Policy Gaps in Prevention of Vector-Borne Diseases in India

Edited by Arpit Chaturvedi

Vector-Borne Diseases (VBDs) have been a public issue in India for decades. They have reached epidemic proportions in India and have become a serious threat to the health and wellbeing of the population. The causes of the diseases’ spread include lack of sanitation and cleanliness, as well as stagnant water, which can be a breeding ground for mosquitoes. Considering that India faces this issue every year, especially after the monsoon season (June-September), the Indian government could implement a preemptive strategy in place to contain these outbreaks and minimize loss of life. Instead, the magnitude of the outbreak in 2016 shows a severe crisis in policy-making, planning, and management on the part of the central and the various state governments in India.

Extent of Loss due to Vector Borne Diseases (VBDs)

As of 25^th September 2016, there have been 45,490 dengue cases and 19,617 clinically suspected chikungunya cases across India, according to the NVBDCP; there have been 88 dengue deaths^[1].

The rise of VBDs and related deaths in India shows that there has been a clear policy and implementation failure across the country to manage an outbreak that could have been minimized if not completely prevented.

Table 1: Top five states with the highest incidences of Dengue and Chikungunya (as of 25^th September 2016)

Further, beyond the ramification on health, the control of VBDs in India is essential to prevent financial losses caused by the depletion of tourism revenues.

India is aiming to attract one per cent of the world’s tourists by 2020 and about 2 percent by 2025, banking heavily on the country’s strong tourism potential, but the spread of VBDs is affecting the tourism industry heavily. According to the Associated Chambers of Commerce of India (ASSOCHAM), monthly foreign exchange earnings from the foreign tourist arrivals are between $1.5-2 billion a month during the winter season. The cluster of months following October is considered the peak season for tourists, due to festivals like Diwali, Dussehra, Christmas, and New Year, but due to recent VBD epidemics, people are traveling less to India, especially families with children. The embassies have issued health advisories and this will severely impact businesses such as hotels, airlines, taxi operators and restaurants.

A study titled ‘Quantifying the Impact of Chikungunya and Dengue on Tourism Revenues’ conducted by the Indian Institute of Management (IIM) Ahmedabad states that “4% decline in tourists from non-endemic countries would result in a substantial loss of tourism revenues” – at least US $ 8 million for the Indian state of Gujarat alone. A 4% decline in tourists traveling from other Indian states to the state of Gujarat would amount to US$ 9.6 million loss in domestic tourism revenues for the state. Similarly, other states that attract a large number of domestic as well as international tourists such as Uttar Pradesh, Rajasthan, New Delhi, Maharashtra and Karnataka face a loss of tourism revenues due to the risk of VBDs.

Underperformance of the Capital (New Delhi) and other State Governments in Preventing VBDs in India

In India, the National Vector-Borne Disease Control Programme (NVBDCP), controlled by the Ministry of Health, is the central nodal agency for the prevention and control of vector-borne diseases, including malaria, dengue, lymphatic filariasis, kala-azar, Japanese encephalitis, and chikungunya. These are communicable diseases spread by mosquitoes, and they are considered among the most fatal diseases in the world today and are the cause of many deaths in India.

In 2016, the number of people affected by chikungunya reached a record high in the national capital of New Delhi, surpassing the figures of the past 6 years put together. The number of positively identified cases of VBDs saw a sharp rise in July-September.

The National Green Tribunal (NGT) mandated by the Parliament of India to handle the expeditious disposal of cases pertaining to environmental issues, stated that the government, civic bodies, and public authorities had failed to tackle the situation, and that their answers to questions on efforts made to control the spread of vector borne diseases were unbelievable and vague. The NGT further stated that the claim made by these parties, that they have been making all possible efforts to control the diseases, was not based on any substantial facts. For example, an officer of East Delhi Municipal Corporation stated that he had seven hundred domestic breeding checkers who have visited eight hundred thousand houses seven times, which would mean that these officers must have made 5,600,000 visits in a year–an obvious exaggeration. Similarly, the North Delhi Municipal Corporation (NDMC) released a statement that claimed that the corporation “pressed into service 1,500 domestic breeding checkers (DBCs), 1,000 employees for fumigation and 300 officials to monitor them and take stock of the situation.” They also claimed to have “…deputed three lakh (300,000) staff to spray larvicide” and that “So far….1.42 crore (14.2 million) houses in North Delhi Municipal Corporation (NDMC) have been checked and treated with mosquito repellents”. These statements follow a consistent pattern of inflating and exaggerating the work done by the Delhi state government.

