur as invitee member.
13. The first meeting was held on 18.10.2006. Shri Jayont Banerji, Amicus Curiae and Dr. T.N. Dhole, Head of Department of Microbiology, SGPGI, Lucknow forwarded their reports. Shri S.M.A. Kazmi, learned Advocate General submitted the Action Taken Report 2006. The court found that the meeting was not attended by representatives of the WHO, Health Ministry, Government of India, National Vector Bond Diseases Control Programme Rehabilitation council of India and National Institute of Virology, Pune. Some of these institutions did not receive information in time for attending the meeting and that some other persons, who had no concern and were not requested to be present, were allowed to participate in the meeting. It was also found that the meeting took notice of certain interventions made by NGOs which was not desirable at this stage. Dr. K.P. Kushwaha, Consultant Pediatrics, B.R.D. Medical College, Gorakhpur stated in the meeting that in the year 2006, 200 children have succumbed to death out of about 1000 JE cases treated in B.R.D. Medical College, Gorakhpur alone. The Court was not satisfied with the outcome of the meeting presided by an IAS officer who was ready with conclusions before the meeting had begun. Learned Advocate General requested for a short adjournment to study the report and to suggest measures including a fresh meeting to be called. The Court as such by order dated 30.10.2006 (JE/4) fixed the matter to be taken up on 9.11.2006. On the next date learned Advocate General assured that the second meeting of the expert nominated by the Court will consider and prepare a comprehensive long term action plan. By order dated 9.11.2006 (JE/5) the Court permitted the second meeting to be convened.
14. Dr. T.N. Dhole has submitted a report of the ''Second Meeting to Control Viral Encephalitis' held on 22.11.2006 at the guest house SGPGI, Lucknow:-
"In compliance to the order passed by the Hon'ble High Court on November 9, 2006 the Government of Uttar Pradesh called the second meeting of experts and persons nominated by the court, at 11.00 am in the Committee Hall of the Guest House of SGPGIMS, Lucknow; to consider and prepare a comprehensive long term action plan for surveillance, research, prevention, treatment and rehabilitation of viral infections including J.E./Coxsackie and other viruses causing public health crisis in eastern U.P. The meeting held on 22nd Nov. 2006, at SGPGIMS, was chaired by Dr. Kamal Sahani, Director General of Medical Education, Lucknow.
The following members, invited as per the directive of the Hon'ble High Court, participated in the meeting:
1. Dr. Kamal Sahani, Director General of Medical Education, Lucknow
2. Prof. T.N. Dhole, Secretary Co-ordination and Head of Department, Dept. of Microbiology, SGPGIMS, Lucknow
3. Prof. A.K. Rathi, Professor and Head, Pediatrics, BRD Medical College, Gorakhpur
4. Prof. K.P. Kushwaha, Professor Pediatrics, BRD Medical College, Gorakhpur.
5. Shri Ashok Shrivastava, Observer, appointed by Hon'ble High Court
6. Prof. Radhey Mohan Misra, Ex Vice Chancellor, Gorakhpur University, Gorakhpur
7. Dr. U.V.S. Rana (nominated by Dr. R K Shrivastava, DGHS, Government of India & Dr. Shiv Lal, Addl DG & Director, NIDC.
Joint Director, National Institute of Communicable Diseases, New Delhi.
8. Dr. A.C. Mishra, Director, National Institute of virology, Pune
(also a nominee of Dr. N K Ganguly, DG, ICMR)
9. Dr. R.S. Sharma (Nominee of Dr. P.L. Joshi Director, NVBDCP)
Joint Director, National Vector Borne Diseases Control Programme, New Delhi
Representative of Word Health Organisation and Rehabilitation Council of India did attend the meeting.
The chairperson, Dr. Kamal Sahni, after a formal welcome and an
introductory session, acknowledged the concern of the Government of Uttar Pradesh over the threat to people's health posed by deadly viral infections such as Japanese Encephalitis/Coxsackie etc. The government is committed to create the necessary infrastructure to meet the challenge and eradicate these viral diseases. The chairperson invited all learned members to express their views and give contribution in the action plan. She emphasized that as per the order of the court no unauthorized persons will take part in the meeting. She welcomed all members of the committee to SGPGI campus and initiated expert discussions on this matter.
