Reducing case fatality rate of acute encephalitis syndrome in developing countries

Abstract

Preliminary analysis in 1995 suggested that > 80% deaths (n = 1,500) and > 88% (n = 1,500) of the complications/ sequel of acute encephalitis syndrome that have no specific treatment (AESn) could have been prevented by reducing the transport time of patients and providing timely basic care by improving rural health services. In order to investigate the effect of preferential strengthening of primary and secondary care hospitals (PSCH) versus preferential strengthening of tertiary care hospitals (TCH) on case fatality rate (CFR) of AESn, a record based study of AESn from 1994 to 2011 from Uttar Pradesh state of India (UP) (34,841 cases with 6,962 deaths) and Nepal (30,670 cases with 3,436 deaths) was done. PSCH were strengthened since 1996, in both cohorts. Recurrent AESn epidemics with high CFR in UP led to preferential improvement of TCH since 2004. Outcome measure was survival or death within 6 mo. Time series analysis followed by Chow test showed that there was a statistically significant increase in CFR of UP at 99.9% confidence level. Odds ratio of CFR in UP was about 1 until 2003 and then progressively increased to 26.37 in 2011 at a P value of 0.000. Confounding variables were excluded. Clinical significance was confirmed. Though strengthening of either PSCH or TCH decreased the CFR, the former reduced it a greater extent (96.41%) and the latter to a lesser extent (20.07%). The risk of death decreased with preferential improvement of PSCH and increased with preferential improvement of TCH. This study can guide policy decisions of governments.