The NGT took up the matter of underperformance on part of the (Delhi) state government in preventing VBDs when a petition was filed by Mahendra Pandey, a former scientist at the Central Pollution Control Board (CPCB). At that point in September 2016 the Tribunal issued various directions for the setting up of committees to implement precautionary, preventive, and curative actions to ensure that the residents of Delhi are not exposed to serious diseases like dengue, chikungunya and other similar diseases.

Policy and Implementation Gaps

While India’s central government is responsible for all policy making and fund allocation, the individual state governments are responsible for implementation of policies put in place by the central government and the proper utilization of funds. The case of the VBD epidemic is unique, as it was exacerbated by failures of both the central and state governments, involving policy making as well as policy implementation.

Use of Ineffective VBD Control Measures

The Operational Guidelines for Urban VBD’s Scheme (2016) by the NVBDCP forms a part of India’s National Health Mission. The guidelines articulate various aspects of VBD management in India and list the staffing requirements and functions, control strategy, and main objectives of the scheme. The guidelines state that in order to control VBDs, the following measures need to be undertaken:

1. Source Reduction: Environmental methods of controlling mosquito breeding, including filling ditches, pits, and low lying areas; streamlining, channelizing, de-silting, de-weeding, and trimming of drains; practicing water disposal and sanitation; emptying water containers weekly; and observing weekly Dry Day; etc.
2. Anti-larval methods:

• Chemical: Recurrent anti-larval measures at weekly intervals with approved larvicides to control the vector mosquitoes.
• Biological control: Biological control of mosquito breeding through biological agents, especially larvivorous fishes and biolarvicides.

1. Aerosol space spray: Distributing pyrethrum extract (2%) via space spraying in fifty houses in and around every malaria-positive case to kill the infective mosquitoes.
2. Early Diagnosis and Complete Treatment: Anti-parasitic measures through passive agencies like hospitals, dispensaries, clinics, and private practitioners, to reduce the reservoir of infection through early case diagnosis and complete treatment.

In urban areas lack of regular water supply drives people to store their water, and these water storage sites can become a breeding ground for mosquitoes. The creation of ‘urban slums’ with poor housing and sanitation conditions have also encouraged mosquito breeding. Old villages in expanding urban centers were kept out of overall development (sullage & sewage disposal) and with unrestricted land use, they maintain high mosquitogenic potential. Policies which promote anti-larval activities are restricted to chemical control and the policy focus is not on integrated source reduction measures.

Taking the Delhi government as an example, the state government’s first response to the dengue outbreak was to start fogging, a fumigation technique. The next step was to increase the beds in hospitals and healthcare centers, and finally, a reminder was issued to the public at large to keep their surroundings clean. The awareness campaign should have been the first step in order to make sure that the people were well informed about dengue and had accurate information; the arrangements for hospital beds should have been the next step to ensure that patients had access to proper health care. Fogging has been declared expensive and ineffective by various agencies, but it is still used by the Delhi government for political impact: the activity of fogging increases the visibility of governmental action. As per Dr. S.K. Seth, Director, Hospital Administration, at the MCD Headquarters: “Fumigation is not a preventive measure; it is only a containment measure. A high-risk formula with only psychological effects — that is, it makes people feel safer.” Further, the insecticide used for fumigation, Malathion, is very dangerous for children, pregnant women, and asthmatics, but no checks are made prior to fumigation to ensure that these groups are not adversely affected. Fogging is also known to contaminate ground water sources and soil. Thus the state governments choose to ignore better and more effective options for controlling VBDs and are using fogging machines instead, a choice with high political impact but with very low impact on the spread of disease.

Despite the NVBDCP guidelines, and even after decades of dealing with these diseases, the central and state governments only gave attention to the VBD epidemic in 2016 after it became a crisis. Keeping in mind the seasonal occurrence of the outbreak every year, efforts towards vector management should have been started months prior to the monsoon season (June-September) but were only announced midway through the season. This shows a lack of planning and preparedness on the state government’s part. Since the main cause of the spread of these diseases is mosquito breeding in stagnant water—which often accumulates at construction sites, in empty containers, or in sewers—the main aim of the government’s schemes should be prevention by eradicating the breeding grounds (in other words, larvae eradication). Fogging, by contrast, can only kill adult mosquitoes—it is ineffective against larvae.

Failure of Central and State Government in Adequate Allocation and Utilization of Funds

The central government has various means for tracking the utilization of the funds provided to the states such as:

• An annual audit by Comptroller and Auditor General.
• Submission of quarterly Financial Monitoring Reports by the states; Annual Statutory Audits; Concurrent Audits.
• Implementation of the Public Management System (PFMS) for monitoring and management of funds on just in time basis.
• Regular reviews on financial matters with State/UT government officials.
• Visits by the team of Financial Management Group of the Revenue Department to states for periodical review.
• Annual visits to states by Common Review Mission, which compares their financial systems and mechanisms.

