India's worst-hit state for encephalitis turning a tide Years of recurring encephalitis outbreaks and high fatality rates of brain inflammation disease among children in some of India's poorest regions reveal cracks in health care system

GORAKHPUR, India -- Seven-year-old Aryan Singh could have met the same fate as his cousin, who died seven years ago because the nearest hospital was too far.

When Aryan returned home from school with a low-grade fever in mid-September, his mother initially dismissed it as seasonal, worrying only when his temperature shot up overnight.

She hopped on her husband's motorbike with her son clinging to her, riding through the rutted roads of their village in India's northern state of Uttar Pradesh before reaching a rural government health care center at around 2 a.m.

Doctors hospitalized Aryan after he was diagnosed with scrub typhus, a bacterial infection spread by rats and mites that accounts for nearly 40% of identifiable causes of encephalitis — potentially fatal brain swelling that is rare globally but prevalent in parts of South Asia and sub-Saharan Africa.

A vaccine for one strain of the disease, Japanese encephalitis, is available, but there is no guard against the strains caused by bacteria.

The survival rate is high if the disease is treated early.

"The boy is on the path of recovery," said Dr. K.P. Yadav, in charge of primary health at the center. "The credit goes to the parents who did not wait till morning and brought the child to the hospital."

His mother said Aryan's cousin wasn't so lucky. He died because the closest well-equipped hospital was 85 kilometers (53 miles) from their village.

Acute encephalitis syndrome, including Japanese encephalitis, is caused by several different viruses, bacteria, fungi, parasites, spirochetes, chemical and toxins.

The outbreak of Japanese encephalitis coincides with the June-October monsoon season and the post-monsoon period when the density of mosquitoes increases. It typically spreads from pigs to people via mosquitoes, and is easily identified through testing. It infects many people in childhood.

Years of recurring outbreaks and high fatality rates among children in some of India's poorest regions have revealed the cracks in the country's health care system. Between 2007 and 2016, almost 75,000 cases were reported from 22 states and union territories in India, according to the National Vector Borne Disease Control Program.

Nearly 25,000 children in India have died from encephalitis since 1978.

By contrast, there were about 7,300 children admitted to U.S. hospitals with encephalitis from 2004 to 2013, according to a 2016 study of a national pediatric health database. Of those, 230 children died.

But things are changing in Uttar Pradesh — India's most populous state, with millions of rural poor.

Encephalitis cases in have dropped sharply because of a new network of rural clinics, doctors and state government officials told The Associated Press.

Uttar Pradesh's eastern portion experienced India's worst encephalitis outbreak in 2005, with over 1,500 deaths reported at state-run Baba Raghav Das Medical College in Gorakhpur, 230 kilometers (143 miles) southeast of Lucknow, the state capital.

But a massive immunization and cleanliness drive launched in 2017 in the seven districts with the highest caseloads is sharply bringing down the fatality rate, said Yogi Adityanath, the state's top elected official.

In the past, the patients had to travel at least 100 kilometers (60 miles) to reach a well-equipped government hospital, with a large number of them dying on the way.

Small hospitals are now being set up within a distance of 10 kilometers (6 miles) from the most disease-prone villages, said Dr. Mahima Mittal, head of the pediatrics department at the public BRD Hospital.

Before taking over the state's top state position two years ago, Adityanath, who is also a Hindu monk of a revered temple in Gorakhpur, represented the region in India's Parliament for 25 years. He faced flak for not doing enough to control the outbreak of the dreaded disease.

When his Bharatiya Janata Party won state elections in 2017, he rose to power.

Adityanath immediately ordered the strengthening of health services in seven encephalitis-endemic districts. More than 100 encephalitis treatment centers and pediatrics intensive care units were set up close to villages. More than 100,000 doctors and paramedics were given special training to treat encephalitis patients.

Over 4 million children were given vaccines against Japanese encephalitis between January and March this year. Last year, 3.5 million children were vaccinated against the disease, Adityanath said.

The state government claims a steady decline in encephalitis fatalities in the last two years. In 2017, encephalitis took the lives of 748 people. The death toll dropped to 278 in 2018. Up to Aug. 31 of this year, only 38 children had died of the disease.

Dr. R.N. Singh, who has battled the disease in the state for the last 25 years, said there was no way to independently verify the government's claims, but that a decline in encephalitis cases was visible.

"Earlier, I used to examine two to three encephalitis cases in a week, but now one case comes in a month or so," he said.

His nongovernment organization targeted Holiya, a village in Gorakhpur district, providing access to toilets and safe drinking water, vaccinations, mosquito spraying and mosquito nets.

Garbage disposal has been taken up by local elected bodies. Tens of thousands of toilets have been built in the region to stop people from defecating in the open, according to state officials.

Dr. Shishir Roy, a pediatrician in a rural dispensary, said besides massive immunizations, the state government also launched a campaign called "Dastak," or "Door-Knock," in the same seven encephalitis-prone districts.

State government workers knock at the doors of every village, educating residents about the symptoms of encephalitis, the need for clean drinking water and how to keep their living spaces free from mosquitoes and other insects.

"If you ask me, it is the knock on the door project which has knocked the encephalitis out of this endemic region," Roy said.