viral outbreak

Behind West Bengal’s dengue disaster is a lax state government and, possibly, a smarter virus

While doctors wonder why the state has not declared a dengue epidemic, they are seeing infections caused by a dengue strain not seen in the state before.

The town of Serampore, barely 30 km from Kolkata via the Grand Trunk Road, has one of the few municipalities in West Bengal that has learnt from dengue outbreaks in previous years.

“Thousands of people were infected with the dengue virus here last year and four people had died,” said Amiya Mukherjee, chairman of Serampore municipality. “The health department declared an outbreak in Serampore. This was shortly before the Durga puja, which was October 7-11, 2016.”

This year, the Serampore municipal machinery swung into action in February, the season when the breeding cycle of the Aedes aegypti mosquito, the carrier of the dengue virus, begins. All wards were repeatedly sprayed with larvicide, health workers went from home to home, inspecting premises for stagnant water, and issuing instructions to change stored water in open tanks, vessels every week.

“We involved the media and community organisations in creating awareness about dengue,” said Mukherjee. “We also bought an ELISA machine with government funding.”

The ELISA test is the preferred mode of diagnosis of the dengue virus in blood samples.

These measures are paying off. The municipality’s data says there have been no deaths from dengue so far in 2017. In all, around 50 people have been infected with the virus till now.

“Most have recovered and only around seven-eight patients are under hospitalisation now,” said Mukherjee.

Serampore is a rare instance where the National Vector Borne Disease Control Programme’s guidelines for containment of dengue and chikungunya have been implemented. The guidelines require health authorities to target and kill adult populations of the Aedes mosquito by spraying insecticides and thermal fogging. For larval control, measures suggested include shredding of unused or discarded tyres, cups, jars, tins and other small containers, in neighbourhoods and households.

“This is extremely crucial,” said Aparna Mukhopadhyay, virology scholar and professor at Presidency University in Kolkata. “Discarded containers are ideal breeding grounds for the Aedes mosquitoes.”

Yet, almost none of these suggested measures were implemented in Kolkata or the neighbouring districts, where dengue has caused multiple deaths.

State government caught napping

Till the beginning of October, West Bengal has recorded more than 10,600 dengue cases and 19 dengue deaths. Since October 4, the state health department has not released any dengue data, National Vector Borne Disease Control Programme joint director Kalpana Barua told the media on November 7. In a submission to the court earlier this week, West Bengal’s Director of Health Services Biswaranjan Satpathy, said that the number of dengue deaths was still 19 but the number of infections had risen to 18,000.

Kolkata Municipal Corporation workers spray chemicals during a fumigation drive on Nov 2, 2017. (Photo: IANS)
Kolkata Municipal Corporation workers spray chemicals during a fumigation drive on Nov 2, 2017. (Photo: IANS)

The accuracy of the data that has come in is also questionable. When visited the health department on the afternoon of November 6, health officials were collating the daily dengue report from various districts. One official who was preparing a consolidated state report remarked to another, “The officer from the district has merely copy pasted the report from yesterday instead of writing a new one for today.”

Meanwhile, local media have collated numbers from government and private nursing homes and hospitals, and reports from municipalities and surmised that between October 24 and November 8 alone, 104 people died due to dengue and unknown fever.

Doctors are surprised that the state has not declared a dengue epidemic yet. National health agencies define and epidemic as a sudden increase in the number of cases of a disease above what is normally expected in the population of a specific area. Declaring an epidemic will allow the health department to channel money and manpower towards controlling the spread of the disease and helps prepare health services or increased hospital admissions.

“When the average case load or death rate for a disease goes slightly above the preceding ten-year average, the outbreak is considered an epidemic,” said said Dr Sajal Biswas of Service Doctors Forum, an apolitical association of doctors employed in government hospitals and clinics.

Citing the trend seen in the National Vector Borne Disease Control Programme’s data, Biswas added,“The ten-year average in Bengal was breached three years ago, and the numbers have only been rising.” tried reaching Satpathy about why there had been no declaration of an outbreak or epidemic, but calls and text messages to him went unanswered.

An official at the West Bengal health department said that the health department has no policy on declaring an epidemic. “The department declares outbreaks locally [as in Serampore] when the numbers [of cases] are obviously larger than the previous years,” said the official. “There is no statistical parameter that is followed in this. Instead decisions are taken as the situation develops.”

Even without the declaration of a dengue epidemic, West Bengal should have had better mosquito control measures on the ground. “Dengue is endemic to Bengal, thus requiring the enforcement of the National Vector Borne Disease Control Programme guidelines throughout the year,” pointed out Biswas. “But no one keeps a watch over implementation.”

Most guidelines put in place by the National Vector Borne Disease Control Programme appear to have been rampantly violated.