However, despite the capacity of the central government to monitor the allocation of funds, in practice, the central government’s lack of attention in tracking the utilization of these funds given to the state governments results in their under-utilization and misappropriation.

Further, the adequate allocation of funds is a problem. The number of combined malaria, dengue, and chikungunya cases in 2016 exceeds 500,000. Yet under the National Health Mission, the allocation of funds for VBDs in the national budget has barely gone from 1.8% to 2.5% between 2012 to 2016. Even these funds have gone unutilized: in 2015-2016, about 93.195 million dollars (620 crore Indian Rupees) were allotted to VBDs, of which only 42% was spent. This is peculiar considering that when state governments submitted plans for spending to the health ministry, those plans asked for much more than what was eventually given. For example, the Delhi government asked for 1.007 million dollars but was allotted only 0.263 million dollars for “fighting Malaria and Dengue”. Further, Delhi made no request for anti-malarial insecticides and requested dengue testing kits under the wrong head, leaving the order unfulfilled. This suggests that even funds spent did not contribute to curbing the spread of VBDs.

Lack of Qualified Staff and Utilization of Informed Research

Post the initial steps taken after the 2016 outbreak of VBDs in New Delhi, the Delhi government and the New Delhi Municipal Corporation initiated an awareness campaign, set up fever clinics in major hospitals, created a door to door treatment service inform of mobile clinics, and established Mohalla Clinics (community clinics) for treatments and tests in various localities.

While these efforts are noble, many discrepancies have been found by on ground media sources. The Mohalla Clinics particularly have been found to be short-staffed, with only one doctor and three other staff members treating 300 patients on average.

A senior South Delhi Municipal Corporation official stated that the Corporation does not have dedicated staff for checking mosquito breeding and that rapid urbanization along with increasing population numbers have made the spread of VBDs easy in urban areas. The Urban Malaria Scheme on NVBDCP website further substantiates this claim, noting that rapid urbanization and population growth in urban areas have not been matched by growth in trained staff strength, which has led to inadequate service delivery.

India faces a shortage of experienced and expert entomologists and since the system is dominated by medical experts, even the existing entomologists are rarely consulted. The country has no entomology programs at the undergraduate/university level; some institutes have recently established medical/public health entomology courses, but since such degrees are awarded by a university, restrictions have been placed on the syllabi, making the theoretical courses themselves more or less inapplicable for work in the field. The net result is that only a limited number of those who take these courses are utilized. Specializing at a higher level is impossible without guidance from experienced mentors, of whom there are precious few.

Important recommendations on disease surveillance and reports by WHO (World Health Organization) are yet to be followed up and implemented by both central government and the state governments. The central government has been criticized for ignoring the knowledge gained through entomologists’ painstaking research and fieldwork to control VBDs. Importance of entomologists is underscored even though vector control is impossible without them. They are responsible for the study of the classification, life cycle, distribution, physiology, behavior, ecology and population dynamics of insects, on the basis of which vector control policies should be based.

Underreporting of Cases and Ineffective Surveillance Mechanisms

A report by the Comptroller and Auditor General (CAG) on the preparedness of Delhi government and municipal bodies in control and prevention of vector-borne diseases states that there is a case of severe underreporting of VBDs. For example, it states that while hospitals reported 409 dengue deaths in 2015, the state’s committee, which includes city government doctors as well as municipal health officers, confirmed only 60 deaths – 46 from Delhi and 14 from other states.

The following passage succinctly summarizes the situation that leads to underreporting of cases:

“Threadbare and chronically understaffed clinics often turn sick patients away or refer them to overcrowded district hospitals. Mosquito nets and pesticide sprays are seldom deployed on time or in sufficient quantities. Overworked laboratory technicians race to keep up with unexamined stacks of blood tests for Malaria in public health laboratories. The country also faced a shortage of anti-Malarial drugs in 2014, and a longer shortage of life-saving mosquito nets. Meanwhile, we learned that government officials responsible for the programme succumbed to a culture of fear, afraid to report poor progress to their supervisors.”

The consequences of underreporting of cases are severe, as the miscount can affect surveillance measures and give an inaccurate picture of the situation.

