Japanese Encephalitis (JE) is a viral infection that causes swelling of the brain. It spreads to humans through the bite of infected mosquitoes, mainly Culex mosquitoes. The virus, known as the Japanese encephalitis virus (JEV), is commonly found in a cycle between mosquitoes, pigs, and wild waterbirds. These animals act as natural hosts for the virus. Humans can become infected when bitten by a mosquito carrying JEV, but they cannot spread the virus to other people or back to mosquitoes because the virus level in human blood is too low.
Most people infected with Japanese encephalitis have no symptoms or only mild signs like fever and headache. In some cases, however, the infection becomes severe and leads to brain inflammation (encephalitis). Symptoms of severe disease include high fever, intense headache, stiff neck, confusion, seizures, paralysis, and sometimes coma. The disease can be fatal in up to 30% of severe cases. People who survive severe infection may suffer long-term effects such as paralysis, movement problems similar to Parkinson’s disease, or learning and memory difficulties.
The virus spreads through a cycle involving mosquitoes and animals, not between people. Culex mosquitoes pick up the virus when they bite infected pigs or birds and later pass it to humans.
There is no specific medicine to cure Japanese encephalitis. Treatment focuses on relieving symptoms and providing supportive care, often in a hospital’s intensive care unit.
The best way to prevent Japanese encephalitis is to avoid mosquito bites. This includes wearing long sleeves and pants, using mosquito nets and window screens, applying insect repellent containing DEET or similar approved ingredients, and staying indoors during times when mosquitoes are most active, such as early morning and evening. A safe and effective vaccine is also available and is recommended for people who live in or travel to areas where the disease commonly occurs.
Historical Background
Japanese Encephalitis was first identified in Japan in the 1870s, where physicians noted cases of acute brain inflammation that often occurred during the summer months. The virus itself was later isolated and identified as a distinct pathogen in 1935. Throughout the early to mid-20th century, large-scale outbreaks were recorded across East and Southeast Asia, particularly in Japan, China, and Korea. These outbreaks often occurred during or after monsoon seasons, when mosquito populations were at their peak.
The devastating impact of these epidemics, especially among children, led to significant public health responses. By the 1950s and 1960s, Japan and other affected countries began developing and distributing vaccines against JEV. The introduction of the first inactivated mouse brain-derived vaccine marked a major milestone in controlling the disease.
Over the decades, as scientific understanding improved, integrated control measures such as mass vaccination campaigns, mosquito population management, and improved disease surveillance systems were implemented. These measures collectively led to a substantial reduction in JE incidence in many regions, particularly in Japan, South Korea, and Taiwan, where vaccination coverage is now widespread.
In recent years, newer and safer vaccines have replaced older versions, making immunization more accessible across Asia.
Global Prevalence
Japanese Encephalitis is considered endemic—meaning it occurs regularly—in 24 countries across Asia and the Western Pacific. Each year, an estimated 68,000 clinical cases are reported globally. Most infections occur in regions where humans, mosquitoes, and animal hosts coexist closely, particularly in agricultural environments that favor mosquito breeding.
Rural communities are at the highest risk, especially in areas where rice paddies and pig farms are common. The standing water in rice fields provides ideal breeding grounds for Culex mosquitoes, while pigs act as important amplifying hosts for the virus. Countries such as India, China, Vietnam, Indonesia, Nepal, and the Philippines experience the majority of cases, often during the rainy or monsoon season when mosquito populations surge. In these regions, children are most affected because adults are more likely to have developed immunity through previous exposure to the virus.
While Japanese Encephalitis is primarily a rural disease, occasional transmission can occur in peri-urban and suburban areas, particularly where agricultural practices and animal farming extend close to human settlements. Urban transmission, however, remains rare due to better sanitation and mosquito control.
Transmission and Life Cycle
Japanese Encephalitis virus (JEV) relies on specific mosquitoes and animal hosts for its transmission. The virus cycles between vectors and reservoirs, with distinct characteristics defining its structure and infectivity.
Mosquito Vectors
Mosquitoes of the Culex genus, particularly Culex tritaeniorhynchus are the principal vectors responsible for transmitting Japanese Encephalitis. These mosquitoes are common in rural and semi-rural environments, especially in areas where rice cultivation and pig farming occur side by side. The stagnant or slow-moving water in rice paddies, irrigation ditches, and marshlands provides ideal breeding sites for Culex mosquitoes, contributing to the high transmission rates seen in agricultural regions.