A detailed and exhaustive discussion took place, keeping in view the directions of Hon'ble High Court regarding various issues related to the problem of Japanese Encephalitis/Coxsackie/other viral diseases and preparation of a long term plan to deal with the surveillance, research, prevention, treatment and rehabilitation.
Dr. T.N. Dhole told the objective of the meeting is to make recommendations to the court both for establishment of virus research centre as well as immediate measures to be taken to deal with the present crisis. He further emphasized that the discussion will occur as per the agenda; the valuable inputs from the experts are required in the form of:
1. Structure, function, Administrative, Financial for surveillance centre.
2. Structure, function, Administrative, Financial for treatment and rehabilitation centre.
3. Details of project report for creation of virus research centre.
Prof. Radhay Mohan Mishra, suggested Gorakhpur as the proposed site for the viral Research Centre. He said that there is an imperative need for the development of centers for diagnosis, surveillance, management, rehabilitation of cases of JE and related diseases at Gorakhpur. He said, there is an urgent need for the development of above mentioned centers to combat with these diseases. He also told that he is disappointed with the fact that State and Central Government are not doing enough despite of the endemic character of JE and related diseases in and around the Gorakhpur district since last 20-25 years.
Prof. K.P. Kushwaha, presented the magnitude of the problem of JE and similar viral illnesses. He told that Gorakhpur is epicenter of Viral Encephalitis (VE). More than 95% patients of VE in UP are reported from Gorakhpur and adjoining Districts. Department of Pediatrics has managed over 14 thousand children out of 25 thousand reported cases from the State since 1978. They are facing difficulties in the diagnosis and management of these cases because of the absence of diagnostic facilities. The rapid etiological diagnoses help in making critical decision, better management plan and predicting the outcome. Furthermore, establishing a casual relationship between vaccination and VAD requires strong laboratory backup. Thus there is an urgent need for such type of diagnostic facilities. He also proposed a joint study, project to assess the efficacy of JE vaccine, along with Dr. T.N. Dhole. The proposed study project has been handed over to Dr. A.C. Mishra for evaluation and suggestions.
He informed that many of the deaths suffering from JE and similar diseases are due to ignorance of people about the disease. UP Government has sanctioned establishment of Viral Research Centre and 108 bedded epidemic ward in year 2005 at Gorakhpur. This proposal of 7 crores, has already been sanctioned by the Government and needs strengthening at present. He further suggested that facilities for Clinical and Microbiological Training; epidemiology and Surveillance as well as Rehabilitation are required for affected areas to combat the disease. He presented a conceptual action plan for the control of Viral Encephalitis.
Prof. A.K. Rathi, & Prof. K.P. Kushwaha, jointly informed that a project for the surveillance of vector borne diseases is being set up at the BRD medical college with the support of NVBCP, Delhi for which an amount of 13.08 lacs has been released. Rehabilitation centre related work has already been initiated by Viklang Kalyan Vibhag. It will start functioning soon.
Dr. A.C. Mishra, briefed about the structure and function of the NIV, Pune. He said that facilities for management rehabilitation and surveillance required at the affected areas are different aspects and should not be the parts of a research centre. He suggested that a centre with facilities for the diagnosis, management and rehabilitation should be formed at Gorakhpur at the earliest. He appreciated the efforts made by State government in this direction. Accoridng to him a separate committee, involving more experts from various disciplines of national and international organizations, is required to establish a Virus Research Centre at par with National Institute of Virology (NIV) Pune, to deal with various viral diseases (vector borne and non vector borne) including JE, Coxsackie, Chikungunya, Dengue, Hepatitis, HIV/AIDS etc which are prevalent in various regions of UP.
He further said that surveillance of these vector borne diseases should be done by a local health authority and under the guidance of State Government. He also clarified that vector borne diseases as well as other non-vector borne diseases should be dealt at the same virus research centre. He assured that should there be need for the additional funds for these activities NVBDCP will support Virus Research Centre, Gorakhpur.
Dr. R.S. Sharma, informed that his department will provide the diagnostic kits, other technical facilities and capacity building for the surveillance of JE viral illness. NVBDCP has already released 9.5 lacs for training. For BCC activities 42.6 lacs has already been released to DGHS, Govt. of UP.
