Daily Editorial : India’s Infectious diseases

India is the fastest growing and an emerging economy, it is expected to grow even more in the coming years by exploiting the demographic dividend. But we don’t have a timetable for universal health coverage and there is a lack of political to loosen its purse strings for higher government expenditure on health.

The health budget this year has set new elimination targets for some major communicable diseases like tuberculosis, kala-azar (Leishmaniasis), Filariasis, leprosy and measles.

Tuberculosis Problem:

India has a higher burden of new patients with TB than estimated earlier — 2.8 million in 2015 compared to 2.2 million in the previous year, a quarter of the world’s cases and 34% of global TB deaths, according to a Global TB report 2016 of the WHO.

TB incidents used to be under-reported and under-diagnosed due to large unregulated private health care providers to the national TB program and their poor health care. The increase in the number of cases seen is due to NGOs linking traditional caregivers to proper system that does evidence based detection and treatment.

• The estimated incidence of TB in India in the age-group 0-14 is whopping 255/1000
• Success rate of TB treatment is 74%, while global average is 83%

The failure in combating this ancient disease is more out of neglect than out of compulsions. Despite these glaring figures, India relies heavily on international funding for dealing with this public health challenge, and our health budget is much lower than the WHO recommended levels.

Controlling TB is an extremely complex task, but it is extremely urgent one too.

• We need to strengthen the reference laboratories and increase the networks by equipping them with more and more rapid techniques for diagnosis of TB and drug resistance.
• Comprehensive data surveillance is pre-requisite, to record, monitor, treat and prevent the spread of disease.
• Regulating both the public and un regulated private sector as regards to standard practices in public health is needed.
• Political commitment shown in this budget has to be fortified and district and state governments have to be taken on board to show commitment to citizen welfare and improve the fight against TB.

India can’t afford to continue to be ranked first in contributing to the global burden of TB. The time to act is NOW.

Leprosy

India’s campaign on leprosy, it announced at the end of 2005 that it had eliminated it as a public health problem, based on a rate of less than one person in 10,000 having it. But, Health Minister J.P. Nadda’s admitted in the Rajya Sabha that there were 1,02,178 leprosy cases on record as of September 2016, and districts of ‘high endemism’, show that the disease was not eliminated, but in fact the cases have increased. India accounts for the 58% of the global burden.

• The government renewed effort is a welcome step at the recognition that the problem still exists.
• The government now should maintain the quality of services. Pro-active steps to modify or repeal laws which discriminate against persons affected by leprosy should be taken.
• Multi-stakeholder approach is necessary here too. Govt, NGOs, private health care agencies should work together in an integrated and co-ordinated manner.
• They should focus on training of the medical personnel for diagnosis and quality treatment along with public education should be a part of agenda.
• Apart from the budgetary support, there should be a focus to develop a holistic and multipronged approach with policy changes, education campaign, sustainable livelihood programmes for the affected, skill training and workshops and bringing other medical stakeholders to generate employment, identify and dispel stigma, and mainstream the affected people.

Kala-azar (Leishmaniasis)

Kala azar is caused by bites from female phlebotomine sandflies – the vector (or transmitter) of the leishmania parasite. The sand flies feed on animals and humans for blood, which they need for developing their eggs. If blood containing leishmania parasites is drawn from an animal or human, the next person to receive a bite will then become infected and develop Leishmaniasis.

Kala-azar is the second largest parasitic killer in the world – only Malaria is more deadly. Along with Chagas disease and sleeping sickness, kala-azar is one of the most dangerous neglected tropical diseases (NTDs)

India accounts for half of the new infections, with the disease flourishing in 54 districts – 33 in Bihar, 4 in Jharkhand, 11 in West Bengal and 6 in eastern Uttar Pradesh.

This is a promising candidate for elimination in the current year, since the few thousand cases are caused by a protozoan parasite with no animal reservoir; control of the vector, the sand fly, holds the key. Though it was targeted to be eliminated in 2015, we haven’t achieved it yet, but hopefully it will happen sooner.

Filariasis

Lymphatic Filariasis (LF), commonly known as elephantiasis or filaria. LF is a parasitic disease caused by microscopic worms, transmitted through the bite of mosquito. It can cause horrible disability and disfigurement in the inflicted people who have to face physical, social and emotional challenges due to lack of awareness and stigma in the society.

• The World Health Assembly resolution of 1997 targets to eliminate the disease by 2020 but India’s National Health policy (2002) envisages elimination of LF by year 2015. But we have missed the target here too.
• Currently as many as 137 districts continue to report the disease and 35 crore people in 137 districts in 13 states continue to remain under the LF risk, Odisha, UP, Bihar, West Bengal, Jharkhand, Chhattisgarh being extremely high incidence states.
• The Union health ministry has prepared the National Roadmap for Elimination of Lymphatic Filariasis (NRELF) with clear goals, objectives, strategies, timelines with activities and functions at appropriate level to achieve the target.
• The current elimination strategy is based on two pillars that is annual mass drug administration with Diethylcarbamazine (DEC) along with albendazole for five years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of the disease.

Eliminating filaria in India can be the country’s next big public health success story after receiving polio-free certification in 2014. The country is now on the verge of reaching elimination targets nationally,the population coverage during mass drug administration has improved from 73% in 2004 to 83% in 2013. The overall microfilaria rate has reduced from 1.24% in 2004 to 0.29% in 2013 at the national level. It is a matter of time, we shall eliminate it for good.

Measles

Measles is a highly contagious viral diseasecaused by the virus paramyxovirus, which affects mostly children. It is transmitted via droplets from the nose, mouth or throat of infected persons. The virus infects the respiratory system, making it highly contagious. The virus cannot survive for too long outside the body. Poor immunity and lack of vitamin A are risk factors for measles. It affects an estimated 2.5 million children every year, killing nearly 49 000 of them.

In malnourished children and people with reduced immunity, measles can cause serious complications, including blindness, encephalitis, severe diarrhoea, ear infection and pneumonia.

• Routine measles vaccinations for children, combined with mass immunisation campaigns in countries with low routine coverage, are key public health strategies.
• India has recently launched world’s largest vaccination campaign against measles to vaccinate more than 35 million children in the age group of nine months to 15 years with MR (measles and rubella) vaccine, demonstrating commitment to improve the coverage.
• India has made important efforts and gains against measles in recent years. Measles deaths have declined by 51% from an estimated 100 000 in the year 2000 to 49 000 in 2015. This has been possible by significantly increasing the reach of the first dose of measles vaccine, given at the age of nine months under routine immunization programme, from 56% in 2000 to 87% in 2015.
• In 2010 India introduced the second dose of measles-containing vaccine in routine immunization programme to close the immunity gap and accelerate measles elimination.
• Apart from improving the life-chances of millions of children in India, the recent campaign is expected to have a substantial effect on global measles mortality and rubella control target as India accounts for 37% of global measles deaths.
• Vaccine will be provided for free across the states from session sites at schools as well as health facilities and outreach session sites. Measles vaccine is currently provided under Universal Immunisation Programme.
• For the MR campaign to be effective, it is important that throughout its duration, and in routine immunization thereafter, no child is left behind.

Conclusion

India has already beaten smallpox, polio, maternal and neonatal tetanus and, very recently, yaws. Further gains in the battle against these epidemics will help achieve a number of other public health priorities.