Fourteen-year-old Afnan Jasim from Kozhikode, Kerala, developed signs of fever, fatigue, and nausea on June 30, 2024. Initially, his parents assumed it was a common viral fever, which often occurs in Kerala during the rainy season. However, by nightfall, Afnan had a seizure and fell unconscious.

"The boy was referred here from a local hospital in their area. Given the recent cases of amoebic meningoencephalitis in Kerala, we suspected the worst. We asked his parents if he had recently been swimming in pools or ponds, and they confirmed he had gone swimming a few days ago," said Dr. Abdul Rauf, Consultant Pediatric Intensivist at Baby Memorial Hospital in Kozhikode.

Afnan was diagnosed with Primary Amebic Meningoencephalitis (PAM), a rare and deadly disease with a 97 per cent mortality rate. After the good news of Afnan’s survival which is considered as the first in India, Kerala was again plunged into grief with the report of a new case on July 26—a three-and-a-half-year-old child in Kannur. According to sources, the child is on ventilator support. He was brought to the hospital four days after showing symptoms, which is a cause for concern.

"It seems it is a bit late. In Afnan’s case, there was no delay in seeking medical support," said a doctor in Kozhikode.

Dr. Abdul Rauf explained the remarkable effort to bring Afnan back to life, a rare achievement for Kerala's healthcare system. "We used a combination of drugs, including one imported from Germany. We were able to save him because there was minimal delay in diagnosing and starting the medication," he said.

Twelve-year-old Mridul from Farook in Kozhikode was not as lucky as Afnan. He succumbed to the same deadly Primary Amebic Meningoencephalitis on July 3, 2024. A couple of weeks back, he went for swimming in a local pond according to his parents. In a few days, he started showing symptoms - fever, nausea and headache. He was first taken to a local hospital from where he was referred to another. As soon as the boy was diagnosed with Amebic Meningoencephalitis, medicine was imported from Germany by the health department. However, it was a bit late and he could not survive. “The same medicine was used for Afnan. So no time was wasted in his case,” says Dr. Abdul Rauf. 

Including the latest case of the three-year-old child, Kerala has reported a concerning total of six cases of Primary Amebic Meningoencephalitis. According to Health Minister Veena George, there are only 11 survivors globally so far, and Afnan is the most recent. Afnan's survival is another achievement for Kerala's healthcare system, which has consistently ranked at the top in NITI Aayog's parameters.

According to the Centers for Disease Control and Prevention (CDC), of the 154 people known to be infected in the U.S. from 1962 to 2021, only four survived. From 2012 to 2021, 31 infections were reported in the U.S., with all but three being fatal. The CDC states that people are infected when water containing the amoeba enters the body through the nose. Infections are most often associated with swimming or diving during the summer in warm freshwater, such as lakes and rivers. 

According to the journal 'Emerging Infectious Diseases,' published by the CDC, there have been eight confirmed cases of survival worldwide from 1971 to 2023: four in the USA, two in Pakistan, and one each in Australia and Mexico. Afnan from Kerala is the first reported survivor confirmed to have been infected with Primary Amebic Meningoencephalitis (PAM) in India.

PAM is caused by Naegleria fowleri, an amoeboflagellate known as the "brain-eating amoeba." Raising grave concerns for the state, Kerala has reported six confirmed cases of PAM in recent months, including the three-and-a-half-year-old child currently battling for life. Another child in the same hospital is suspected of being infected with the deadly amoeba but is yet to be confirmed. The state is on high alert, and the Health Department has issued technical guidelines for prevention, diagnosis, and treatment, along with SOPs for hospitals.

How are people infected with this deadly disease?

As explained by the CDC, people are infected when water containing the amoeba enters the body through the nose. Sometimes infections occur after people put their heads underwater in hot springs. Infections have also occurred when people use contaminated drinking water to cleanse their nasal passages or get contaminated water up their noses during recreational play. One cannot be infected by drinking contaminated water; the infection occurs only when the amoeba enters the brain through the nose.

It is also alarming to note that most confirmed cases of death and survival have been among young children, primarily boys. In the United States, most infections have come from freshwater lakes, rivers, and hot springs in southern states.

Kerala, with its abundance of water bodies, humid climate, and high temperatures, might have a higher risk of hosting the brain-eating amoeba in its freshwater sources. Climate change is perceived to be a potential reason for the increasing spread of this lethal amoeba. According to a paper published in the International Journal of Hygiene and Environmental Health, the incidence of Primary Amebic Meningoencephalitis (PAM) has likely increased due to the effects of climate change. "This parasite is widely distributed and has been isolated from several environments, mainly those involving water, which is the habitat where there is a greater probability of infection," states the journal.

Another journal, JAMMI (Journal of the Association of Medical Microbiology and Infectious Disease Canada), notes that "the free-living amoeba with the most evidence of the effects of climate change is Naegleria fowleri, known for causing primary amebic meningoencephalitis (PAM), which is predominantly associated with recreational water exposure."

However, as these studies are in their early stages, doctors in Kerala are cautious about making any definitive conclusions on how threatening this disease could be for a state like Kerala, which has water bodies as its lifeline. "The probability of global warming being the reason for this sudden surge in cases is high, but in the absence of conclusive studies, we cannot comment on it," says Dr. Rauf.