Eliminating Infectious diseases from India
India faces the challenge of a range of infectious diseases. While deaths from noncommunicable diseases (NCDs) are becoming increasingly prevalent, huge numbers of Indians continue to die annually due to infectious disease.
This dual burden of disease has the potential to put a substantial amount of stress on an already underfunded and under resourced health system. This could allow for infectious disease to go unchecked and begin to show a resurgence, diminishing any progress India has made towards elimination targets.
Elimination of tuberculosis (TB) by 2025?
Prime Minister Narendra Modi announced in early 2018 his government’s intention to rid India of TB by 2025. This is an ambitious deadline, one which is five years in front of the global elimination deadline. Can this goal be achieved or is the new deadline simply political point scoring?
India has a bad track record in meeting these self imposed elimination deadlines. The most recent example of this is kala-azar, or leishmaniasis. The National Health Policy 2017 aimed to eliminate the disease by the end of 2017. This deadline was not achieved. Similar elimination deadlines were failed in 2015 and 2010. This presents a negative view of the potential for elimination of TB by 2025.
“By 2025, we wish to eliminate tuberculosis from India,” claimed Union Health Minister Dr Harsh Vardhan earlier this year. “We [the Government] are also working for the elimination of many other diseases in the country like Kala-azar and measles,” Vardhan said “we have ambitious plans of [a] universal immunisation programme delivered to 100 percent [of] people all over the country…and for that ‘Mission Indradhanush’ is already running.”
Tuberculosis remains one of the most widespread infections within the Indian nation
Around 2.79 million individuals were diagnosed with TB in India according to data from 2016. India is far from eliminating the disease, with reports showing India as the country harboring the highest number of TB cases in 2014, followed by Indonesia and China. This comes after an increase of 29% in notifications following introducing mandatory national web-based notification methods in 2012.
Concerns about resistant strains of TB are also growing in the country. “Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. The World Health Organization (WHO) estimates that there were 600,000 new cases with resistance to rifampicin, the most effective first-line drug, of which 490,000 had MDR-TB. Almost half of these cases were in India, China and the Russian Federation,” claims a WHO statement.
This trend coincides with a high rate of hospital derived infection, lack of sanitation and generally low adherence of patients to prescription medication. At a rate of one infection per four hospital visits, poor sanitation could be facilitating the spread of drug resistant infection among Indian patients, made worse by the potential for already weakened immune systems.
MDR occurs when people stop taking medicines midway, making subsequent treatments more difficult and complicated. It has forced the WHO to change its earlier stand when it dissuaded countries like India from diverting resources for treating ordinary TB to boost drug-resistant TB programmes. Now, it has urged countries to make MDR-TB part of the national programme as it requires urgent attention.
Drug resistance terminology: MDR-TB, XDR-TB and TDR-TB
Extensively drug resistant TB (XDR-TB) is a rare type of MDR-TB that is resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). As XDR-TB is resistant to the most potent TB drugs, patients are left with treatment options that are much less effective, and often considerably more expensive.
A new entity –ominously called Totally Drug-Resistant TB (TDR-TB) — was isolated as far back as 2012 in the fluid samples of twelve TB patients in the Hinduja Hospital at Mahim. Such developments show the necessity for continued developments of new TB medications, as previously effective means of treatment are quickly being rendered obsolete.
Controversy has broken out in India regarding access to two treatments that are used to address drug resistant tuberculosis (TB). The medications, bedaquiline and delamanid are all but unavailable, with fewer than 1,000 DR-TB patients in India receiving bedaquiline and only 81 receive delamanid. Though these medications have been hailed as “miracle cures” — being some of the only medications available to treat drug resistant cases — their efficacy and safety are questionable.
Conservative disease figures
Once a pioneer in TB treatment among developing nations, the government’s resolution to fight the disease has developed cracks over the years. The 2.8 million TB cases is a conservative figure, given that worldwide three million cases go undetected each year, an estimated one million of these occurring in India.
A potential forty percent of the Indian population may harbour a strain of latent TB. Though these individuals cannot spread the disease, they still hold a viral strain, with an estimated five to ten percent developing a full infection some time in their lives.
Why tuberculosis is one of India’s biggest public health problems
India is home to 2.8 million tuberculosis patients, making it the largest number in a single country. According to estimates, 423,000 people died from TB in India in 2016. This roughly equates to around 1158 a day, or 48.25 per hour, meaning that a person dies from TB in India every 1.5 seconds.
Leprosy no longer considered eliminated in India?
More than a decade after India eliminated leprosy, the disease continues to be a thorn in the side of Indian health policy. As the disease potentially shows signs of a resurgence, we may soon have to rethink its status as “eliminated”.
