In Bhagalpur, the historic Bihar city on the southern banks of the river Ganga, doctors disagree about the threat of dengue in the area. Vijay Kumar, the civil surgeon for Bhagalpur, says dengue is under control. His statement has been flatly contradicted by doctors at Bhagalpur’s Jawaharlal Nehru Medical College and Hospital. The hospital identified its first dengue case about four or five years ago. Since then, said an administrator, the number of cases has grown. “We had 441 confirmed cases last year – almost double from the previous year.”

Bihar’s exposure to dengue is relatively recent but the state needs to start fighting the disease. Fighting dengue can be easy because there are clear measures that need to be taken. Since there is no cure and no vaccines for the disease, doctors can only treat symptoms – pain, chills, fever, nausea and vomiting, rashes and bleeding. In most cases the disease subsides but a few cases may be so severe that without hospitalisation and treatment it can lead to death. If a patient has excessive bleeding or a very low platelet count he might be given a platelet infusion.

But fighting dengue is also difficult because it requires meticulous and consistent control of the Aedes aegypti mosquitoes – the main species of mosquitoes that carry and spread the dengue virus. This can be done using anti-mosquito sprays to kill the mosquitoes that are normally active during the day. Dengue control also involves thwarting the mosquitoes from breeding, which can be done by reducing places – any stagnant water – where they can lay eggs. To ensure this, regular water supply is essential so that people stock less water. Also important is good garbage disposal.

Cleaning cities, towns and villages of stagnant water and garbage needs to be done on war footing because Aedes aegypti mosquitoes grow rapidly. The egg becomes a larva in two to seven days. The larva takes another four days to become a pupa and then, in two more days, a fully grown mosquito emerges.

Poor water drainage and garbage disposal in Patna, no more than two kilometres from the Patna train station (Photo: M Rajshekhar)

Ragini Mishra, lead epidemiologist at the central government’s Integrated Disease Surveillance Programme’s office in Bihar, said that to fight the disease India needs to move beyond its current focus on responding to outbreaks and start anticipating outbreaks instead. The questions that health authorities need to start asking, she said, are: “What is the vector density before the monsoon? What pathogen is it carrying? Which serotype? And then prepare accordingly.”

Manju Rahi, an epidemiologist working on vector-borne diseases at the Indian Council for Medical Research, pointed out that countries like Singapore have controlled the disease by controlling their mosquito populations. Even though people might still acquire a dengue infection outside the country and bring it in, mosquito control brought down the number of reservoirs, or already infected persons, in the population.

Who’s there to help fight dengue?

Bihar has had a suboptimal response to its health crises, whether arsenic poisoning or dengue. The state does not have the administrative capacities needed to fight disease. This shows up in the state’s failure to spend centrally allocated funds on sanitation. In 2015, for instance, Bihar spent just 18.24 % of the Rs 404 crore it got from the Swachch Bharat Fund. It also shows up as extraordinary understaffing among public health field officers.

Bhagalpur city’s sanitation is handled by the municipality. Bhagalpur district’s sanitation is managed by the state health department, which is headed by the district medical officer. A field worker working on vector-borne diseases who had come to the Bhagalpur office for a review meeting laid out the hierarchy of the health administration. The state medical officer has medical in-charges reporting to her. Each medical in-charge has block health workers and block health in-charges reporting to them. This system is riddled with staff vacancies.

“There should be eight medical in-charges but seven have retired and only one remains,” said the field worker. “There used to be 16 block in-charges, now there are zero. There used to be 71 block health workers. Now there are three.”

At the neighbouring zonal office for malaria, which is supposed to control the disease in eight districts, a senior official said: “We have a sanctioned strength of 140 people. What we have is six.”

Understaffing reduces preemptive work, like Rahi and Mishra advocate, to a pipedream. For instance, field workers say that in Bhagalpur, anti-mosquito spraying, also called fogging, is conducted within a 500 metre radius of a patient’s house and, even that, only when a dengue case is confirmed. In contrast, the National Vector Breeding and Control Programme suggests a far wider scope of actions.

Even this 500 metre spraying might not always be done scrupulously. During last year’s dengue outbreak at Krah, spraying was done well only after the outbreak had started, said resident Shafiq Alam. This post-outbreak spraying was done “only around the local councillor’s house and those close to him,” he said.

Lack of garbage disposal in Chapra city, the headquarters of Saran district in Bihar. (Photo: M Rajshekhar)

This is the story across Bihar, said a senior official at the Integrated Disease Surveillance Programme’s Patna office. “Municipalities are in charge of urban areas and the health department is in charge of rural parts. Neither does the fogging well.”