After feeding on an infected animal, the mosquito becomes a carrier of the virus. Inside the mosquito, JEV undergoes a period of replication known as the extrinsic incubation period, which lasts about 10 to 14 days. During this time, the virus multiplies and spreads to the mosquito’s salivary glands. Once this process is complete, the mosquito becomes infectious for the rest of its life and can transmit the virus each time it bites another host.
Culex mosquitoes are primarily active during dusk and dawn, aligning with the times of highest transmission risk for humans and animals. Because these mosquitoes prefer to feed on animals but will bite humans when available, people living near rice fields or livestock farms are particularly vulnerable.
Reducing mosquito populations and preventing bites are key to interrupting the transmission cycle.
Reservoir Hosts
The virus depends on certain animals to maintain its presence in nature. Pigs and wading birds (particularly herons and egrets) serve as the primary reservoir hosts for JEV.
Pigs as Amplifying Hosts
Pigs play a central role in the amplification of Japanese Encephalitis virus. When a mosquito carrying JEV bites a pig, the animal becomes infected and develops a high level of the virus in its bloodstream (a condition known as viremia). This allows uninfected mosquitoes that feed on the pig to acquire the virus easily, continuing the transmission cycle.
Because pigs are often kept near human settlements in rural Asia, their proximity increases the likelihood of infected mosquitoes biting humans. While pigs usually recover from infection without severe illness, their role as amplifying hosts makes them crucial in sustaining outbreaks. Some control programs recommend separating pig farms from residential areas or vaccinating pigs in high-risk zones to reduce transmission.
Wading Birds as Maintenance Hosts
Wading birds, such as herons, egrets, and other migratory waterbirds, are essential for the long-term maintenance and geographic spread of the virus. These birds can harbor JEV without showing symptoms and carry it across long distances during seasonal migrations. When they rest or breed in new areas, they introduce the virus to local mosquito populations, expanding the range of infection.
This interaction between mosquitoes, pigs, and migratory birds forms a self-sustaining natural cycle that allows the virus to persist in the environment, even in the absence of human infection. Humans and other mammals, such as horses, cattle, and goats, can become infected when bitten by an infected mosquito, but their viremia levels are too low to infect new mosquitoes. As a result, they are considered incidental or dead-end hosts.
Virus Structure
The Japanese Encephalitis virus is a small, spherical, enveloped virus with a diameter of approximately 50 nanometers (nm). It belongs to the Flavivirus genus within the Flaviviridae family, a group that also includes the dengue virus, Zika virus, West Nile virus, and yellow fever virus.
The virus contains a single-stranded, positive-sense RNA genome, which means its genetic material can directly function as messenger RNA (mRNA) inside host cells to produce viral proteins. This RNA genome is enclosed within a lipid envelope, a fatty membrane derived from the host cell that contains specialized proteins responsible for infection and immune evasion.
Three major structural proteins form the viral particle:
- Core (C) protein: Protects and packages the viral RNA.
- Membrane (M) protein: Stabilizes the virus during its assembly and release from infected cells.
- Envelope (E) protein: Plays a critical role in attaching to and entering host cells. It is also the main target of the host immune response and a key component in vaccine development.
In addition to structural proteins, JEV produces several non-structural proteins (NS1 to NS5) that help the virus replicate inside host cells and interfere with the host’s immune defense mechanisms. These proteins enable the virus to evade immune detection and prolong infection, enhancing its ability to spread between hosts.
Symptoms and Clinical Manifestations
Japanese encephalitis (JE) typically progresses through several clinical stages, beginning with mild, flu-like symptoms and potentially advancing to severe brain inflammation and long-term neurological damage.
Initial Symptoms
The first stage of Japanese encephalitis often begins suddenly, with general symptoms that resemble other common viral infections. These may include fever, headache, vomiting, and muscle pain. Fatigue, weakness, and loss of appetite are also common during this phase. Because the early signs are nonspecific, distinguishing JE from illnesses such as influenza, dengue, or malaria can be difficult at this point.
