Apropos of thought provoking editorial on investigation of outbreaks in India(1), the author needs to be commended for bringing out some of the inadequacies and ills affecting public health system in our country.

The most apt reply to this query is because the peripheral public health delivery system in India is in shambles and almost non-existent in some states such as U.P. and Bihar. It does not have enough expertise nor infrastructure to either investigate or control any ongoing epidemic. The expected ‘knee-jerk’ response of the health administration is to rebuff any attempt to highlight emergence of any known or unknown illness and to suppress any information provided to them. Probably, they are not provided with enough guidelines or directives from higher ups on how to deal with these situations. There is an urgent need to conduct workshops and reorientation courses for health officials to impart a correct knowledge of how to investigate, when to investigate, what to investigate and whom to approach for assistance in case of emergence of a new disease or outbreak of a known disease.

Delay in instituting the investigational mechanism at an appropriate time and level is another important factor. During the last year outbreak at Saharanpur, when investigating teams from NICD, Delhi and NIV, Pune reached the spot, the epidemic was already on the wane. There was hardly any record of the cases and neither the samples of sera nor CSF were available for investigation.

Another important reason is inability to know whom to report. The only recourse available to a practicing clinician is to break the ‘news’ to local media. It is quite ironical considering that it is lay media rather than professional academic bodies reporting and breaking the news to public, and consequently creating a panic among them. Here the inertia displayed by academic medical organizations is most unfortunate.

But, perhaps, the most serious obstacle to proper investigation of an epidemic is provided by intense political pressure under which even a premier investigating agency like NICD is subjected to work. There is almost complete censorship, no public briefing on progress of investigations, and non-involvement of private health sector and NGOs.

Dr. Balraj has cited an example of SARS as a proof of result of proactive approach in dealing and diagnosing an epidemic of new infectious disease. However, the one remarkable attribute of SARS management was its association with ‘speed’- the speed with which real time information disseminated through internet and media, and the speed with which world medical community got hold of it and contained the emerging pandemic! Sorely, this attribute is clearly lacking in our working environment. There is scarcity of credible, interactive medical websites, very few people use internet and exchange information with outside world, and still fewer dare the odds of writing and later get their accounts published in good, reputed scientific journals. Even those who get succeeded through these hurdles, it takes usually 8-10 months to see their reports in print.

Some good Indian journals, such as ‘Indian Pediatrics’ are having their own websites. These can be made interactive with a facility of automatic submission and publication of brief reports. Responses and opinions of experts then can be published online in form of ‘rapid responses’ as is the case with majority of international medical journals. In print version also a section like ‘National Alert’ can be added just like ‘Global update’ where a brief account of an emerging illness from different parts of the country can be published pending detailed reports in subsequent issues.

Both Dr. Jacob John(2) and Dr. Balraj(l) have urged academic NGOs like IAP to play a more positive role. But, sadly, so far the only directive available to an average IAP member is to go public and brief the local media about emergence of the disease. There is no dearth of infectious disease experts in the Academy, and a core group of them either under the aegis of Infectious Disease chapter of IAP or central IAP with a designation of ‘Epidemic Management Cell’ can be constituted to respond and to issue guidelines to members residing in the affected areas, to seek cooperation and to help investigating national agencies, to seek collaboration of international agencies like CDC and WHO, if need arises. Further, the expertise gained through successful AFP surveillance system and resources and infrastructure of laboratory network for viral isolation and genetic surveillance can be utilized to keep a vigil on emergence of new epidemics and to crack mysteries of these so called ‘mysterious diseases’.

Vipin M. Vashishtha,
Consulting Pediatrician and Neonatologist,
Mangla Hospital, Shakti Chowk,
Bijnore 246 701, U.P., India.
E-mail: [email protected]

1. Balraj V. Investigation of outbreaks in India. How good are we at it? Indian Pediar 2003; 40: 933-938.

2. John TJ. Outbreaks of killer brain disease in children. Mystery or missed diagnosis? Indian Pediatr 2003; 40: 863-869.