The new era of communicable diseases demands fresh strategies and a balance of resources, policies and technology
Apart from already existing communicable diseases like Tuberculosis (TB), AIDS and Malaria, there is an increase in the frequency and scale of communicable diseases with pandemic potential. The most recent being COVID-19. This new era of communicable diseases is defined by outbreaks of emerging, re-emerging and endemic pathogens that spread quickly, aided by global connectivity and shifted ranges owing to climate change.
Talking about the impact of infectious diseases on society, Dr Gunisha Pasricha, Principal Scientist, Infectious Disease Expert, MedGenome Labs said, “Infectious diseases present a critical threat to global health security with high morbidity, mortality, and healthcare costs. A key contributor to the emergence and re-emergence of infectious diseases is human behavior. The movement of human beings, growing population, social and health inequalities, and climate change have caused imbalances in the complex ecosystem which have caused newer communicable diseases or the re-appearance of the older ones. There is a constant need for the development of rapid and cost-effective diagnostics, prevention, therapeutic strategies and maintaining real-time epidemiological surveillance for these diseases.”
Dr Monalisa Sahu, Consultant Infectious Diseases, Yashoda Hospitals, Hyderabad highlights, “Communicable diseases with pandemic potential pose a real public health threat, and these disease outbreaks can have serious social, political, and economic impacts. Lessons were learned from the previous outbreak events, and farreaching advances have been made. Although, pandemic preparedness remains a global challenge. The global need for funding for pandemic preparedness and response is presently falling short in comparison to its requirement. Several important factors relating to human behavior and activities, pathogen evolution, poverty, and changes in the environment as well as dynamic human interactions with animals have contributed to infectious disease emergence and transmission.”
Where do we stand: Current status?
There are enormous advances in medical sciences accompanied by innovations, more R&D, new technologies and realisation of incorporating mass awareness programs, especially in case of diseases like HIV/AIDS, TB, Malaria, Severe Acute Respiratory Syndrome (SARS), Avian Flu, and Antibiotic-Resistant Infections (superbugs). But we still have a long way to go to completely eradicate them from the system, considering the rise in factors like globalisation, climate change, urbanisation and mass travel.
India had been making progress in diagnosing and treating a progressively increasing proportion of communicable diseases like TB, Malaria and HIV but this was before the pandemic. There was a significant disruption of this positive trend during the pandemic.
One of the examples is, in 2020, fewer people were diagnosed with TB than the year prior for the first time in many years. However, this did not mean that TB incidences were declining, but rather more resources were allocated and redirected toward COVID-19. Applying some of the lessons learned to respond to other infectious diseases effectively is the need of the hour. One of the lessons is introduction and incorporation of new medical technologies in the system. Elaborating on the impact of the pandemic on Malaria management, Pratik Kumar, Country Director, Malaria No More said, “The year 2020 brought along with it a myriad of challenges as it exposed us to the deadly COVID-19 pan demic. The world responded by focusing all resources and attention towards battling the disease, as was the need of the hour. Thankfully, we have now reached a situation where COVID is more under control, and hopefully, the worst of the pandemic is behind us. While prompt redirection of public health priority towards COVID at its onset was essential, a byproduct of that was also the de-prioritisation of other public health issues – communicable diseases such as mosquito-borne diseases amongst them. An illustration of this decreased priority is the reduction in malaria surveillance by approximately 38 per cent between 2019 and 2020, as highlighted by official numbers.”
“Now since the storm of the pandemic has settled, there is an imminent need to prioritise communicable diseases, such as malaria in the post-pandemic world. India has observed tremendous progress over the last few years in controlling the spread of malaria. However, as the country approaches elimination, realising the honourable prime minister’s ambition of eliminating malaria by 2030, we need an aggressive and targeted strategy that addresses the key gaps and challenges currently existing in our malaria elimination drive.”
The new era of communicable diseases demands fresh strategies and a balance of resources, policies and technology.