The incubation period between the mosquito bite and the appearance of symptoms usually ranges from 5 to 15 days. Some patients may experience digestive issues, such as nausea, abdominal pain, or diarrhea. In many cases, especially when the infection is mild, symptoms may subside within a few days without progressing to more serious disease. However, in individuals who develop severe JE, the virus invades the central nervous system (CNS), leading to inflammation of the brain (encephalitis).
Neurological Complications
Once the virus reaches the brain, the second phase of the illness begins, characterized by neurological complications. Patients may exhibit confusion, irritability, or disorientation, which can rapidly worsen. Seizures are common, particularly in children, and may occur frequently or with severe intensity.
As brain inflammation progresses, patients can develop stiff neck, tremors, muscle weakness, and paralysis. In many cases, the paralysis affects one side of the body (a condition known as hemiparesis), resembling the effects of a stroke. Other symptoms may include involuntary movements, difficulty speaking, and problems with coordination or balance.
In severe cases, the infection can cause coma or respiratory failure, conditions that require immediate intensive care. The progression from mild to severe disease can occur rapidly, often within a few days, highlighting the importance of early recognition and medical intervention.
Long-Term Effects
For survivors, recovery can be slow and incomplete. Roughly one-third to one-half of patients who recover from the acute stage of JE experience lasting neurological or psychological complications. These may include:
- Cognitive impairments such as memory loss, difficulty concentrating, or slowed mental processing.
- Motor dysfunction, including paralysis, tremors, or abnormal body movements caused by damage to brain regions that control motion.
- Speech and language difficulties (aphasia or dysarthria), which can interfere with communication and daily activities.
- Behavioral and emotional disturbances, including depression, anxiety, mood swings, or personality changes.
- Learning difficulties and developmental delays in children, which can affect education and social development.
The severity and permanence of these effects depend largely on how severely the brain was affected and how soon the patient received medical care. Many survivors require long-term rehabilitation, including physical therapy to regain movement, speech therapy for communication issues, and occupational therapy to restore independence in daily tasks.
While some people recover completely from Japanese Encephalitis, many are left with long-term physical or mental disabilities. These lasting effects can make daily activities difficult and may require ongoing care. The strain on families can be significant, as caring for a loved one with disabilities often takes considerable time, effort, and financial resources. Because of this, emotional and psychological support for both patients and their families is an important part of the recovery process.
Risk Factors and Vulnerable Populations
Japanese Encephalitis (JE) risk depends on where people live, their age and immune status, and seasonal factors. Certain regions and times of year see higher transmission. Vulnerable groups include children and those without prior exposure.
Geographic Distribution
Japanese Encephalitis (JE) mainly occurs in Asia and parts of the Western Pacific. It is a major cause of viral brain infection in these regions. The disease is closely linked to rural and farming areas where mosquitoes and certain animals help the virus survive and spread. The mosquitoes that transmit JE belong mostly to the Culex species, while pigs and waterbirds act as the main animal hosts, meaning the virus can multiply inside them without causing illness.
Countries most affected include India, China, Nepal, Vietnam, Indonesia, the Philippines, Myanmar, Thailand, Cambodia, Laos, and Bangladesh. In these regions, the landscape and farming practices play an important role in transmission. Rice paddies, irrigation canals, and pig farms provide ideal breeding places for Culex tritaeniorhynchus, the main mosquito species that spreads the virus. These mosquitoes breed in standing water and become more active during the rainy or monsoon seasons, when warm and humid conditions allow their numbers to increase rapidly.
Urban areas, large cities and towns generally report fewer cases. However, outbreaks can occasionally occur in peri-urban areas, which are zones where cities meet farmland. These outbreaks usually happen when there is a mix of favorable conditions: plenty of mosquitoes, animal hosts like pigs, and suitable breeding environments such as flooded fields or open water containers.
Travelers to countries where JE is common are also at risk, especially if they spend time outdoors in rural or semi-rural areas. The danger is greatest during and just after the monsoon season, when mosquitoes are most active. Even short visits can pose a risk for people who are not vaccinated and who engage in outdoor activities in the evening or at night, such as camping, hiking, or fieldwork.
Age and Immunity
Age plays a major role in determining vulnerability to Japanese Encephalitis. Children under 15 years of age are the most commonly affected group in endemic areas. Because they have not yet been exposed to the virus, they lack natural immunity and are more likely to develop severe illness if infected.