To obtain reliable, representative information on severe cases of VBDs, hospitals in high endemic districts have been developed by the state government into sentinel sites. These are usually government hospitals, though in cases of high numbers of patients, even private hospitals can be designated as sentinel hospitals. The overall objective of the sentinel surveillance hospital for severe VBD outbreaks is to improve the management of such cases in order to reduce case fatality. The specific objectives as per the central government guidelines are to:

• Assess the magnitude of severe cases
• Know the patterns of severe cases
• Analyze the reasons/situations which lead to complications
• Improve referral from primary health care facilities to sentinel surveillance hospitals
• Ameliorate the capacity of medical and paramedical staff in management of severe cases
• Improve the infrastructure in identified hospitals for management of severe cases

The surveillance mechanism for VBDs is entirely dependent on reporting of cases by these sentinel surveillance hospitals, but rampant underreporting of cases makes the surveillance mechanisms counterproductive. Instead of alerting the government to an epidemic, the misinformation can provide a false sense of comfort based on inaccurate figures. This can lead to a crisis like the 2016 VBD outbreak, which was caused when the State Government was unable to handle the epidemic due to lack of preparedness caused by the failure of surveillance mechanisms.

Lack of Schemes to Counter VBDs in Rural Areas

According to Dr. P.K. Sen, Director of the National Vector Borne Disease Control Programme Directorate General of Health Services, Ministry of Health & Family Welfare, “Generally, the high risk areas for VBDs are rural and tribal areas and urban slums inhabited by the poor, marginalized and vulnerable groups with limited access to quality health care, communication and other basic amenities in those focal areas.”

No schemes have been implemented with a special focus on health care and vector management in rural areas despite their being high-risk areas.

Ways Forward

1. Establishing Standard Operating Procedures (SOPs) to prevent VBDs

Considering that VBDs are endemic to India and we have to counter the spread of disease post-monsoon season every year, the Indian government should have a standard operating procedure in place to prevent an epidemic. Starting from awareness campaigns in the first few months of the year, anti-larval methods during and after the monsoon season (July-September), along with surveillance methods, a procedure must be followed, preferably the one provided by the NVBDCP in their operational guidelines (but which is not being currently implemented). Efforts must be made to standardize a vector control program that can be implemented efficiently.

The main action plan in order to tackle VBDs in India depends on surveillance of the disease to ensure early diagnosis to prevent an epidemic. Both these activities, creating a standardized procedure and efficient surveillance, are not possible at the state level due to underreporting of figures. States may want to prevent actual numbers from being made public, but underreporting should not come at the cost of a national health crisis. To resolve this situation central government agencies should play an active role in ensuring correct reporting of figures related to the incidences of VBD outbreaks.

2. Fixing Accountabilities between Central and State Governments

Containment of VBDs in India is complicated by the blame-game played out among the central government, state governments, health department, and civic authorities during each outbreak; public accusations of mismanagement are followed by cleanliness drives to destroy the breeding grounds of mosquitoes, but all such work stops when infection ends, during the cold and dry winter months that bring down mosquito breeding.

The governments, both central and state, must come up with a preemptive strategy to tackle the problem efficiently and in a more coordinated manner. Dr. Poonam Khetrapal Singh, the regional director of WHO South East Asia Region has noted that “Health responses have to be integrated and backed with an efficient public health delivery system and evidence based strategies to prevent and control diseases and improve people’s quality of lives.” The Indian central government must hold states accountable for funds allocated to them by conducting audits and making the information public. The central government and the state governments hold a collective responsibility to ensure that epidemics like the 2016 outbreak can be prevented in the future.

3. Assimilation of relevant lessons from other countries

Many countries around the world are facing the challenge of tackling VBDs, and much can be learned from their experiences. In the early 1990s, many nations made the major shift from vector control (mosquito control) to parasite control strategy to contain infections. “Where India fails is in providing consistent and quality public healthcare delivery system across states,” said D. R. Srinath Reddy, President of the Public Health Foundation of India. “Low visibility of primary healthcare services leads to their neglect by politicians as well as medical professionals.” The lack of testing is also a cause for concern, with more dangerous viruses like Zika infecting people around the world. These viruses can reach India via tourists and, without testing, the disease cannot be identified and measures cannot be taken to control it. Zika virus does not show symptoms in 80% of cases, but it can still cause complications in pregnancies. Thus, according to WHO “With 26 million babies born in India every year and most infected people not developing symptoms, the potential of disability is great for lakhs (hundreds of thousands) of unborn babies”.