Neeraj Gupta, Founder & CEO, Genes2Me said, “There is no shadow of a doubt that 2020 has been a year which taught all of us a lesson in some way or the other. If cleanliness may not be next to godliness, it will surely be next to healthy living. At times when even breathing without a mask in public was stifled, it taught a lesson that it’s not too late to be prepared. This hang of COVID-19 has helped people understand the need for sheer protection from spreading diseases which is indeed a good thing It can be conceded that after years of campaigning, people could be made aware of the gravitas of safe sex. Sexually transmitted diseases could be controlled by organising awareness programs. However, in the light of COVID-19, when the pandemic has become endemic, the need for detecting these diseases faster has become a prime concern.”
Access to high-quality diagnostics to manage the burden of communicable diseases
As per WHO, an estimated 66 million lives were saved through TB diagnosis and treatment between 2000 and 2020. World Hepatitis Alliance highlights that more than 300 million people are infected with the hepatitis B virus (HBV) or the hepatitis C virus (HCV) and 9 out of 10 people living with viral hepatitis are unaware. Access to high-quality testing and treatment monitoring is important for managing the burden of communicable diseases. The diagnostic landscape of infectious diseases has undergone major growth, especially during the pandemic which highlighted the role of the 3T (Test, Track and Treat) strategy in containing and managing the infectious disease.
Stressing on the current status of diagnostics, Dr Anup Warrier, Consultant-Infectious Disease & Infection Control, Aster Medcity, Kochi said, “Molecular diagnostics has entered the arena in a big way with lots of PCR testing capable labs coming up and the regular labs ramping up to accommodate PCR based testing. This infrastructure can be used for the diagnosis of many other infectious diseases other than COVID-19, including newer pathogens. The gaps are in the cost barrier with sequencing and the high investments required for sequencing. Without access to cheaper and widely available sequencing technology, it will be difficult to face new/emerging pathogens. There was also a huge amount of unscientific and unnecessary use of diagnostics – especially among biomarkers of inflammation during the COVID.”
Ashish Vikram, CEO, Flebo.in stresses that, “One of the important means to prevent the spread of communicable diseases and also prevent other diseases from becoming serious and lifethreatening is to get tested quickly for any suspected diseases. This allows for timely preventive measures such as self-isolation or changes in lifestyle and if required start medication early. Prevention is better than cure is an adage that everybody has heard of but most of us still take an avoidance-avoidance approach to medical tests. India needs to remain vigilant and develop ‘safe’ practices that include regular preventive diagnostic testing both to reduce the impact of future pandemics and to reduce and eliminate the prevalence of communicable diseases like TB.”
Dr Pasricha adds, “COVID19 has thrust diagnostics to the forefront of healthcare conversations across the globe. Before COVID hit, diagnostics as a sector was not given its due importance although doctors rely heavily on it for making clinical decisions. Awareness about molecular diagnostic tests has also increased by leaps and bounds among consumers since then. Presently over 3000 diagnostics laboratories across India offer Real-time PCR-based tests for COVID-19. Now when the COVID-19 pandemic is plateauing towards endemicity, it is very important to leverage and harness the infrastructure and talent pool already available for molecular testing. Infectious diseases are here to stay as stated by World Health Organization (WHO) in its 2007 report wherein it mentions that infectious diseases are emerging at a rate that has not been seen before. Since the 1970s, about 40 infectious diseases have been discovered, including SARS, MERS, Ebola, Chikungunya, Avian flu, Swine flu, Zika and most recently SARS-CoV-2 and Monkey Pox.”
Dr Sahu emphasises that advances in molecular diagnostics and sequencing technology have played a pivotal role in the control of many infectious diseases. She said, “The development of nucleic acid detection and genome sequencing technology has tremendously revolutionised infectious disease research and helped better delineate the pathogenesis, diagnosis, and treatment and hence optimum patient care and management. For the early and accurate detection, characterisation, and quantitation of the ever-increasing number of infectious pathogens, newer molecular assays have been developed as compared to traditional methods.”