Playing with numbers

The more than 400 dengue cases that the doctors at Bhagalpur’s Jawaharlal Nehru Medical College and Hospital estimate they had last year are the proverbial tip of the iceberg. There are likely to be many more undiagnosed or unreported cases.

There are two ways of confirming a dengue case. One is the highly accurate enzyme-linked immunosorbent assay or ELISA test, which takes 24 hours and can be conducted only at a laboratory. The other is by using an instant diagnostic kit, is is not as accurate as ELISA but gives an answer in just five to 10 minutes.

Bihar counts only an ELISA positive test as a confirmed case even though only medical college hospitals in the state conduct these tests. There are only six medical colleges for the state’s 38 districts. This automatically brings down the number of confirmed dengue cases – and reduces the number of places where spraying takes place.

But even with imperfect numbers, it is clear that Bihar has a problem with dengue. The Integrated Disease Surveillance Programme’s estimation is still a work in progress. The programme on field reports from village-level health department workers, primary health centres and government hospitals. Still, programmes officers on independent field visits have found dengue cases where the state had not reported any. When the programme started work in Bihar, the state government challenged the programme’s estimated numbers of dengue cases as too high, said the senior official. “They said Bihar doesn’t have these diseases. The question state government officials would ask is: ‘Why are you creating a panic?’”

Even the programme’s numbers might be underestimating the dengue burden since some private hospitals send in their data but not all. While the programme’s annual reports indicate a steady rise in dengue outbreaks in Bihar, it is hard to tell whether the number of cases is rising or whether those gathering and submitting information to the programme are becoming more scrupulous. As such, what the data suggests is the lower limit of dengue cases in the state.

What could that higher limit be? Dr Shakeel Rahman who runs a non-profit clinic in Patna saw 2,000 cases last year in just two months. “If there are even 500 clinics like mine in Patna, that will be 10 lakh cases,” he said about a city with a population of 16.8 lakh.

There is a dire need for Bihar’s private hospitals to be involved in disease surveillance since, as Mishra said: “Disease surveillance is the backbone of disease prevention.”

In the absence of information, the state fails to take preemptive action and neglects some very obvious curative actions. Bhagalpur’s Sadar Hospital, the biggest government hospital in the district, does not even have a blood bank and so is ill-equipped to carry out platelet infusions on severe dengue victims.

On April 13, emailed questions about dengue outbreaks and control to RK Mahajan, Bihar’s principal secretary for health, and to Madan Prashad Sharma, state programme officer for malaria and other vector-borne diseases in the state. They had not responded at the time this article was published. It will be updated when they respond.

The big picture

Bihar’s experience with dengue explains the state’s shifting disease burden. Factors like poor sanitation, understaffing among health workers and impaired immunity among residents explain why Bihar is seeing a rise in multiple infectious diseases. Bihar has had some success controlling diseases like measles, polio, diphtheria and pertussis largely due to two factors, said Dr T Sundararaman, who heads the School for Public Health at Mumbai’s Tata Institute of Social Studies. First, unlike dengue, these diseases have been controlled through vaccination in drives that have been underway for a long time. Second, he said, these eradication programmes run by national agencies limited the role of the state government, leaving the national disease control agencies room to carry out their programmes. For instance, kala azar has been controlled through a national programme that focuses on control of sand flies and treating infections with an effective single-dose drug.

But there is no such strategy to combat dengue.

“There is no comprehensive action plan and without that, there won’t be any lasting change,” said a scientist at Patna’s Rajendra Memorial Research Institute. “That is what we see with malaria. We controlled it for a while but it is rising again now. Instead of focusing on one disease [like kala azar], we need to focus on the fundamentals.”

Migration across India has posed another big problem to health systems across the country as every state is now receiving and sending out pathogens. Sundararaman said: “Kerala is seeing a resurgence of diphtheria, leptospirosis, scrub typhus and kala azar. Migration is a reason for these diseases reaching that state.”

As Indians range across the country seeking work, pathogens are traveling too. Based on rail passenger data, a map of inter-state migration in India. (Image: Economic Survey 2016)

Bihar is no different and it is home to a large number of migrant workers. As infected workers travel, they help the spread of disease. So, Bihar’s failure to control disease had implications beyond its state borders.

For now, little wonder that that PK Sen, an additional director at the central government’s National Vector Borne Disease Control Programme, said: “Dengue is the fastest growing disease in the country.”

This is the second story in a two-part series about the spread of dengue in Bihar. Read the first part here.

Previous articles in’s Ear To The Ground series have highlighted the growing challenges as administrative capacities are failing across India. The next set of articles will look at why administrative capacities continue to be weak in Bihar.

This reporting project has been made possible partly by funding from New Venture Fund for Communications.