well as chemicals and toxins. AES mostly affects children below 15. In India, AES was chiefly associated with Japanese encephalitis virus (JEV) before 1975. The JEV cases and outbreaks became more frequent and endemic regions developed between 1975 and 1999. After 1999, non-JEV cases and outbreaks of AES were increasingly reported caused by other viruses including Chandipura virus (CHPV), Nipah virus (NiV), and enteroviruses. After 2012, it is observed that the cause shifting to JEV. Initial examination shows little sign of the JEV or other viral routes in the affected children. A study by AIIMS Patna found the presence of enterovirus. High temperature, humidity, malnutrition, poor hygiene and lack of awareness are known aggravating factors of AES. Cases of AES tend to occur during the country's monsoon season. In June 2019, the temperature in Muzaffarpur had remained above and the rains were delayed which might have aggravated the situation. It was the second-longest heatwave in the region. Poverty and malnutrition is widespread among children in the region. Malnourished children lack a buffer stock of sugar as glycogen in the liver which puts them at higher risk of hypoglycemia. Awareness campaigns were carried out in March–April 2019 but were not conducted later due to the 2019 Indian general elections. The local administration was not watchful due to the few cases of AES in recent years. The region is the largest producer of lychee fruits in India. A 2014 study published in Lancet found that the methylene cyclopropyl acetic acid and hypoglycin A found in unripe lychee (Litchi chinensis) fruit can cause hypoglycemia and cited them as plausible cause of AES outbreaks. A diet heavy on unripe lychee fruits without having an otherwise full meal later in the day may put malnourished children at risk of hypoglycemia. Others disputed the findings citing the unlikeliness of very large consumption of unripe lychee fruits, lack of cases in healthy, well-nourished children and many other pediatric illnesses causing hypoglycemia. Health officials reported that most of the victims suffered severe hypoglycemia. The hospitals and primary health centres lacked the required facilities to treat children. Government response The Chief Minister of Bihar Nitish Kumar announced an ex gratia payment of to the next of the kin of the children who died from AES. He also visited the hospital and ordered the expansion of the hospital. The union minister of health Harsh Vardhan visited and announced the set-up