The Central Leprosy Division of the Union Health Ministry reported the detection of 135,485 new leprosy cases in India in 2017. This means that, every four minutes, somebody was diagnosed with leprosy in India. The media is currently rife with claims that this is nowhere even close to being considered eliminated.
Given the current population of India, cited in 2017 as being 1.36 billion, these additional 135,485 cases would establish a rate of one person per 10,045 individuals who have contracted leprosy. While this figure falls within the accepted rate for elimination, it is worth reminding that this figure is just the new cases detected within 2017. This potentially entails that the overall figure for leprosy in India is now above the accepted limit for elimination criteria.
Malaria still a major threat in India
India’s malaria surveillance system ranks among the worst in the world according to the World Health Organization’s (WHO) World Malaria Report 2017. Documented within the report is a claim that the surveillance system uncovers only eight percent of all malaria cases within the country.
This opens up the possibility that statistics for malaria within India are hugely underreported. A correlation is drawn between nations with weak surveillance systems and those with high disease burdens. India was found to share six percent of the global disease burden. Nigeria, with a comparable 16 percent of cases uncovered by their surveillance system, shared 27 percent of the global disease burden.
India was found to have the highest burden of malaria outside of Sub-Saharan Africa, which shares the brunt of the disease burden.
India has suffered from regional outbreaks of the disease in recent years. The state of Odisha has seen its incident rate doubled since 2013. This makes the state India’s most highly endemic region. It has also contradicted the trend of the South East Asia region in seeing a rise of cases, compared to reductions elsewhere.
Unsanitary conditions become mosquito breeding grounds, even within hospitals
Reports of unsanitary conditions creating breeding grounds for mosquitoes are not uncommon in India. The finding that these conditions are also present in hospitals however is a more distinct threat, especially to patients already in a vulnerable condition, such as those with compromised immune systems due to a current illness.
The Swachh Bharat (Clean India) initiative seems to have had no lasting effects, at least in these areas, with unsanitary conditions returning soon after campaigns. Many reports show the poor are disproportionately affected by the conditions, for example the case of Sainik farms, in which a rich area of bungalows are using the slum nearby as a dumping ground. The mosquitoes however do not distinguish rich and poor: should the area become a breeding ground anyone living nearby is at risk.
Mosquitoes thrive in any area with stagnant water. While historically this would have occurred in rural regions, modern urban regions, particularly those with a lack of sanitation, often have enough artificial water containers to support breeding populations of mosquitoes, causing outbreaks within cities.
Across Lucknow a number of hospitals, as well as buildings surrounding the hospitals, are presenting ideal conditions for mosquitoes to breed. Unsanitary conditions such as the improper disposal of garbage and stagnant water were rife in a number of hospitals across the city, claims a team sent by the Health Department to inspect the area.
Elimination by 2030?
Marking World Malaria Day in 2017, the Asia Pacific Leaders Malaria Alliance (APLMA) claimed that India, as well as the rest of the South East Asia region, could eliminate malaria by 2030.
This may be yet another ambitious deadline with little evidence of its possibility. A number of factors could prevent the achievement of this goal. Simple prevention methods such as insecticide treated nets are all but unavailable to many of India’s poor population, this allows rural villages as well as urban slums to become hotbeds of the disease. Significant funds from the central government would be required to make significant strides towards elimination.
Though not yet spread to India, there are reports of Artemisinin-resistant strains of malaria present in other south Asian countries such as Cambodia, Vietnam and Thailand. If these strains spread to India, widely used anti-malarial medications will be useless.
Insect vector diseases
India reports some 1 million malaria cases each year with about half being caused by Plasmodium Falciparum (Pf), a severe and an often fatal strain that is spreading rapidly. India also bears a high burden of other vector borne diseases (VBD) such as dengue, Japanese encephalitis, lymphatic filariasis, and the sandfly-transmitted kala-azar which typically affects poor individuals who live in unhygienic housing conditions.
Kala-azar was due to be eliminated by the end of 2017. However, due to sporadic and inefficient surveillance of the disease, outbreaks still occur regularly across any areas where sandflies are a regular occurrence. Due to the fact that an untreated person may continue to pass on kala-azar via sandfly bites for many years after symptoms end, it is incredibly difficult to be sure resurgence will not occur.
Another reemerging disease, scrub typhus, has not been commonly seen since the second world war. In 2016, 700 cases were reported in the northern state of Himachal Pradesh. These cases resulted in 20 deaths. Though the disease was largely isolated to rural communities, there were also several cases of the disease occurring in Delhi.