The committee concluded the following action points;
Rehabilitation centre related work has already been initiated by Viklang Kalyan Vibhag, it will start functioning soon.
For the surveillance work, National Vector Borne Diseases Control Program, Government of India will provide full support to virus research centre at BRD medical college in the diagnosis and Surveillance of JE and other vector borne diseases.
It is also advised by the experts present in the meeting that the administrative control and functioning should be decided by the State Government.
The proposed project of virus research centre and epidemic ward was handed over to Dr. A.C. Mishra for review. The suggestions made by Dr. Mishra will be incorporated.
The committee has constituted a core committee of 4 members comprising Dr. A.C. Mishra; Dr. T.N. Dhole, Dr. K.P. Kushwaha and Dr. A.K. Rathi. This core committee will time to time evaluate the programme of the project and submit a report to DGME.
The meeting ended with vote of thanks to the chair."
15. Dr. Ashok Nigam, Additional Solicitor General of India was requested to intervene in the matter and to submit comments of the experts. He has taken keen interest in the matter along with Shri K.C. Sinha, Assistant Solicitor General of India, High Court, Allahabad and has filed an affidavit of R. Lakshmi Narayana, Senior Administrative Officer, National Institute of virology Pune. This affidavit encloses observations of Shri A.C. Misra, Director, National Institute of Virology, Pune. These valuable observations are:
"The Hon'ble Judge Sunil Ambwani, J. has directed to prepare a long-term plan on the issue of surveillance, research, prevention, treatment and rehabilitation of patients of Viral encephalitis in Uttar Pradesh mainly in Eastern U.P.
National Institute of Virology (NIV) Pune has been directed to contribute to these efforts as they have extensive experience in this area. It is felt that the issue of prevention, control and rehabilitation of patients suffering from viral encephalitis is extremely complex and needs to be addressed to in a radically different manner. The successful implementation of the programme would need a clear-cut understanding of contribution of each component. NIV would like to make following observations in this regard.
1. Clinical definition of "Viral encephalitis" encompasses many viral etiological agents along with Japanese encephalitis virus. In addition, there is overlapping clinical picture of bacterial meningitis and cerebral malaria, which gets included in the statistics of VE. Extent of encephalitis caused by other viral etiological agents varies every year and from season to season. Any future measure must take this into consideration as modalities of prevention and control of each one of these is dramatically different.
2. Sporadic and distributed nature of the clinical encephalitis makes it essential to implement all the measures in entire region year after year without exception consisting of vast susceptible population.
3. Mass vaccination for JE is possible but would be required to be carried out every year due to the basic nature of the maintenance and spread of the infection. In addition, this would prevent encephalitis due to JE only and cases of "Viral encephalitis" caused by other etiological agents would continue to occur.
4. Endemicity of any virus in a region is multifactorial phenomenon. In addition to the presence of appropriate conditions like rainfall, mosquitoes and virus; farming practices, presence of amplifying hosts, housing type and location from the breeding places would contribute in virus infection rates. Water logging is essential for rice cultivation however, it results in breeding ground for mosquitoes. Thus vector control of the entire region becomes very difficult.
5. In addition to this, socio-economic conditions and lack of education of the population make it impossible to implement some of the simple preventive measures.
It should be noted here that mandate of National Institute of Virology is studying many viral diseases affecting entire nation. In addition to Japanese encephalitis, NIV carries out work on viruses causing hepatitis, diarrhea, respiratory diseases, hemorrhagic diseases to name a few. Also, mandate of NIV is to carry out surveillance, development of diagnostics and vaccine. On this background a more realistic view needs to be taken for the alleviation of the suffering of people from the scourge of all encephalitis rather than focusing on Japanese encephalitis. This would help in setting realistic and achievable goals. Following suggestions are made.
1. Key to prevention of the disease is detection of the earliest case. This can be achieved by setting up a diagnostic laboratory capable of diagnosing variety of encephalitic virus infections within the current set up. This facility would be available both for public and private clinicians in rural and urban areas. "Viral diagnostic laboratory" should be developed with extensive training facilities. While implementing this system it would be essential to carry out refresher courses for clinicians and Government Health system officials to differentiate in clinical pictures of different infections. Once a case is detected a quick rapid action for vector control measures can be taken to prevent further spread of the disease. A network of information resulting in rapid action force would reduce the cost of unnecessary insecticide treatment of vast areas also. This would help in disseminating the existing knowledge to the peripheral units.
