The annual outbreak of dengue has spread its wings aggressively this year in Prime Minister Narendra Modi’s parliamentary constituency Varanasi with at least 10 dead—including a government doctor and a policeman—in the space of a month. Over 70 others are battling the mosquito-borne virus at two major hospitals in Varanasi—the world’s oldest inhabited city which is now being decked up for the 2019 general elections.

More alarming are the figures of dengue-positive cases. “In the last four weeks, over 637 people with high fever and low platelet counts have tested positive in the preliminary diagnosis of dengue test (called NS1, or non-structural protein 1),” said officials at Sir Sunderlal Hospital (SSL), Varanasi’s largest medical institution affiliated with Banaras Hindu University.

Another prominent government institution, Pt Deen Dayal Upadhyay Hospital (DDU), the divisional hospital and other public health centres in Varanasi have reported approximately 300 NS1-positive patients over a month, bringing the estimated count of dengue incidences in Varanasi to over 900, said health officials on condition of anonymity.

The figures are several times higher compared to previous years. Alarmed at the situation, the chief medical officer of Varanasi, Dr VB Singh, has ordered the cancellation of weekly and festival holidays of all employees of the health department and the municipal body. Health facilities across the district have been kept on “extra alert”.

There were over 107 dengue-positive cases in Varanasi in 2017 with no casualties, while 171 positive cases and three deaths were reported in 2016. Singh said his office was collating data from all institutional and non-institutional facilities to put together the entire picture.

The dengue wards of SSL and DDU were running out of beds over the weekend, forcing patients to rush to private hospitals. Blood bank managers said the demand for random donor platelets and single donor platelets (SDP, more effective in critical cases) have risen three-fold over the last week. Severe dengue cases require platelets transfusion as soon as the platelet count goes below 40,000.

A local said, “Many private hospitals carry out transfusions unnecessarily and also charge exorbitant prices for the platelets to make money out of the epidemic.”

Health facilities on ‘extra alert’

Chief medical officer Dr VB Singh told Newslaundry that while all health facilities have been kept on extra alert, relatives of dengue patients are being tested and staff are visiting patients’ neighbourhoods to provide anti-larvae treatment for water bodies and indoor spray. Awareness campaigns have also been increased.

Dr Singh said, “We are also keeping tabs on other vector-borne infections such as chikungunya and even Zika (which has spread in Jaipur) since Varanasi is a tourist city, although no such cases (of chikungunya or Zika) have been reported in Varanasi so far.”

Dr Singh remained tight-lipped when asked about the total number of dengue-positive cases and dengue deaths in the district. He also denied there was any shortage of platelets. When told about the estimate dengue statistics in the district, the chief medical officer claimed not all NS1-positive cases were necessarily dengue.

“The NS1 is a quick and early detection test but has poor sensitivity and specificity,” he said. “It gives a positive result in dengue, Japanese encephalitis, chikungunya and a few other flavivirus infections. Platelet count drops in other viral infections also. Hence, dengue is confirmed only with the detection of IgM antibody through ELISA (enzyme-linked immunosorbent assay) to be conducted seven days after the first symptoms.”

However, Dr Singh admitted that most patients with suspected dengue don’t undergo confirmatory tests in Varanasi. Even SSL doesn’t conduct IgM-ELISA in all suspected cases—something which is regarded as very important to fight the spread of the virus. The institution carried out IgM-ELISA on only 67 suspected patients out of 117 admitted over the past four weeks. There is no clear picture of “confirmed dengue” cases.

Dr Vijay Nath Mishra, medical superintendent of SSL, claimed, “Only seven of 67 patients tested IgM-ELISA-positive and they suffered from various ailments.” The hospital is currently treating 37 admitted patients for suspected dengue in various wards including a 20-bed dengue ward. Dr Mishra admitted that all NS1-positive cases must be referred to a confirmatory test as per protocol. He said, “Machines are available which provide NS1 and ELISA together. But most doctors don’t follow the protocol which adversely affects the drive against the disease.”

When asked about the number of “suspected” and “confirmed” cases in Varanasi, Dr Singh claimed his office receives only confirmed dengue reports. “The NS1-positive cases are not reported to us. We only get confirmed dengue figures of IgM-ELISA positive cases. So far, only 72 confirmed cases of dengue have been reported at SSL and DDU hospitals. The statistics of the entire district are awaited.”

Contrary to Dr Singh’s claims, a 2016 notification from the Union Ministry of Health and Family Welfare clearly mandates that all government, private, trust-run hospitals and private practitioners inform district health authorities of both suspected and confirmed dengue cases (based on NS1) on a weekly basis. This order also mandates doctors to send suspected cases for a confirmatory ELISA test. It says: “…to ensure early diagnosis, case management, reduce dengue transmission, address the problem of emergency and spread of disease in newer geographical areas, it is necessary to have complete information on dengue.”

Regarding the 10 deaths, Dr Singh and Dr Mishra insisted that the patients were suffering from other ailments apart from dengue such as acute respiratory syndrome, haemorrhage, acute hepatic failure and neurological complications which led to their deaths. An infectious disease expert points out these are the manifestations of severe forms of dengue—dengue shock syndrome and dengue haemorrhagic fever as outlined in the Centre’s guidelines for dengue.

Is dengue being under-reported?

Under-reporting of infectious diseases is a common practice in most states. Sources in the Union Ministry of Health and Family Welfare said, “Confirmatory tests are not being carried out at most places unless the patient is serious. The concerned officials must take adequate measures but this ambiguity helps them to hide their inefficiencies.”

Since no medicine or vaccine is available for dengue, prevention is the only strategy. The 2016 notification says, “The reporting becomes important especially since dengue is a major public health concern in the country accounting for substantial morbidity and mortality.”

Chief medical officer Dr Singh dodges every question over the huge mismatch in “preliminary” and “confirmed” dengue cases—a stance also taken by Dr Mishra, who said, “We receive blood samples from across the districts for the NS1 test. It is up to the doctors from all institutional and non-institutional set-ups to follow the protocol and get the confirmatory test done.”

Unplanned development, lack of fogging to be blamed

The government’s National Vector Borne Disease Control Programme explains the factors responsible for the dengue epidemic as follows: unprecedented human population growth; unplanned and uncontrolled urbanisation; inadequate waste management; water supply mismanagement; and lack of effective mosquito control, among others. Locals say that at present, Varanasi is experiencing all these factors.

Avnindra Singh, a local journalist, said, “The entire city has been dug up repeatedly due to haphazard construction work to lay roads, underground cables and pipelines. This has led to piling up of garbage, debris and construction materials at various places, making waterlogging easier.”

The lack of fogging is also being cited as a reason for the spike in dengue cases. A leading Hindi daily quoted the district malaria officer, Sharat Chandra Pandey, as saying, “There are just 18 employees to spread pesticide in the entire city spread across the river Ganga. As a result, most areas remain uncovered, leading mosquitoes to breed. There has been no fresh recruitment in the malaria department over the last decade which makes the matter worse.”

Civic health officials, however, claim fogging is being carried out consistently with the help of 14 machines and that more equipment is being procured now.