infectious diseases

Trying to understand chikungunya? Everyone, including Delhi's health minister, is

The chikungunya virus might exacerbate existing medical conditions, which in turn cause death. It might also be turning more potent, say doctors.

Even as political parties continue the blame game for the spread of chikungunya in Delhi, experts are divided on whether they can attribute the death of 12 patients to the mosquito-borne viral disease. Some researchers even say there is a possibility that the chikungunya virus has become more potent and this may have triggered severe complications in the patients who died in Delhi hospitals while being treated for the infection.

This year, India has recorded 14,656 cases of chikungunya. Karnataka has the most cases followed by Maharashtra and Delhi, according to the National Vector Borne Disease Control Programme under the Union health ministry. But this is the first time in India that a city has recorded deaths attributed to chikungunya.

Delhi's health authorities seem ill-equipped to handle the situation. Health minister Satyendra Jain declared that the virus cannot cause death because that is what he read on Google. The World Health Organisation has, in fact, documented 191 deaths in different parts of the world that can be attributed to chikungunya.

Chikungunya is unlikely to kill a healthy person who has no other serious medical problems. Public health experts say that the virus does not cause death often but sets off debilitating symptoms that may affect patients even years after the onset of the disease. With hospitals in Delhi recording deaths attributable to chikungunya, there is an urgent need to study the “pathology of the virus” or the mechanism by which is causes disease, they said. But doctors are divided on whether chikungunya can be fatal.

Can chikungunya kill?

Health officials in Karnataka, a state that has recorded 66% of the chikungunya cases in the country since January this year, said they had never seen a chikungunya patient develop complications that could have a fatal outcome. “I am rather shocked that hospitals (in Delhi) are recording chikungunya deaths," said Dr Prakash Kumar, deputy director in Karnataka's health department. "We have had so many cases here but not a single death. It is a crippling disease and it does not exaggerate the pre-existing illness in a patient.”

A study published in Emerging Infectious Diseases in 2008 found an increased mortality rate during the chikungunya epidemic in Ahmedabad in 2006. The study’s lead author, Dr Dileep Mavalankar, studied the association between the chikungunya epidemic in India and the mortality rate in Ahmedabad then. “We found that 2,944 excess deaths occurred during the epidemic period when compared to the same months in the previous four years,” said Mavalankar.

Public health experts said that in the case of the 12 people who died in Delhi, chikungunya did increase their risk of dying. “Though it may not be a direct reason, it did contribute as a cause of death,” said a senior doctor from Delhi.

People suffering from dengue and chikungunya being treated at a Delhi hospital. Photo: IANS.
People suffering from dengue and chikungunya being treated at a Delhi hospital. Photo: IANS.

However, Dr Suranjeet Chatterjee from Indraprastha Apollo Hospital, who has treated over 100 cases of chikungunya, said it was incidental that the people who died were suffering from chikungunya. “It could be any other virus," he said. "It is just because we are actively testing patients for chikungunya in Delhi that we found they had chikungunya.”

Out of the 12 deaths, five were at Indraprastha Apollo Hospital. Chatterjee was not involved in their treatment.

Possible mutation?

According to the Indian Council of Medical Research, the chikungunya strain in circulation in India has not undergone any change since previous outbreaks. A senior official said the East Central South African strain continues to remain in circulation since 2006, when the country witnessed a major outbreak of the vector-borne infection. “There are no detailed studies about mutation but we know that there is always a risk of an increased outbreak potential as viruses like chikungunya keep on changing,” added the official.

But Dr Paluru Vijayachari from the Regional Medical Research Centre at Port Blair in the Andaman and Nicobar Islands suspects a change in the genetic content of the virus. “It is perhaps becoming more potent,” said Vijayachari, who has published several papers about the chikungunya epidemic in the islands. “We had reported instances where patients had developed acute flaccid paralysis – a complication not commonly reported among chikungunya patients.”

Causes of death

A statement by Indraprastha Apollo Hospital stated that of the five deceased, four were elderly patients with associated pre-existing chronic illnesses such as chronic kidney disease, diabetes mellitus, hypertension, coronary artery disease and old-age debility. In fact, the health authorities as well as the Delhi health minister have maintained that those suspected to have died of chikungunya actually died of other illnesses they were already suffering from. On Friday, Union Health Minister JP Nadda asked for a detailed report from the Delhi government on deaths due to dengue and chikungunya.

Disagreeing with the government’s attempt to downplay the role of chikungunya in these deaths, Dr Dileep Mavalankar said that the cause of death is identified as the disease that triggers a chain of events, which ultimately leads to a person’s death. “Blaming a pre-existing illness for someone’s death is not correct," he said. "Half of the population will have some co-morbidity. What we need to [ask] is that if chikungunya would have not happened, would the person have still died.”

When dengue causes confusion

The presence of active dengue and chikungunya transmission in the community could also be triggering severe complications in patients, said doctors. In Karnataka, out of the 4,000 people who tested positive for dengue recently, six were also suffering from chikungunya. “There is always a possibility that a patient may have been infected with both dengue and chikungunya,” said Dr Prakash Kumar from the state's health department. “Though chikungunya is non-fatal, dengue is, which could explain the rising mortality.”

The challenge, doctors said, is the possibility of false negative results of blood investigations. Many tests are available in the market and not all are reliable. Also, the test has to be done at a particular stage of the infection to get accurate results, said doctors. Rapid test kits to test for dengue can produce wrong results and are not considered reliable by the government.

Hence, doctors said, there was high possibility of a person not testing positive for a co-infection but actually suffering from it.

Is the virus adapting?

The National Vector Borne Disease Control Programme’s director Dr AC Dhariwal said the rainfall pattern in Delhi this year has led to an increase in the breeding of the Aedes aegypti mosquito, which can bear the dengue, chikungunya and even Zika viruses. “We are seeing more cases of chikungunya as the incubation period of the virus is as low as two days,” said Dhariwal. He added that Delhi had not seen an outbreak of chikungunya in the recent past and this made the population susceptible to the infection.

In 2010, Delhi had recorded 120 cases compared to 1,724 cases since January this year.

Infectious disease consultant in Mumbai, Dr Om Shrivastav, said the focus should be on understanding the interaction between the virus and the mosquito. “Despite all the vector control activities, the transmission of the virus is only increasing," he said. "Also it’s causing complications we didn’t see in the past, which only means that the mosquito is responding differently to the virus and causing the virus to change and adapt.”

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.