The Health Department of Kerala has released special guidelines for Amoebic Meningoencephalitis, a brain infection that has killed three children and affected two others in the state. Health Minister Veena George said on Sunday, July 21, that this is the first time that technical guidelines have been released for the disease in India. The guidelines cover prevention, diagnosis and treatment of the disease. For further studies and research, a committee will be appointed in collaboration with the Indian Council of Medical Research (ICMR), the minister said. She also directed the hospitals in the state to strictly adhere to the guidelines.

It was on May 20 that the first death due to primary amoebic meningoencephalitis (PAM) occurred in Kerala this year, when a five year old girl from Malappuram passed away within a week of her infection. Four more cases have since been identified, all of children aged between 12 and 15. All five of them had been infected from coming into contact with contaminated water. 

The guidelines issued by the Health Department contain an introduction to the disease, the impact of global warming, life cycle of the amoeba, sex and age-related demographics, prevention, clinical stages, diagnosis, treatment and recommended Standard Operating Procedure, among other details.

Preventive measures

Following are the preventive measures:

• Avoid diving and jumping into stagnant freshwater.

• Use nose plugs for unavoidable exposures or pinching your nose shut when diving or swimming in freshwater. The use of nasal plugs and nose clips completely eliminates the risk of infection.

• Keep your head above water when swimming in freshwater, hot springs,

and other untreated thermal bodies of water.

• When participating in water-related activities, avoid digging, or stirring

up the sediment.

• Use boiled, filtered, or sterile water for nasal or sinus irrigation, not tap

water.

• Wading pools should be emptied each day

• Swimming pools/water theme parks and spas should be kept clean,

chlorinated and maintained correctly

• Keep sprinklers and hoses away from noses.

• Flush still water from hoses before letting children play with them

• If you are using unchlorinated water: Don’t let water go up your nose when showering or washing your face, watch children playing with hoses or sprinklers, teach children not to squirt water up their nose.

Not contagious

The disease is not contagious, doctors have earlier told TNM. It is rare too, infecting only one in 26 lakh people who come into contact with water containing a type of amoeba. PAM is usually caused by an amoeba called Naegleria Fowleri, which infects the brain. It is therefore also called brain-eating amoeba.. The amoeba enters the body through the nose, and reaches the brain through the cribriform plate. In 97% of the cases, the infected person dies.

Symptoms and diagnosis

The symptoms of the disease – such as severe headache, fever, nausea, vomiting and stiffness of the neck -- should occur within nine days of the infection. The disease is confirmed after a PCR test of the fluid taken from the spinal cord. 

The guidelines also note that PAM must be distinguished from acute bacterial meningitis, an infection of the membrane covering the brain and the spinal cord. In the first case of the five year old girl, the doctor had initially thought it might be bacterial meningitis. 

It also advises health practitioners to suspect PAM when the results for bacteria and common viruses turn out negative. "In the current Kerala context, any person with an epidemiological link should be immediately suspected of having PAM,” the guidelines say.

Treatment of the disease is with a combination of five drugs known to be effective against amoeba. 

Other details

Unlike PAM, the other type of amoebic encephalitis -- Granulomatous amebic encephalitis -- affects people of all ages. PAM however affects children and young people (mostly in their early to mid 20s). It occurs more during the warmer months of the year and in warmer climates. The increased presence of the free-living amoeba, N fowleri, is presumed to be an effect of climate change. The amoeba is thermophilic and one of its food sources is cyanobacteria, which flourishes in warmer waters. 

Overall, the male to female ratio of the disease is 2:1. In Kerala, two of the five children have been girls. 

The guidelines mention the first case of PAM in the world as described by Fowler and Carter in Australia in 1965 followed by the first case described in the United States in 1966.