2. Surveillance on vector population in the area can be introduced on regular basis through the existing vector monitoring systems. A system of reporting can be devised to take rapid action in case of increase in the specific vector population. This should accompany effective vector control measures around the sites for amplifying hosts like piggeries.
3. Training of health officials in newer patient management modalities should also be taken up for the primary health clinicians and other private clinicians in the area.
4. It was noted during visits of affected areas that although facilities for treating encephalitis cases existed in district hospitals cases were getting concentrated only in BRD Medical College. This puts the burden on specialty medical colleges and also increases the suffering of parents in bringing cases in regional hospitals rather than nearer district hospitals. By carrying out confidence building measures it is possible to change the psyche of the population in taking the cases to regional specialty hospitals.
5. Rehabilitation of recovered cases is a monumental task and can be decentralized at district head quarters rather than centralized as Regional or State facility. This is essential as rehabilitation would be long term effort involving repeated visits by patient and accompanying parent. Loss or wages, affordability to take the patient should be taken into consideration while establishing these units.
6. While establishing these diagnostic, surveillance, training and rehabilitation centers care should be taken to upgrade the knowledge base on regular basis by involving experts from various fields. A stable funding system, a charge based diagnostic facility for those who can afford would lessen the burden on the exchequer. Along with funding for building it is necessary to allot specific and stable funding for consumables, salaries and maintenance of machines. All the systems involved in the task should coordinate with each other and should be capable of absorbing the newer knowledge and modalities.
In summary, a Encephalitis centre for diagnosis of different type of agents causing encephalitis, surveillance of cases and vectors like mosquitoes, training of health workers at all levels should be set up at Gorakhpur in first phase. Similarly, district level small rehabilitation centers independent of encephalitis centre should be established. This kind of set up can be easily established with moderate and realistic budget and manpower. If we are after very large set up involving several hundred crore rupees it will taken years and people would continue to suffer."
16. Shri S.M.A. Kazmi, learned Advocate General has placed on record Second Status and Action Taken Report of Medical Education Department in two parts. Part-1 of the report is submitted by the Medical Education Department and Part-2 by Medical & Health Department. Both these reports are relevant and are reproduced:-
"1. In compliance of Hon'ble High Court order dated September 5th, 2006, answering opposite party has submitted the report regarding the steps taken by the State Government for control & management of Japanese Encephalitis & Cox Sackie virus encephalitis and also on the facilities available in Medical College, Gorakhpur as well as in the hospitals which are under the control of Medical & Health Department. It is stated that following facilities for treatment of virus of J.E. & Cock Sackie are available in Medical College, Gorakhpur.
a) The state government established a Viral Encephalitis Ward and an Intensive Care Unit (ICU) for encephalitis patients with the expenditure of Rs. 73.60 lacs which was completed in September 2006. The ICU (Intensive Care Unit) has 7 ventilators and 6 monitors, central suction, central oxygen supply, defibrillator, ABG machine and electrolyte machine. The current encephalitis Ward is fully air-conditioned, and looked after by the Pediatrics Department.
b) All medicines for Viral Encephalitis patients are provided by the State Government.
c) In the year 2005-06, Government sanctioned a Viral Research Centre and an Epidemic Ward for which an amount of Rs. 4.76 crores has been released till now. The buildings of research centre and epidemic ward are under construction and are likely to be completed by December, 2006.
d) During 2005 and 2006 epidemics, Government posted additional number of Medical Officers, nurses and paramedical staff for management of viral encephalitis in the Medical College, Gorakhpur.
2. Hon'ble High Court has been pleased to direct the opposite parties to prepare a detailed plan for control of viral encephalitis in U.P. and submit the same to the Court. Beside this, Hon'ble High Court has observed that the Central Government is equally responsible for providing assistance and funds for achieving the objects.
3. In compliance of the direction of Hon'ble High Court dated Sept. 12, 2006, a meeting was called on Sept. 13, 2006 in which officers of Medical Health & Medical Education Deptt. planned coordinated action regarding preparation of the action plan.