In contrast, adults living in endemic regions often have partial or complete natural immunity due to repeated, low-level exposure to the virus throughout their lives. As a result, symptomatic infection in adults is less common. However, outbreaks can still occur among adults who have not previously been exposed or vaccinated, particularly in areas where the virus was previously under control but later reemerged.
People with weakened immune systems, such as those living with chronic illnesses, undergoing chemotherapy, or receiving immunosuppressive therapy, are at greater risk of developing severe disease. Similarly, unvaccinated travelers, health workers, and military personnel deployed to rural regions are considered high-risk groups.
Pregnant women may also face increased risk, as JE infection during pregnancy has been linked to complications such as miscarriage or stillbirth, although such cases are relatively rare.
Seasonality
The transmission of Japanese Encephalitis follows a strong seasonal pattern linked to mosquito activity and rainfall. In temperate climates such as Japan, China, and Korea, most cases occur during the summer and early autumn months. In tropical regions like Southeast Asia, transmission can occur year-round, with peaks during or just after the monsoon season, when stagnant water accumulates and supports mosquito breeding.
The presence of pig farms near human settlements is a key environmental risk factor because pigs act as amplifying hosts, meaning they allow the virus to multiply to high levels that can infect mosquitoes. Communities located near rice fields or marshes are similarly at greater risk.
Diagnosis of Japanese Encephalitis
Diagnosing Japanese Encephalitis (JE) relies on specific laboratory tests, careful evaluation of symptoms to rule out other diseases, and imaging techniques to observe brain abnormalities. Accurate detection focuses on identifying the virus or immune response in body fluids and excluding infections with similar clinical features.
Laboratory Tests
Laboratory diagnosis primarily involves detecting JE virus-specific IgM antibodies in cerebrospinal fluid (CSF) or serum using enzyme-linked immunosorbent assay (ELISA). Presence of IgM antibodies indicates recent infection. Reverse transcription-polymerase chain reaction (RT-PCR) can identify viral RNA early in the disease but is less commonly positive due to transient viremia.
CSF examination typically shows lymphocytic pleocytosis and elevated protein levels, supporting viral encephalitis diagnosis. However, virus isolation from CSF or serum is difficult and rarely done in routine practice. Paired serum samples may assist in confirming diagnosis by showing a fourfold rise in antibody titers.
Differential Diagnosis
JE shares symptoms with other viral encephalitides like West Nile virus, dengue, and herpes simplex virus infections, complicating diagnosis. Malaria, bacterial meningitis, and other neurological disorders must also be considered. Clinical evaluation combined with travel and vaccination history helps narrow causes.
Laboratory tests ruling out these diseases are essential. For example, negative herpes simplex PCR tests can exclude herpes encephalitis. Similarities in symptoms require comprehensive testing to confirm JE and avoid misdiagnosis.
Imaging Techniques
Magnetic resonance imaging (MRI) is preferred for visualizing brain involvement. Typical findings in JE include bilateral thalamic lesions, which appear hyperintense on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences. These lesions help distinguish JE from other causes of encephalitis.
Computed tomography (CT) scans may show hypodense areas in the thalami, basal ganglia, and midbrain but are less sensitive than MRI. Imaging supports clinical and laboratory findings but is not definitive alone and should be interpreted in context.
Prevention and Control Strategies
Effective prevention and control focus on reducing mosquito populations, improving immunity through vaccination, and advising travelers on risk reduction. Combining these methods minimizes transmission of Japanese Encephalitis virus in endemic areas.
Mosquito Control Measures
Mosquito control is one of the cornerstones of JE prevention. Because the virus is primarily spread by Culex mosquitoes, especially Culex tritaeniorhynchus, reducing mosquito breeding sites and preventing bites are vital steps in minimizing transmission.
Environmental management is the first line of defense. Efforts focus on eliminating or managing stagnant water where mosquitoes lay their eggs. This includes draining puddles, cleaning gutters, clearing ditches, covering water storage containers, and periodically drying rice fields. Since Culex mosquitoes often breed in rice paddies and irrigation channels, local agricultural practices may be modified to disrupt mosquito life cycles such as alternating wet and dry field periods or introducing larvivorous fish that feed on mosquito larvae.
