Wednesday, January 2, 2019

Is not notifying TB punishable? If yes, should positive XDR patients be isolated?

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.

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:

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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