Will making dengue a notifiable disease actually help fight outbreaks more effectively?

On June 9, the Central government made dengue a notifiable disease. This means that any confirmed or suspected case of dengue, as per the set parameters, should be reported to the district health authority. This rule applies to both public and private practitioners.

So far, the number of dengue cases has been grossly underreported in India.

As per the National Vector Borne Disease Control Programme, in 2015, India reported nearly one lakh cases, and 220 deaths due to dengue. This year, the provisional figures till July 28 stood at 15,099, with 26 deaths.

The real figures are possibly much higher since private sector hospitals have so far not been required to report cases of dengue, and many people with suspected dengue are more likely to go to a private doctor near their homes, instead of a government hospital.

“The response of the private sector, including hospitals and laboratories is good,” said Dr AC Dhariwal, director of National Vector Borne Disease Control Programme. “Some states such as Delhi and Maharashtra have taken it seriously and are trying to implement it.”

Gross underreporting

In 2014, a study published in the American Journal of Tropical Medicine and Hygiene, said that the National Vector Borne Diseases Control Programme in India captures only 0.35% of the annual number of clinically diagnosed dengue cases.

Said Dr Narendra Kumar Arora, director of INCLEN Trust International, one of the researchers of the 2014 study: “Apart from the fact that the private sector is excluded, a lot of facilities for testing are not available at even district hospital level. The treatment is given as per the symptoms and usually involves antipyretics [drugs such as paracetamol], doctors do not feel compelled test for the disease.”

Thus, for an average of 20,000 cases of dengue reported every year between 2006 and 2012, the results after correcting the underreporting is six million cases.

The dengue underreporting rates are comparable to the low reporting rates of malaria deaths, malaria cases or chikungunya cases, the study noted.

Even in the public health sector, sometimes the numbers do not add up.

The Praja Foundation, a non-profit organisation in Mumbai, conducts a study every year to understand the state of health in the city. Almost all years, it has found discrepancies in the reporting of tuberculosis and malaria deaths particularly.

For instance, in Mumbai, the health department of the municipal corporation reported 1,459 deaths due to tuberculosis, whereas the department that handled birth and death registration issued 5,680 death certificates giving tuberculosis as the cause of death. Death certificates, however, are not relied upon as final causes of death.

“The Registration of Births and Deaths Act talks clearly about using the data for mortality and morbidity studies,” said Milind Mhaiskar, of the Praja Foundation.

Accurate data can help governments gear up for possible outbreaks better. “If we do not have good data, then how do we assess an outbreak,” said Dr Arora. “The public health system needs to invest in resources to tackle such outbreaks.”

The result of under-preparedness is evident in the way public hospitals have had to arrange for beds on the floors during the malaria and dengue outbreaks in Mumbai and Delhi in the past few years.

The private sector can help

In case of tuberculosis, the Mumbai civic body worked on implementing the notification of the disease. The health department roped in private laboratories particularly to gather more accurate numbers of the disease.

A similar effort needs to be made for dengue.

“Sending a decree will not make the private doctors notify the disease,” said Dr Arora. “Bodies such as the Indian Medical Association will have to be involved. There has to be a dialogue with them to help them understand the significance of reporting dengue cases.”