4. It is submitted that a committee has been constituted in compliance of the direction issued by the Hon'ble Court for monitoring and coordinating various activities relating to construction and functioning of Viral Research Centre and Epidemic Ward.
6. In compliance of the directions issued by Hon'ble High Court, Principal, Medical College, Gorakhpur has revised his previous proposal regarding establishment of Viral Research Centre & Epidemic Ward in which additional provisions have been incorporated. In addition, to Rs. 4.76 crores already released, he has sent an additional demand of Rs. 11.30 crores.
7. In compliance of the direction issued by the Hon'ble High Court, Principal, Medical College, Gorakhpur has also prepared a proposal regarding establishment of Rehabilitation Centre for the patients, handicapped due to viral encephalitis.
8. So far as the direction regarding establishment of Viral Research Centre comparable to the status of National Institute of Virology, Pune is concerned, Director, S.G.P.G.I. Lucknow has been directed to prepare D.P.R. (Detailed Project Report) of the same.
9. Hon'ble Chief Minister, U.P. vide his letter No. 3875/71-1-2006/G-224/06 dated Sept. 25, 2006 has requested Hon'ble Prime Minister, in view of the direction issued by Hon'ble High Court, in which he has requested to establish Viral Research Centre comparable to the status of National Institute of Virology, Pune in U.P.
Hon'ble Chief Minister has sent the same request to Hon'ble Health Minister, Government of India, also vide his letter No. 3876/71-1-2006-G-224/06 dated Sept. 25, 2006.
Director General Medical Education
As stated in para 12 of the order passed by Hon'ble Court in the said petition on 12th September, 2006, it is submitted that keeping in view the severity of the disease J.E. in the districts of Basti division, adjoining Gorakhpur, highly J.E. affected division, the Chief Minister of the State has sent a letter to the Prime Minister of India to make the vaccine available for district Basti adjoining Gorakhpur division, in addition to previously selected four districts.
It reference to para 13 of the order, it is submitted that the State Government has a system of reporting of all cases of communicable diseases including Japanese Encephalitis from all the districts of the State. Every district of the state sends report of cases and deaths occurring in the district on daily, weekly, monthly basis. The same is being complied and the report thus prepared is sent to the concerned authorities, accordingly.
As stated in para 16 of the order, it is submitted that the state govt. has already taken step to vaccinate 01 to 15 years children of the highly vulnerable age group of other remaining J.E endemic districts of the state in the ensuing years by 2010-11, for which Govt. of India has made time frame schedule (Annexure-1) (Page No. 62-64) During 2007, children of District Bahraich, Shravasti, Gonda, Balrampur & Basti will be vaccinated and Govt. of India will assist in supplying the vaccine & technical imput 41.22 lakh doses of the vaccine will be required for vaccination of above mentioned age group of children in these five districts.
In order to ensure early and adequate treatment facilities for viral encephalitis patients, district hospitals of J.E endemic districts have been instructed to reserve 10-20 beds for this disease, whereas separate wards is being established for encephalitis patients in District hospital Saharanpur, Ram Manohar Lohia Hospital Lucknow & Pediatrics Hospital medical college, Allahabad.
To fulfill the shortfall of the clinicians (doctors), 932 doctors have been appointed on contractual basis and 743 doctors selected by Public Service Commission, Uttar Pradesh have been issued appointment letters to resume their duties in respective districts of the State. Remaining vacant posts of doctors and paramedical are being filled up very soon for ensuring patient care.
To control encephalitis in all the districts of the state, surveillance & MIS system is being strengthened by imparting training through capacity building. The Additional Chief Medical Officer of the district for Vector Borne Diseases, is being designated as nodal officer at district level to strengthen the MIS.
The Additional Chief Medical Officer, medial officers of CHC/PHC and paramedical staff of J.E. affected 34 districts are to be trained in prevention & control, lab. Diagnosis, clinical management and rehabilitation of the patients. The training schedule has been prepared and course curriculum has also been finalized. The officers of Animal Husbandry are also being included in the capacity building activities.
J.E. Command Control Committee is being constituted to monitor and coordinate the activities being carried out to prevent & control the encephalitis.