“The newer nucleic acid amplification methods today have a high-throughput capacity to generate a wealth of data on various types of pathogens including bacteria, parasites, and viruses, with specific disease markers such as virulence, antibiotic resistance, and susceptibility factors. Multiple types of specimens including blood, stool, swabs, urine, Cerebrospinal Fluid (CSF) samples, and respiratory secretions can be used for these studies. Automation of nucleic acid detection technology provides “cutting-edge” platforms, which ultimately greatly impact patient management and afford more efficient epidemiological and public health interventions. The genomic and protein data, elucidated in the genomic and proteomic studies, has contributed mainly to successful vaccine design and drug development against most infectious disease pathogens”, she added.
Madhav Joshi, CEO, India Health Fund (seeded by Tata Trusts) considers technology as a major boom in the diagnosis of TB. He explains, “While the traditional screening for TB using a lung X-ray, is the most sensitive and cost-efficient way, it is also a workforce-heavy and time-consuming process. As India continues to face an acute shortage of trained radiologists, TB diagnosis can often take weeks leading to missed cases, increased disease spread, delayed treatment, and higher mortality. In the last decade or so, digital advances like Artificial Intelligence (AI), machine learning, the internet of things, and deep tech have shown their promise in the automated detection of various infectious diseases, including tuberculosis where AI powered deep learning neural networks are increasingly being used to analyse medical images, such as chest radiographs or x-rays. AI algorithms have proven to be highly accurate and useful triage tools for TB detection, especially in remote low-resource settings where skilled radiologists are in shortage.”
Talking on similar lines, Dr Rahul Pandit Director-Critical Care, Fortis Hospitals Mumbai, Member of National COVID19 Taskforce & Maharashtra’s COVID-19 Taskforce also highlights, “The global medical field has come a long way in diagnostics. Technology has evolved from simple culture to polymerase Chain Reaction-Based Markers for gene tagging in the past few decades. This has changed how diseases and conditions are diagnosed. However, the challenge at the current time is to identify and analyse new threats at high speed so that it saves valuable time and enables us to combat the condition in a faster manner. To achieve this, techniques like molecular, immunological diagnostics, signature gene and proteomicbased platforms will always have to be available. Also, quick sampling from small outbreaks and surveillance samples for sewage water and other materials will have to be screened for any potential threats of a large outbreak. Similarly, the home-based kits will have to be more specific and sensitive, with an inbuilt default mode so that any test result is immediately reported to a central agency. By doing this, the onus of reporting does not fall on the patient’s shoulder.”
Disease surveillance and technology
The effectiveness of India’s current available surveillance systems is inadequate. Surveillance systems like Integrated Disease Surveillance Program (IDSP) are in place already but the overall reporting and upkeep of the data through it is very limited. Increasing the scalability of technology in these systems will not only strengthen its overall implementation.
Genomic surveillance has also proved to be promising in the management of spread of emerging infectious diseases. This helps researchers, epidemiologists and public health officials monitor the evolution of infectious disease agents, signal alerts on the spread of pathogens, and develop countermeasures such as vaccines.
Pointing out exploiting the intersection of technology and healthcare in the interest of the public at large, Arvind Sharma, Partner, and Pallavi Mall, Associate, Shardul Amarchand Mangaldas & Co shares, “There is immense scope to exploit the intersection of technology and healthcare in the interest of the public at large. By implementing adequate measures, allocating sufficient resources towards the cause, and encouraging this intersection to grow to cause further innovation, technology as a tool will prove to be a great solution to the problem of increasing communicable diseases. Additionally, the implementation of technology with respect to communicable diseases may also help in reducing the transmissibility of diseases from one affected person to another by doing away with physical inter-personal contact, as was helpful in the case of COVID-19, as a prevention and containment strategy. Further, technology can offer holistic approaches to managing communicable diseases by enabling tracking, surveillance and prevention. However, placing increasing reliance on technology in the healthcare sector would also call for adequate data protection and privacy safeguards to be set in place.”