In the slums and middle class neighbourhoods of Kolkata, residents said that health authorities began fogging, larvicide dispersal and taking other preventive measures only in late September. These preventive actions were often performed just once in a given area. In most rural blocks neighbouring Kolkata, there had been no intensive control measures.

The government’s assurances of dengue control have proven hollow. For instance, in a press conference on October 30, Chief Minister Mamata Banerjee said anganwadi workers would be roped in to undertake a door-to-door inspection and awareness campaign. But Neelima Maitra, former president and representative of All India Federation of Anganwadi Workers and Helpers, said, “In most places, anganwadi workers and helpers have jumped into awareness and inspection programmes at the local level voluntarily, with some financial support from the panchayats. The government has issued no instructions in this regard.”

Dilemma over diagnosis

In early November, some residents of a slum settlement alongside railway tracks in Dhakuria, a locality in south Kolkata, had been diagnosed with “unknown fevers”. Residents of at least three of the sixty-odd hutments said members of their households had been admitted at government hospitals, with such unknown fevers.

At a recent seminar in Kolkata, several doctors observed how doctors and diagnostic laboratories across the state were under immense pressure to not mention dengue in prescriptions and reports, even if the patient was infected with or had died due to the dengue virus. This has resulted in many dengue cases being referred to as ojana jor or unknown fever. Doctors were writing “febrile illness bleeding disorder”, “multiple organ failure”, or simply “fever” as causes of death in death certificates, the doctors at the seminar said.

Some of this is due to official orders pertaining to what diagnostic tests are relevant. Only the ELISA test is considered a valid confirmatory test for dengue. ELISA tests are available only at district hospitals and a handful of sub-divisional hospitals. These hospitals have been under immense pressure since October, when large numbers of urban and rural patients started showing up with fever.

Meanwhile, many laboratories diagnose dengue using the cheaper, faster and more easily available Rapid Diagnostic Test. The National Vector Borne Disease Control Programme’s guidelines note that the commercially available Rapid Diagnostic Test, which tests for a dengue antibody called NS1, has a high rate of error and should not be used for management of dengue. The union health ministry issued a circular in 2016 saying that a patient can only be declared a “probable case of dengue” based on the Rapid Diagnostic Test.

A senior technician from a private diagnostic laboratory who did not wish to be identified said the West Bengal health department last year instructed private labs not to write dengue in reports, after it found that many labs were running Rapid Diagnostic Tests.

CPI-M workers stage a demonstration in Kolkata on Nov 2, 2017 to protest against dengue outbreak in the state. (Photo: IANS)
CPI-M workers stage a demonstration in Kolkata on Nov 2, 2017 to protest against dengue outbreak in the state. (Photo: IANS)

The health department official said that clinicians may not be writing dengue in diagnostic reports now because of confusion over what the state health department’s instructions mean.

But the absence of a firm denial by the government that the health department has deliberately asked doctors to refrain from attributing fever cases to dengue has only served to obfuscate the scale of the crisis.

Weaker population, stronger virus?

India has had four strains of the dengue virus – DEN-1, DEN-2, DEN-3 AND DEN-4 – in circulation. However, West Bengal’s earlier dengue outbreaks, doctors say, have been caused by the DEN-1 and DEN-3 strains. This year there seems to be an outbreak of the DEN-2 strain infections.

“This year, patients are coming to hospitals with complaints of excessive joint pain that is rendering them immobile within one or to days of the fever setting in,” said Dr Swapan Biswas, who has been part of several dengue-related medical camps organised by doctors associations in the districts. “They are also suffering from distended bellies and acute stomach pain due to capillary leakage. In several cases, patients are brought in in a state of shock, with blood pressure having dipped significantly.”

These clinical symptoms, Biswas said, are different from the symptoms patients had exhibited in outbreaks that occurred over the past two years and match the set of symptoms due to DEN-2 infection.

This outbreak of a new strain that has previously not been seen in the state means an increased risk of mortality, especially among those facing a second dengue attack.

“Antibodies help combat only the same genotype of the virus in case of dengue,” said Aparna Mukhopadhyay from Presidency University. “When a person is infected with another genotype of the dengue virus (like this year), the virus is able to establish itself faster.”

Previous dengue outbreaks through the state have rendered the population weak and more susceptible to an attack by a different dengue genotype.

The Indian Council for Medical Research Virus Unit that is housed under the National Institute of Cholera and Enteric Diseases in Kolkata is the apex referral laboratory in the eastern zone authorised to conduct vector surveillance and analyse the genome sequences of the viruses in dengue positive blood. The institute has, however, not come out with any report on the change in dengue virus strains.

“As long as the data is not in the public domain and we do not know the changed genetic sequence of the virus, how can we possibly probe the reasons for its mutation and strengthening or the measures that can be taken to control the virus,” said a senior scholar researching the dengue virus, who did not want to be identified.

We welcome your comments at
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the marketing team and not by the editorial staff.