When Sunitha, a resident of King Koti in Hyderabad went to a private doctor for fever-like symptoms in the last week of August, she was asked to do a blood test for dengue at the nearest diagnostic centre. Sunitha was asked to do the NS1 rapid test to determine dengue symptoms and she paid Rs 1,250 for the test. A few days later when her situation didn't improve, she approached doctors at the state-run fever hospital and shelled out Rs 3,000 for an IgM-Elisa test at another diagnostic centre. Sunitha is one among the 372 persons reported with dengue from Hyderabad, up until August this year.
If one goes by the government data, for the year 2018, there were about 4,592 dengue cases in Telangana with only two deaths, which the state’s Health Minister doesn't even acknowledge as dengue-related. This year too, with the onset of monsoon, hospitals in Hyderabad are witnessing a high number of patients with viral fever and symptoms of dengue. The city hospitals, both government and private, have tested over 1.15 lakh blood samples and have confirmed 372 cases as of August, higher than any other year for the corresponding period. The number of dengue cases in the city has been rising every year, with 145 cases in 2017 and 220 cases in 2018, suggests data from the Health Department.
Numbers higher than reported
Officials with the Health Department admit that the number of dengue patients being reported in the city and also across the state could be much higher and that the historical data on dengue patients may not be painting the true picture of dengue in the state. In Telangana, dengue patients are only added to the state figures if they have been confirmed dengue positive through the Igm-Elisa test. Those confirmed positive from other tests and treated are not added to the state’s numbers. The same goes for those who could have died due to dengue, but were confirmed positive through other tests.
Dengue is caused by the Aedes aegypti mosquito. It is a viral infection and its symptoms last for two to seven days that could get cured within days or weeks. It causes flu-like illness and has no specific treatment. If left untreated, the disease could prove fatal.
In Telangana, according to data from the Ministry of Health and Family Welfare, there have been just nine deaths from 2014 to 2018. However, Telangana Health Department admits that the number of deaths being recorded as dengue-related is not accurate, and the real numbers could be much higher. The state government pins the skewing of state records due to the lack of standardisation in how private hospitals in the state do blood tests during treatments to identify dengue.
No standardized tests
A doctor has a choice to suggest two tests, the NS1 rapid test or the IgM-Elisa test. The NS1 rapid test is cheaper and quicker but more prone to error, while the latter is slightly more expensive and time-consuming with higher accuracy. The state government insists that all private hospitals in the state should use IgM-Elisa test to identify dengue cases, but not everyone does so.
At a recent meeting with private hospitals, J Vankati, the District Medical Health Officer for Hyderabad insisted that the city hospitals stick to Elisa tests and not other tests to determine dengue cases. "But I have no way to enforce them to follow through," says Vankati to TNM. "Some hospitals recommend the NS1 rapid test for their patients, some of the diagnostic centres say people choose the tests depending on the costs. The problem with choosing NS1 rapid tests to determine dengue cases is that there are chances of errors in the results. If there is a false positive, that is, a person who is without dengue is misidentified as a dengue case, then there is no problem as at least the person is getting treatment. However, if the test results come out as a false negative where a person with dengue is not given treatment, then it is a cause for worry," said the official.
(A long queue to the OPD at Fever Hospital on Monday)
Thus, for the Health Department, the data on dengue cases from private hospitals are unreliable and they count only the data from state government hospitals. "The actual numbers could be higher, but the numbers don't really matter. What matters are that we take adequate steps for prevention of dengue," says Vankati.
While the state government insists that hospitals should standardise the tests, Dr Anish Anand, general physician with Apollo Jubilee Hills, says all tests done on a patient are part of procedure. "When a patient first walks in, it is natural that the doctors would do all the tests. A separate test for dengue is only needed if the viral fever-like symptoms persist after four to five days. We are flooded with patients, never seen such a huge crowd for people coming in with viral fever, dengue is only a small part of the viral fevers being observed.”
The private hospitals
While the Health Department insists there were no means to enforce standardisation for dengue identification, in 2016, the Telangana government had asked all city-based hospitals to send all second blood samples of suspected patients to the Institute of Preventive Medicine (IPM) for Elisa tests. But this never took off, as IPM charged the hospitals for the Elisa tests. "This time, we have given guarantees to the hospitals that they won't be billed by IPM, but still they don't send the second blood samples," said the official who added that no deaths have been confirmed as dengue-related in the state. "We are yet to confirm if they are dengue deaths or other deaths, we are forming a committee and will check case by case and then confirm.”
“If people have done the Rapid test, they will still claim it to be Elisa, then how can we determine with accuracy that the person died of dengue? The only way out is for us to visit diagnostic centres to ask them what kind of tests they do for determining dengue and keep a record," he added.
Dr T Hari Prakash, secretary for the Telangana Network Hospitals Association, says all issues related to standardisation for dengue identification can be worked out if the state sits for talks involving the Indian Medical Association (IMA), doctor associations and network hospital associations.
The doctor, however, pins the blame on the government officials for not being diligent when it comes to data collection for dengue cases. "Private hospitals also share dengue numbers but the data is collected by government officials. If they are sincere in collecting the correct numbers, the dengue numbers for the state will be correct. They don't collect from every hospital as they can’t. They just release some questionnaire on WhatsApp, we take the print out, put ticks and send it back and then it moves up the ladder. Of course, there will a chance of mismatch in the data when it's not collected properly," said Hari.
When asked about the standardisation of tests to identify dengue cases, Hari said, "In some patients, one test is positive and the second test is negative, but the dengue symptoms will be there, dengue is nothing but viral fever through mosquitoes. Only after a few days will both tests show positive. Elisa is not a test, it’s a method of test, there are different tests. If the government is insisting on Elisa test, then let them issue an order through Health Secretary and further to all health systems to maintain all private labs across the state to do Elisa tests when it comes to dengue.”
Hari warns that this would upset the diagnostics industry and the manufacturers of chemicals and lab equipment for various tests. "The Central government must get involved to sort this out. The government has to work with the Indian Medical Association (IMA), doctors and network hospitals instead of asking a government official who doesn't have much knowledge to frame policies on diagnostics.”
The prevention
The task of bringing down malaria and dengue numbers and eradicating the disease through control of the mosquito population falls with the National Vector Borne Disease Control Programme (NVBDCP) under the Ministry of Health and Family Welfare. However, the task of prevention is completely in the hands of the Entomology Department under the Greater Hyderabad Municipal corporation (GHMC).
To combat malaria, the GHMC uses DDT and malaria larvicidal (ML) oil to control breeding. DDT is banned in most countries and India for agricultural use, however, it is still being allowed to fight malaria despite several studies showing mosquitoes turning resistant to the insecticide.
"The actual number of dengue could be higher but that doesn't matter, what matters is the measures we have to take ultimately to prevent the disease in the first place," says Vankati who insists that the only way out is to educate the masses on what a mosquito larva is and teach them on ways to prevent its breeding. "This is what we are working on trying to raise awareness. We want the GHMC to do more anti larva operations," he adds.
The GHMC, however, has just 150 portable fogging machines and 13 vehicle mounting fogging machines for the whole city, which is not enough by their admission to combat mosquitoes in the city.