Kyasanur Forest disease (KFD): A vaccine campaign mismanaged?
Kyasanur forest disease (KFD), or ‘monkey fever’, is a disease known to increase on a yearly basis in and around Karnataka. An estimated 500 cases of KFD are reported in India every year. Though the disease shows only a limited number of cases on a yearly basis, it is of particular concern due to its mortality rate of around ten percent.
The disease is vaccine-preventable. However, mismanagement of vaccination campaigns have effectively allowed for the disease to leapfrog from village to village. Standard guidelines are to vaccinate a 10km area surrounding the initial infection site. However, in many cases the vaccination campaign is often limited to just 5km, allowing the infection to pass to villages within the 10km diameter and so begin the spread of infection again.
Lymphatic filariasis unlikely to be eradicated by deadline
Lymphatic filariasis — known commonly as just filariasis or elephantiasis — is targeted to be eliminated by 2021. However given the widespread nature and long incubation times associated with the disease, this goal may be unachievable.
Currently, at least one million people in India are estimated to be infected by the disease. Even after the infection has subsided, the disease can leave lasting disability: this is believed to affect more than 23 million according to the Indian Council of Medical Research (ICMR). The disease is known to be present in at least 160 districts, making the condition both widespread and relatively common given the infection numbers.
India leads the world in dengue burden
According to a multinational study published in 2013 by Nature, Dengue fever is the world’s most rapidly spreading mosquito-borne viral disease. The study suggested it is taking a far bigger human toll than was believed to be the case, with as many as 390 million people across the globe could be falling victim to the virus each year.
Rising temperatures may be directly linked to the increased numbers of dengue fever outbreaks India is currently experiencing.
New evidence suggests that, as temperatures rise, the incubation time of the dengue virus within their mosquito hosts shortens. This leads to increased rates of transmission.
Polio vaccine controversy
India’s polio scare made headlines in October 2018. In mid-October it was found that live type-2 polio strains were circulation in samples of vaccines. This sparked concerns that India was facing a polio resurgence.
Though polio is eradicated in India, it is one of the most vulnerable countries for a potential new outbreak. This is due to it sharing a border with Pakistan. It is not improbable that an individual harbouring the virus could cross the border. As such, India must maintain a state of vigilance, ensuring high immunisation levels.
India has the highest burden of pneumonia in the world
Pneumonia will kill 1.7 million of India’s children by 2030. Why is this the case for a disease that is both preventable and treatable?
A study published to mark World Pneumonia Day estimates eleven million children under the age of five are likely to be killed by pneumonia over the next twelve years worldwide. Only Nigeria is projected to have a higher death toll from the disease than India. However, the difference between the two nations is marginal.
The study estimates that potentially millions of lives in this time period could be saved by increasing global immunisation levels to over ninety percent as well as increasing access to affordable antibiotics.
Sharp drop in HIV cases in India
India had witnessed a sharp decline in the number of new HIV cases. “HIV infections have declined by 56 per cent during the last decade from 2.7 lakh in 2000 to 1.2 lakh in 2009 in our country,” then-Health and Family Welfare Minister Ghulam Nabi Azad said in Delhi in 2012.
This rapid reduction has diminished in more recent years. Though still falling, the reduction is less drastic, with 80,000 new cases recorded in 2016. The epidemic is concentrated in high risk populations such as sex workers and their clients, men who have sex with men, as well as injecting drug users.
Free antiretrovirals are available in government run hospitals, however, the uptake of the free medications has been limited as supplies will not often extend to rural locations, with many living too far away from government run facilities to be able to receive the free medications regularly.
“As far as possible” controversy in India’s recent HIV bill
In May 2017, an HIV/AIDS bill was launched by the Health Ministry that was hailed as a historic accomplishment in the fight for human rights for those infected with the condition. The bill was however called out by many rights groups over the use of a specific phrase in section 14 (1): “as far as possible”.
This specific phrase related to the provision of treatment. By using the phrase many rights groups claimed this was a purposely included loophole that would allow the central government to escape an obligation to provide free treatment under all circumstances. Use of the term in an official bill was claimed to have set the legal precedent that treatment does not necessarily need to be provided.
The controversy was fuelled by claims that many rural HIV patients had stopped going to urban government clinics to obtain medication after being turned away multiple times due to stock shortages. Many had resorted to selling their belongings in order to afford the antiretrovirals on the open market.
Over 40m in India carry the hepatitis virus, less than one percent are treated
India is amongst the top 11 countries which carry the global burden of chronic hepatitis according to WHO statistics. There are an estimated 40 million Indians suffering from hepatitis B with a further six to twelve million suffering from hepatitis C.