J.E. ''Steering Committee' is also being constituted at state level under the chairmanship of Secretary, Medical, Health & Family Welfare, Government of Uttar Pradesh. The Director General, Medical Education, Government of Uttar Pradesh will be its member secretary and Special Secretary, Medical Education, Special Secretary Finance etc as its members.
As regards the strengthening of the surveillance of patients and the vector, instructions have been sent to the districts to report JE cases on standard reporting formats vide order no. 21-F/2006/8167-A dated 22nd September 2006 (Annexure -2) (Page no. 65-67). Similarly, different entomological teams have been deputed to undertake regular entomological surveillance.
In view of pigs playing a major role in the spread of J.E. action is being initiated by Medical & Health and Animal Husbandry Departments to do the sero-surveillance in the pigs to demonstrate presence of virus in the blood of pigs (Anneuxre-3) (Page No.68).
It is proposed to send a team of experts from the state to South Asian countries, where this disease has been eliminated, to study the control measures taken by these countries.
To assist the court in this matter, Mr. Jayont Banerji, Advocate is being appointed as Amicus Curiae, the payment of which shall be paid @ Rs. 10000-00 per month as honorarium. "
17. Shri O.P. Singh, Principal, B.R.D. Medical College, Gorakhpur has placed on record a report of Dr. O.P. Pathak, Director, (Communicable and Vector Bond Diseases) U.P. Lucknow and a proposal for Vector Borne Diseases Surveillance Unit, B.R.D. Medical College, Gorakhpur.
18. The Advocate General has also placed on record a Government Order dated 8.12.2006 by Shri Rohit Nandan, Director, Viklong Kalyan Anubhag, proposing establishment of ''Manovikas Kendra' at B.R.D. Medical College, Gorakhpur for high level specialized consultancy, diagnostic tests, rehabilitation and training . The proposed ''Manovikas Kendra' will consist of (1) I.Q. Testing Unit; (2) Idiometry Unit; and (3) Physiotherapy and Occupational Therapy Unit. The action taken reports along with the valuable suggestions given by Shri A.C. Misra, Director, National Institute of Virology, Pune and the suggestions given by Dr. Radhay Mohan Misra, Chairman of ''Samarpan Sansthan' were considered and discussed. It was found by all concerned that a comprehensive action plan with directions of the Court, to be monitored on quarterly basis will effectively coordinate and motivate the authorities and experts to deal with the crisis at hand.
19. The Viral Encephalitis strikes eastern U.P. every year with the beginning of monsoons. BRD Medical College reports the arrival of patients between July-August to November-December each year. It is reported, that in the beginning of December this year a strange strain of virus has affected adults and children in district Kushi Nagar and district Padrauna with almost 100% fatality rate, within 36 hours of the symptoms of infection. In the last two weeks thirty people have died in Kushi Nagar and Padrauna and that three people referred to BRD Medical College have died in last two days. Dr. A.K. Upadhyay, Prof. S.P.M., BRD Medical College, Gorakhpur has confirmed this fact. He, however, states that these patients were suspected with infection of Coxsackie virus.
20. With the consent of all those present in Court and with the help of the expert's intervention and the material collected by the court, the following directions are issued to be carried out by all concerned. It will be open to the concerned authorities to approach the court for modifying the directions for its better implementation:-
1. The State Government with the help of Central Government will set up a ''Nodal Centre for Control of Viral Encephalitis'; to carry out the surveillance; research; prevention; infrastructure and rehabilitation of viral encephalitis in eastern U.P. covering all the 34 districts in eastern U.P. identified in the action taken reports submitted by the State Government. The Nodal Centre shall consist of Director, one Additional Director and two Assistant Directors appointed on full time basis with their offices and requisite secretarial staff and necessary grants to operate from the Lucknow. The Nodal Centre will monitor and coordinate all activities and submit reports to the State Government and to the court of the action taken by all the component units every fortnight;
2. The State Government shall set up a ''Vector Borne Diseases Control Surveillance Unit' (VBDC Surveillance Unit) at B.R.D. Medical College, Gorakhpur. The Director, National Vector Borne Diseases Control Programme has sanctioned Rs. 13.08 lacs for the salary, vehicles, other allowances and office expenses for this unit. The amount is grossly inadequate. The State Government will provide a grant of Rs. 50 lacs for increasing its capacity.