In this context, India must look at third-world regions and the disease-control methods, techniques, and policies implemented by them as by emulating the best practices India can prevent many VBD related deaths. Sri Lanka was recently declared malaria-free by the WHO. The country has used various measures over the years to counter malaria, such as the widespread use of dichloro diphenyl trichloroethane (DDT) to kill mosquitoes and chloroquine to cure the disease during the ’60s, and a mix of indoor spraying, bed nets, rapid diagnostic kits, and medicines containing artemisinin in the last decade. Sri Lanka also set up a nationwide electronic case-reporting system and mobile clinics near labor camps, airports, and ferry landings, offering diagnosis and treatment to all. By comparison, India uses very old school techniques and can learn from Sri Lanka’s experience. India needs to encourage thinking outside the box like Sri Lanka, which uses live web-based surveillance to track, test, and treat all suspected cases.

Senegal, Africa has come up with Faso Soap, which is a soap designed to repel mosquitoes. The soap works for up to 6 hours, and the soapy water is thrown out after bathing prevents insects’ breeding. It was conceived by two students as a simple and affordable solution to ending malaria.

In order to deal with this side effect of urbanization, such as incomplete construction sites which become breeding grounds, Singapore has followed measures for larval source reduction. It is recognized by experts that it is easier to kill larvae than to kill a flying mosquito. The country’s National Environment Agency works with contractors and uses ‘Gravitrap’ at construction sites. Gravitrap is a cylindrical container with a sticky inner surface that attracts and traps egg-laying mosquitoes. Delhi and other places in India should also implement similar measures of vector management to limit side effects of urbanization on public health.

Unlike malaria, dengue does not have an established cure, and therefore vector control is the only option for controlling outbreaks and preventing fatalities. In April 2016, WHO approved the world’s first dengue vaccination, known as Dengvaxia. Its production built on research conducted by the France-based multinational company Sanofi Pasteur. Mexico, Brazil, El Salvador and the Philippines have already licensed Dengvaxia. The vaccine is given in three doses throughout a year, and results based on clinical trials show that the vaccine is 70 percent effective for those with pre-exposure to dengue and 90-95 percent effective against severe hospitalization. But, India’s Health Ministry axed a proposal by Sanofi to skip phase three trials and introduce Dengvaxia in the country citing insufficient data about the vaccine’s performance and that it reportedly wasn’t equally protective against all strains of the disease. India should be funding its own research to create a vaccine or an alternative solution considering VBDs have a high fatality rate in India, but there has been no indication of any such research being fruitful.

4. Understanding Role of Climate Change in Countering VBDs

The correlation between climate change and VBDs is very important in understanding and predicting future outbreaks. A rise or fall in temperature, rainfall, and humidity can greatly affect the egg-laying patterns of mosquitoes and increase or decrease survival of larvae into adulthood. The Intergovernmental Panel on Climate Change (IPCC) of the United Nations noted in its 2007 report that climate change may contribute to expanding risk areas for infectious diseases such as dengue and may increase the burden of diarrheal diseases, putting more people at risk.

Studies undertaken in India on malaria in the context of climate change impact reveal that “transmission windows in Punjab, Haryana, Jammu and Kashmir and north-eastern states are likely to extend temporally by 2–3 months and in Orissa, Andhra Pradesh and Tamil Nadu there may be reduction in transmission windows.”

India must adopt a low carbon footprint approach in its policies, as the expenditure on controlling the spread of diseases in India will be much higher than taking small measures to counter climate change according to studies.

Conclusion

A nation’s progress, according to the economist Amartya Sen, is best measured by calculating the Human Development Index (HDI). Health indicators and life expectancy at birth are one of the primary aspects of the HDI calculation. India ranks at 131 out of 188 countries in terms of HDI as per the 2016 Human Development Report (HDR) released by the United Nations Development Programme (UNDP). To improve its HDI rankings, India needs to improve upon its quality of healthcare and prevention of diseases. The aforementioned measures of establishing SOPs, fixing responsibilities between central and state governments, assimilating lessons from other nations and understanding the role of climate change in preventing VBDs could go a long way in improving the HDI ranking of India and prevent the loss of thousands of lives.

Notes

1. While deaths have been reported in the case of chikungunya as well, there is a big debate amongst members of the political and medical community whether the disease is fatal or not. This is because, children, elders, pregnant women, and other groups of people with suppressed immunity could suffer dangerously adverse effects due to the disease. ↑

Wamika Kapur

Wamika Kapur is a Research Assistant to Legislators (RAL) at Rajiv Gandhi Institute of Contemporary Studies (RGICS), New Delhi, India. Prior to her time at RGICS, she studied law at the Indian Law Society (ILS) Law School, Pune, India in 2014 and pursued her Masters in East Asian Studies from the University of Delhi in 2016, with a concentration on Korea and China. She is interested in understanding the role of domestic politics and political institutions in policy making and its implications. Her research is focused on Indian and North East Asian political systems (China and Korea). Her areas of interest include law and society, institutional reform, political economy and comparative politics.

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