It is estimated that of all those affected by hepatitis in India, around ninety percent remain undiagnosed. The study was published in early 2018 in The Lancet. The study drew on a plethora of data to produce a comprehensive estimation of HBV infection rates worldwide.
9.175 million Indians are eligible for HBV treatment, the study adds. However, just 4,700 – less than one percent of those eligible – are receiving it.
Dr Ajit Sood, head of department, gastroenterology at Dayanand Medical College and Hospital (DMCH), says “In particular, types B and C lead to chronic diseases in hundreds of millions of people and together, are the most common cause of liver cirrhosis and cancer. Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of prenatal contact with infected body fluids”.
Indian generics, the solution to hepatitis?
Recent studies have praised the cost effectiveness of Indian generics in the fight against hepatitis. One study, published in PLOS ONE discusses directly acting antivirals (DAAs) such as sofosbuvir (Sovaldi) and the hugely beneficial effect they have had in the treatment process of HCV. However, these DAAs often come at a very high cost, making them all but unavailable in many countries.
The contrast between the costs of the medications is extreme. In the US, a full course of brand name DAAs will cost around $65,000 USD. This price is still considered cost effective because the consequences of untreated disease are so severe. This kind of cost however, is out of the price range of many even in wealthy countries. The Indian generic version costs a far lower $300 USD for a full course.
India holds second highest number of children unvaccinated against measles
India has the second highest number of children unvaccinated against measles. This is despite government campaigns to boost immunisation against the disease.
2.9 million children remain unvaccinated in India, estimates say. India is only surpassed by Nigeria, which holds 3.3 million unvaccinated children.
Progress towards elimination stalling?
Though India has shown considerable progress towards disease reduction for many years, it is a consistent trend across many different diseases that the progress towards elimination of many diseases is slowing. Despite the central government putting in place ambitious deadlines, a lack of financial investment on their part may be limiting the successes of the Indian medical system.
Nearly half of all vaccines delivered globally are manufactured in India. This is a considerable accolade for India’s pharmaceutical industry. Indian vaccines are saving potentially millions of lives on a global basis, however, homegrown misinformation could be limiting India’s success in delivering vaccines to its own people.
Currently, India is seeing a growing anti-vaccination movement, creating fears over the human papillomavirus (HPV) vaccine. This is due to the spreading of unsubstantiated rumours of potential side effects, spurred on by social media and the resulting echo chambers.
However, HPV is one of the most common causes of cervical cancer, which kills more women in India than in any other country. The HPV vaccine is very effective in preventing infection by strains of the virus that cause the majority of cervical cancers. By neglecting to use this vaccine, women in India continue to be placed in danger, potentially facing huge medical costs down the line or even, in the worst cases, death.
Failed vaccination campaign
Five deaths occurred in the state of Karnataka in January 2019 after an outbreak of Kyasanur forest disease (KFD), also known as “monkey fever”. The outbreak in Karnataka follows a similar outbreak which occurred in 2018 in Maharashtra.
Shivanand Patil, Health and Family Welfare Minister of Karnataka, has suggested a lapse in protocol for vaccination is to blame for the outbreak. Patil stated, “It has come to my notice that there have been lapses committed by the Health Department…The focus is on restricting the spread of the disease once again.”
Common protocol is to administer the vaccine within a ten kilometre radius of any known infected people or infected monkeys. In this case, the vaccines were only administered in a five mile radius, allowing for isolated incidents to continuously spread the infection.
Is the Zika virus likely to become the next big infectious disease in India?
The Centers for Disease Control and Prevention (CDC) in the US have issued an advisory message to pregnant women. This message states that travel to India is ill-advised as Zika is “endemic” in the country.
The situation with the Zika virus — though seeming dire across October and November — has been deemed by the Indian government to be under control, with no internal travel warnings currently being issued. It is due to this that the current advice of the CDC to avoid the state comes as a shock to the country.
The Indian government has requested that the warnings are removed.
The Nipah virus, a clear success story
In May 2018, news reports were released the world over that a disease touted by the World Health Organization (WHO) as one of ten potential upcoming large scale epidemic was found in India.
The disease, the Nipah virus, is a worrisome prospect. The disease has a seventy percent mortality rate, making the threat to life considerable. More troubling still is that there is no known vaccination for the disease, making fears of large outbreaks more pronounced.
The disease outbreak first occurred in Kerala at the beginning of May. Several people were taken ill and there were a small number of deaths associated with the disease in the area.
Experts have credited a strong public health response with containing the deadly outbreak of Nipah virus in India in the same month that it began. No more cases of the virus have been reported as of May 29.
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