The VBDC Surveillance Unit will be set up as proposed:-
a) to predict J.E. outbreak by developing early warning system;
b) to prevent J.E. outbreak;
c) to reduce J.E. case fatality rate.
The VBDC Surveillance Unit will strengthen epidemiological surveillance; vector surveillance to study viral infection relating to suspected J.E./CS and other Viral infections; to strengthen earlier diagnosis and proper management of V.E. cases by training medical and para medical workers of District Hospitals/ PHCs/CHCs and to evaluate the existing control measures and trials of new approaches of V.E. control in the region.
3. The State had covered only 07 districts out of 34 for vaccination in the year 2005-06 and proposes to cover seven more districts in 2006-07. The State Government will cover all the affected districts this year and will approach the Central Government for importing and vaccinate children with atleast 20 million doses of vaccine. It will seek expert's intervention for clinical trials of the vaccine before the vaccination drive begins. The VE vaccination will be made a part of Universal Immunisation Program (UIP) in the 34 endemic districts from the year 2007.
4. The State Government shall with the assistance of the VBDC Surveillance Unit provide extensive vector control methods by removing piggeries from the human habitats, and by extensive fogging immediately before the onset of monsoons. It will also arrange for aerial fogging of identified and protected area. The Nodal Centre will provide requisite datas with the help of VBDC Surveillance Unit, identify the areas with the help of district units to function for early warning signals from reported infections.
5. The State Government will set up a ''Viral Research Centre' at Gorakhpur and ''Viral Diagnostic Laboratories' at the places identified and recommended by the Nodal Centre in the first phases, at seven District Hospitals covering the entire affected area. The requirement of technical staff, equipment, functioning and maintenance of these centers shall be planned and worked out with the help of National Institute of Virology, Pune. The ''Viral Research Centre' at Gorakhpur and the ''Viral Diagnostic Laboratories' set up in the districts in first phase shall be funded, equally both the Central Government and State Government. They shall function independently under a full time Director with office at ''Viral Research Centre' at Gorakhpur. The State Government may immediately prepare a plan and request for a grant from the Central Government with matching grants to be given by the State Government and for appointment of Director and other technical staff. The research centers shall be made functional on or before 31.3.2007.
D. INFRASTRUCTURE AND TRAINING
6. The State Government shall strengthen the infrastructure in B.R.D. Medical College, and all the district hospitals; CHCs/PHCs and in 34 districts. They will provide special training sessions in newer patient management modalities to be coordinated by the Nodal Centre. The training programme prepared in the second action taken report shall be adhered and strengthened. The State Government will provide necessary funds for training.
7. The State Government will immediately set up a ''Rehabilitation Centre' as proposed by it at B.R.D. Medical College, Gorakhpur with experts, to function under the supervision of the nodal centre. The specialist and technical staff may be appointed with immediate effect. The State Government may immediately sanction necessary infrastructure equipment and staff for the purposes of functioning of the Rehabilitation Sub Centres atleast in seven districts in the entire affected area in the second phase. In the third phase such centers may be opened in all the districts affected by viral encephalitis.
21. In order to encourage continuous presence of medical officer in rural health centers, a special allowance may be provided by the State Government to be known as ''VE Allowance' both the medical officers and technical staff posted in all the 34 affected districts.
22. The appointment of consultants in B.R.D. Medical College has been delayed. At present Dr. A.K. Rathi, the Prof. and Head Pediatrics and Dr. K.P. Kushwaha, Prof. Pediatrics with experience of two decades, are taking care of the crisis. It is reported that Dr. A.K. Rathi is going to retire on 31st December 2006. This will precipitate the crisis as the programme will lose an expert with valuable expertise. The Court as such recommends that he and all other experts, technicians or para medical staff retiring in next three months should be given extension of at least two years in the same capacity in which they are working, until ''Viral Encephalitis Programme' is developed and implemented.
23. The directions shall be implemented without any delay. The matter shall be listed again on 22nd January 2007 for the State Government to submit the fourth action taken report.
24. Dr. Ashok Nigam has agreed to provide the necessary help in this regard. He may communicate this order to the Secretary, Health, Government of India, to provide the requisite expert assistance and for the necessary grants.
25. List on 22nd January 2007.
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