Stressing the need to establish a formal global surveillance network specifically to prevent pandemics, Vikram Thaploo, CEO, Apollo Telehealth said, “A global, risk-based, multisectoral viral surveillance network would focus on detecting new “high consequence” viruses in humans and animals in hotspots for emerging risks. However, establishing such a network for longitudinal surveillance has considerable challenges, particularly in under-resourced, hotspot regions, where basic health and laboratory capacities are weak.”
“Technical and logistical challenges exist in designing sampling frames for viral surveillance, establishing mechanisms for information sharing about rare spillover events, training a skilled workforce, and ensuring infrastructural support across public and animal health sectors for the collection of biological samples, transportation, and laboratory testing. For the sustainability of an early warning system, strong political commitment, a sound governance structure, and long-term financing will have to be assured. The opportunity exists to leverage political and financial support to establish and implement a global early warning surveillance network to detect emerging threats”, he added.
Explaining the role of disease surveillance, Dr Rashmi M, Consultant-Microbiology & HIC, BGS Gleneagles Global Hospital, Bengaluru said, “Main role of surveillance is to detect an outbreak, identify variants, map geographical spread, and monitor vaccine efficacy. The WHO oversees developments globally. In India surveillance and coordination are taken care of by the national center for disease control (NCDC). Integrated health information platform (IHIP) is a decentralised state saved surveillance system for epidemic-prone diseases to detect early warning signals so that timely and effective public actions can be initiated. Artificial intelligence/ machine learning techniques are increasing in healthcare and have been widely applied to infectious disease outbreak detection & early warning, trend prediction & public health response modeling & assessment. AI is still in its early stage of development with a lot of potential to be explored in the future.”
Stressing the need for prioritising surveillance, Dr Preet Pal Thakur, Co-Founder, Glamyo health said, “The primary goal of priority surveillance is to make the best possible use of restricted human and financial resources for disease control while keeping changing needs in mind. It is difficult to prioritise diseases for surveillance as it involves extensive value judgments, such as weighing the importance of early detection of a highly infectious disease versus monitoring endemic, common, but less severe diseases. Therefore, priorities must be established that guarantee that both planning and resource availability are rational, explicit, and transparent. Priorities should also be reviewed regularly because dangers evolve over time.”
Dr Sravani Reddy, Global COO & Executive Director of Board, Ojaska also agrees that “Web-based surveillance systems can help better reporting if geographical surveillance gaps are filled. This will ensure accurate acquisition and analysis of data from the internet.”
Dr John Paul, Infectious Disease specialist, SPARSH Hospital emphasises, “COVID has given us a very good template. We are better prepared to handle an outbreak as compared to where we were three years ago. We are able to identify an outbreak quickly and take the necessary precautions and measures to control it. There are disease notification systems and epidemiologists are working on identifying an outbreak. We now have robust systems in place to respond to such outbreaks. There are certain disease surveillance practices in place led by the government. A lot of diseases are classified as notifiable diseases. Once there is an increase in the notifications or incidences of these diseases, there would be a response from the government. For example, for a given area, if the number of deaths due to dengue crosses a particular limit, then it automatically activates a particular vertical which will look into the reasons behind it and figure appropriate response for it.”
Infrastructure to deal with communicable diseases The biggest example of an intrinsic linkage between infrastructure and infectious diseases was COVID-19. A well-managed, implemented and strengthened healthcare infrastructure in place is the most crucial parameter when dealing with infectious diseases.
Commenting on this, Dr Warrier said, “Managing communicable diseases requires the development of infrastructure for both diagnostics (molecular diagnostics and sequencing, genotyping, etc.) and treating patients in “isolation rooms”. Presently hospitals are poorly equipped to admit and manage infections requiring airborne isolation. We need to look at cost-effective and scalable solutions to handle the influx of airborne infections from the community. Also, we need to build up resilience in our supply chains for access to personal protective equipment (PPE) and diagnostic kits/reagent, etc. Capacity building for healthcare facilities that can handle infectious diseases and labs that are capable of advanced sequencing will be required.”
