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A few days back a
police complaint was filed by the Ahmedabad Municipal Corporation (AMC)
against a doctor couple who have a clinic in Vejalpur in Ahmedabad for
failing to notify tuberculosis to the AMC, as reported in TOI.
This is the first
such complaint in the state against any doctor for suppressing information
about tuberculosis. According to government statistics for 2018, Gujarat was
among the top five states in reporting tuberculosis after Uttar Pradesh,
Rajasthan, Madhya Pradesh, and Maharashtra. According to medical health
officer Bhavin Solanki, the AMC had in April 2018 directed all doctors to inform
it about tuberculosis cases. Solanki said 100 doctors were issued such
notices. However, it was observed that private doctors were not reporting all
tuberculosis cases.
The AMC found
during an investigation that a patient from Srinand Nagar was undergoing treatment
at Akshar Hospital in Vejalpur. The AMC had issued a notice to Dr Nilesh
Makkani and Dr Pragni Makkani of the hospital on April 21. However, despite
getting the notice, the couple did not inform the AMC about the Srinand Nagar
case.
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TB has been a
notifiable disease since 2012 (notification Z-28015/2/2012-TB ) and
“all healthcare providers (clinical establishments run or managed by the
Government (including local authorities), private or NGO sectors and/or
individual practitioners) are required to notify every TB case to local
authorities i.e. District Health Officer/Chief Medical Officer of a district
and Municipal health Officer of a Municipal Corporation/Municipality every
month in a given format.
In a notification
issued on March 16 this year, the Health Ministry also made it mandatory for
all Pharmacies, Chemists and Druggists dispensing anti-tubercular medicines to
notify respective TB patients along with details of medicines. They are also
required to maintain a copy of the prescription and submit to the appropriate
local authority. As per this notification, failure on the part of the doctor,
Pharmacy, Chemist and Druggist to notify a TB patient to the Ministry of Health
and Family Welfare would invite punishment in the form of imprisonment and fine
or both, under sections 269 and 270 of the Indian Penal Code.
Section 269
IPC: “Negligent act likely to spread infection of disease dangerous
to life. - Whoever unlawfully or negligently does any act which is, and
which he knows or has reason to believe to be, likely to spread the infection
of any disease dangerous to life, shall be punished with imprisonment
of either description for a term which may extend to six months, or with fine,
or with both”.
Section 270
IPC: “Malignant act likely to spread infection of disease dangerous
to life. - Whoever malignantly does any act which is, and which he knows or
has reason to believe to be, likely to spread the infection of any disease
dangerous to life, shall be punished with imprisonment of either
description for a term which may extend to two years, or with fine, or with
both.”
Besides the IPC,
India also has other regulatory Acts such as the Epidemic Diseases Act
1987, which also provide for the control of communicable diseases such as
TB. The Act empowers state and central government to take special measures and
prescribe regulations that are to be observed by public to contain the spread
of disease. It gives legal protection to persons acting under the act and has
also defined penalty - a punishment under Section 188 IPC (disobedience of
order duly promulgated by public servant) of either description for a term
which may extend upto 6 months imprisonment or 1,000 rupees fine or both, for
violating the regulations.
In most of the municipal corporation acts for example DMC
Act (Delhi) TB is defined as a dangerous disease under 2 (9) "dangerous
disease" means— (a) Cholera, plague, chicken-pox, small-pox, tuberculosis,
leprosy, enteric fever, cerebrospinal meningitis and diphtheria; and (b) any other
epidemic, endemic or infectious disease which the Commissioner may, by
notification in the Official Gazette, declare to be a dangerous disease for the
purposes of this Act; Prevention of dangerous diseases. The DMC act also
mandates reporting under section 371. " Obligation to give information of
dangerous disease: Any person being in charge of, or in attendance, whether as
a medical practitioner or otherwise, upon any person whom he knows or has
reason to believe to be suffering from a dangerous disease, or being the owner,
lessee, or occupier of any building in which he knows that any such person is
so suffering shall forthwith give information respecting the existence of such
disease to the Municipal Health Officer. Under Section 482 DMC, the
person shall be fined as penalty for breaches for bye-laws.
India launched a TB
Free India Campaign on March 13, 2018 and set itself a target of eliminating TB
from the country by the year 2025, five years before the global target at the
Delhi End TB Summit. The global target for eliminating TB is 2030.
Certainly,
notification is important to know the prevalence and incidence of TB cases in
the country. A strategy can be then drawn up to eliminate the disease from the
country to meet the target.
It is equally important
to ensure that patients complete the full course of treatment. Those who discontinue
treatment may become infectious, or the period of infectiousness may be
extended if currently infectious, and also are at risk of developing drug
resistance.
But, a question then
arises “Is it enough to only notify TB?” without ensuring that they are not
spreading the infection to close contacts or the community?
TB spreads by
airborne droplet infection.
Open cases are
considered contagious and just being within close proximity of an infected
person who had just coughed, sneezed or spat (even if only while speaking) may
expose a person to the risk of acquiring the infection.
The risk of disease
transmission is particularly high in overcrowded conditions.
Such open cases could
be found anywhere in all walks of life and could be anybody. And they may
expose a large number of people to the TB bacteria in day to day life.
So, “Shouldn’t TB
patients (especially NDR and XDR), especially open cases, be isolated?”
“Shouldn’t persons
who have been exposed to the TB bacteria be quarantined?”
Isolation means
separating sick persons with a contagious disease from those who are not
sick. Quarantine, on the other hand, means separating and
restricting the movement of people who have been exposed to a contagious
disease, but are not yet ill, to see if they become sick.
The CDC has defined
the “minimum period of isolation of the patient – pulmonary
tuberculosis (also includes mediastinal, laryngeal, pleural, or miliary). Until
bacteriologically negative based on three appropriately collected and processed
sputum smears that are collected in eight – 24 hour intervals (one of which
should be an early morning specimen), and/or until 14 days after the initiation
of appropriate effective chemotherapy, provided therapy is continued as
prescribed, and there is demonstration of clinical improvement (i.e.,
decreasing cough, reduced fever, resolving lung infiltrates, or AFB smears
showing decreasing numbers of organisms.” (Available at: https://www.cdc.gov/tb/programs/laws/menu/isolation.htm)
In its “Guidelines
for the prevention of tuberculosis in health care facilities in
resource-limited settings” published in 1999, the WHO says, “Ideally,
infectious TB patients should be isolated from other patients so that others
are not exposed to the infectious droplet nuclei that they generate.”
On discontinuing
isolation, it further says that “In settings where MDR-TB is uncommon,
those with a diagnosis of sputum-positive pulmonary TB can be considered to be
non-infectious and eligible for transfer from isolation or discharge for
outpatient management when two criteria are met: they have received appropriate
anti-tuberculosis chemotherapy directly observed for a minimum of two weeks and
they have shown clinical improvement.”
Dr KK
Aggarwal
Padma Shri Awardee
President
Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP
Publications
President Heart Care
Foundation of India
Past National President IMA
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