Chemical control through insecticides complements environmental management. Spraying insecticides during peak mosquito activity (dusk and dawn) helps kill adult mosquitoes. However, to prevent resistance, the use of insecticides must be carefully managed and rotated. Additionally, larviciding, the application of chemicals to kill mosquito larvae can be used in breeding areas that cannot be drained.
Personal protection is equally essential, especially for people in rural or peri-urban regions. Using bed nets treated with insecticides, installing window and door screens, and wearing long-sleeved clothing can dramatically reduce exposure. Insect repellents containing DEET, picaridin, IR3535, or oil of lemon eucalyptus are effective for personal use.
Vaccination Programs
Vaccination remains the most effective and sustainable method of preventing Japanese Encephalitis. Since its introduction, widespread vaccination has drastically reduced JE incidence in several endemic countries, turning once major epidemics into rare events.
The World Health Organization (WHO) recommends routine immunization for all children living in or near endemic regions, as they are the most vulnerable group. In areas where JE is newly introduced or where risk is seasonal, vaccination campaigns are often conducted before the monsoon season when mosquito populations surge.
Several vaccines are available and approved globally, including:
- Inactivated Vero cell-derived vaccines (e.g., IXIARO®, JESPECT®) – administered as two doses, 28 days apart, with possible booster doses after 1–2 years.
- Live attenuated vaccines (e.g., SA 14-14-2 strain) – typically require a single dose and provide long-lasting immunity.
- Recombinant vaccines – newer options combining JE antigens with safe delivery systems, showing strong immune responses.
The effectiveness of JE vaccines exceeds 95%, with side effects generally mild and temporary, such as soreness at the injection site or low-grade fever. In some countries like Japan, China, and Vietnam, national vaccination programs have successfully reduced the disease burden to near elimination levels.
Travelers heading to endemic regions are strongly advised to receive the vaccine at least one week before departure. Those who plan to stay in rural areas for extended periods or during transmission seasons are at the highest risk.
Travel Precautions
Travelers visiting countries where Japanese Encephalitis (JE) occurs should take several precautions to lower their risk of infection. Although the risk for short-term visitors to large cities is generally low, people who spend time outdoors in rural or farming areas such as agricultural workers, researchers, backpackers, or military personnel are at greater risk because mosquitoes that spread the virus are more common there.
Before traveling, it is recommended to speak with a healthcare provider to assess personal risk based on travel destination, length of stay, and planned activities. Vaccination is the most effective protection and should ideally be completed a few weeks before departure to ensure full immunity.
While traveling, preventing mosquito bites remains essential. Effective measures include:
- Wearing protective clothing: Long-sleeved shirts and long pants, preferably treated with permethrin (a chemical that repels mosquitoes).
- Using insect repellents: Applying repellents approved by the U.S. Environmental Protection Agency (EPA), such as those containing DEET, picaridin, or oil of lemon eucalyptus, on exposed skin.
- Sleeping under treated bed nets: Especially in areas without air conditioning or window screens.
- Choosing safe accommodations: Staying in air-conditioned or well-screened rooms to keep mosquitoes out.
- Avoiding peak mosquito hours: Limiting outdoor activities during dusk and dawn, when Culex mosquitoes are most active.
For those traveling to remote or high-risk areas, carrying personal mosquito protection supplies such as repellents, treated nets, and mosquito coils is strongly advised.
Treatment and Patient Management
The treatment and management of Japanese Encephalitis (JE) focus primarily on supportive medical care, as there is currently no specific antiviral medication that can directly eliminate the virus.
Supportive Care
Since no antiviral treatment has proven effective against JEV, medical care is supportive and symptom-driven. The primary goal is to maintain the patient’s vital functions like breathing, circulation, hydration, and brain function, while the body fights the infection.
- High fever is one of the earliest and most common symptoms. Antipyretic medications, such as acetaminophen (paracetamol), are administered to lower body temperature and improve comfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally avoided due to the risk of bleeding or liver complications. Seizures, which may occur as a result of brain inflammation, are controlled with anticonvulsant medications such as diazepam, phenobarbital, or phenytoin. Continuous monitoring is required to prevent prolonged or recurrent seizures (status epilepticus), which can worsen brain injury.