Dr Manav Manchanda, Director & Head- Respiratory, Critical Care & Sleep Medicine, Asian Hospital believes that we need to have proactive measures in place rather than acting in times of crisis. He said, “The corona pandemic has made it very clear that infectious diseases and infrastructure are closely linked and how infrastructure can be impacted by infectious diseases. We need to be better prepared for future infectious disease threats – for this, we need to have proactive measures in place rather than acting in times of crisis. Besides, the interconnectedness of the world today means emerging outbreaks can have far-reaching impacts within a very short time. Infrastructure settings can become safer and more resilient spaces within their limits. A pandemic resilient infrastructure can contribute to a more stable economy by continuing to provide employment and enable continuity of necessary services thereby improving social outcomes for all.”
Pramod Kutty, CEO & Co-Founder, Connect2MyDoctor considers poor doctor-patient ratio as a major gap in the infrastructure. He said, “In India, the doctor-patient ratio is poor, at 0.7 doctors per 1,000 people. By increasing the number of training institutes, one can address the poor doctor-patient ratio to some extent. Considering India’s mammoth population, we need significantly a greater number of hospitals and doctors and other medical staff. Technology adoption is crucial and so is the rate of adoption. To streamline the operational and clinical process technology can play a huge role besides keeping the patient-doctor ratio in check.”
“Small clinics and hospitals constitute a significant part of the healthcare chain in India and it’s crucial that the bulk of these centres adopt healthcare tech in their daily lives. Many are worried about their return on investments but in the long run, they will benefit immensely through digital adoption. The faster they realise this; the safer will be their business models. While the government is taking up measures to set up specialised units like AIIMS in multiple cities, we have to also set up medical colleges in every district, increase bed capacities at private and government facilities, and build and develop ICU type facilities in all districts. We have to also pay our nurses better”, he added.
Policy intervention
COVID taught us how prompt and well-implemented policy interventions can help in quickly turn the tide against infectious diseases. The government and private sector need to work together and in sync for better outcomes of the policies. India already has strong policies and goals to eradicate and manage communicable diseases focusing on creating awareness, diagnosing them on time and making their treatment and medication accessible and affordable to the population. But there are gaps and challenges which require an integrated approach across the ecosystem.
Elaborating on the accessibility and availability of medicines part, Vani Ahuja, CoFounder and Director, NatureCode states, “Regardless of one’s economic, social, cultural, religious, or political background, achieving one’s right to health is a core objective of the state’s policies and programmes. However, for millions of people around the world, fully achieving their right to health remains a distant dream, in part because of barriers to accessing high-quality, timely, and affordable medicines, which are typically found in developing nations. The values of equality, non-discrimination, openness, participation, and responsibility are inextricably intertwined with the availability of medications. Although the issue of access to medicine concerns us all, those who are most impacted reside in low- and middle-income nations. Since everyone should have equal access to good health, this inequality should not be tolerated. These businesses have the resources and influence to increase the accessibility, affordability, and acceptability of their medications for those in need. No one will be left behind if they take steps to increase access to their medications.”
Dr Manchanda believes that “For effective access to healthcare during pandemics, the research and the guidelines must be systematically directed by a systemic framework. Availability of medicines and essential resources was hard hit during the first phase of COVID-19. As countries across the globe went into lockdown shutting down or limiting transport, this in turn affected manufacturing, supply and ultimately availability of medicines. Ensuring access to medicines and necessary healthcare services is critical to prevent illness and death.”
Dr Reddy said, “Political interests and National trade priorities should be set aside and a rigorous international collaboration is essential for the detection, prevention and control of an emerging infectious disease outbreak with potential for global spread.”
Way forward
Characterising pandemic risk and identifying gaps in pandemic preparedness is essential for prioritising and targeting capacity-building efforts, which can be used to eradicate and manage communicable diseases in the post-pandemic world.
Kalyani.sharma@expressindia.com