- Brain swelling is a major cause of death in severe JE cases. To manage this, patients may receive osmotic diuretics such as mannitol or hypertonic saline, which help reduce intracranial pressure. The head of the bed may be elevated, and sedation is sometimes used to decrease brain activity and oxygen demand. Close monitoring of neurological signs such as pupil response, level of consciousness, and limb movement is essential for detecting worsening brain pressure early.
- Patients often experience vomiting, poor appetite, or altered consciousness, which can lead to dehydration. In such cases, intravenous fluids are administered to maintain hydration and stabilize blood pressure. Careful fluid management is crucial, as overhydration can worsen brain swelling. Electrolyte levels (sodium, potassium, and chloride) are regularly checked and corrected when necessary to avoid metabolic complications.
- In patients with severe brain inflammation or paralysis affecting the respiratory muscles, oxygen therapy or mechanical ventilation may be required. Maintaining adequate oxygen supply prevents secondary brain injury caused by hypoxia (low oxygen levels). In some cases, medications to support blood pressure (vasopressors) are administered if the patient develops circulatory instability or shock.
- Good nutrition is vital for recovery. If patients cannot eat normally due to difficulty swallowing or altered consciousness, feeding tubes (nasogastric or orogastric) may be used to provide balanced nutrition. Nutritional support not only aids recovery but also strengthens immune response and prevents complications such as muscle wasting or pressure sores during prolonged hospital stays.
- Patients with severe JE are vulnerable to hospital-acquired infections, including pneumonia, urinary tract infections, and bedsores. Preventive care includes regular repositioning of bedridden patients, proper hygiene, sterile handling of catheters and intravenous lines, and early antibiotic therapy if secondary bacterial infections are suspected.
- As soon as the patient’s condition stabilizes, physiotherapy and occupational therapy should begin to prevent muscle stiffness, joint contractures, and bedsores. Early rehabilitation helps preserve muscle strength and mobility, which are often compromised by paralysis or prolonged immobilization.
Hospitalization
Patients with moderate to severe Japanese Encephalitis require hospitalization for close observation and continuous medical support. Those with neurological impairment, seizures, or respiratory failure are often admitted to intensive care units (ICUs).
Inside the hospital, vital signs including heart rate, blood pressure, oxygen saturation, and temperature are continuously monitored. Neurological assessments are conducted frequently to detect any signs of deterioration, such as increasing confusion, unequal pupils, or decreased responsiveness.
Advanced medical imaging techniques, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans, may be used to assess the extent of brain inflammation or damage. Lumbar puncture (spinal tap) may also be performed during the diagnostic stage to analyze cerebrospinal fluid (CSF) for evidence of infection, though this is typically avoided in patients with increased intracranial pressure.
In severe cases, mechanical ventilation becomes necessary to support breathing, especially when the brainstem, the part of the brain that controls vital functions is affected. Sedation may be administered to reduce brain stimulation, manage restlessness, and control seizures.
The duration of hospitalization can vary widely from a few days in mild cases to several weeks or even months in severe cases. Prolonged hospital stays are often required for patients who develop complications such as respiratory distress, persistent seizures, or severe neurological impairment.
Prognosis and Recovery
The outcome of Japanese Encephalitis (JE) depends on how much the brain is affected when the illness is diagnosed and how quickly medical care begins. Among patients who show symptoms, about 20–30% die from the disease, usually because of serious complications like brain swelling or breathing failure.
Of those who survive, 30–50% are left with long-term problems affecting the brain and nervous system. These lasting effects can greatly reduce quality of life and may include:
- Movement problems: Weak or paralyzed muscles, stiffness, or uncontrolled movements.
- Speech and swallowing difficulties: Caused by damage to brain areas that control movement and coordination.
- Thinking and memory issues: Problems with memory, learning, or concentration.
- Behavioral or emotional changes: Increased irritability, anxiety, or depression.
- Movement disorders: Tremors or stiffness similar to symptoms seen in Parkinson’s disease.
Children are especially at risk of long-term effects because brain damage from JE can interfere with normal growth and learning. Recovery can be slow, and some patients may need rehabilitation for months or even years after leaving the hospital.
Rehabilitation programs are essential to help survivors regain as much function as possible. These often include physical therapy to improve movement, speech therapy to restore communication, and occupational therapy to help patients perform daily activities independently. Emotional and psychological support for both patients and families is also important to help them adjust to the lasting challenges caused by the disease.