With an unusual strain of the Hepatitis B virus claiming over 50 lives in Modasa, Gujarat, the sleepy town is reeling under the most perplexing epidemic in recent historyH ead shaven in ritual mourning, Jetha Patel, a farmer in Varutha village, north of Modasa, says, “I had kissed her, tended to her at the Ahmedabad hospital. But when she was gone, the doctors asked me to wear gloves before touching her body.” His 13-year-old daughter, Daxa, succumbed to Hepatitis B on February 18. It is no solace to him that her death perplexes epidemiologists and taxes the state health machinery like no other case has in recent medical history. Experts say the Hepatitis B virus (HBV) is endemic in many parts of China and other parts of Asia, but what now stalks Modasa is an unknown, mutated form of the virus, which seems to be killing and infecting people at will.
Modasa is a highway town in Gujarat’s tribal Sabarkantha district, with a history of communal riots and a still-unsolved bomb blast. This sleepy town of farmers and truckers is now living a page from a medical thriller.
From the time the outbreak was detected early this month till Friday evening, the blight has killed 53. Much of Modasa lives off the transport business, and its private medical fraternity off patients from neighbouring Rajasthan. But mysteriously, none of the dead so far belongs to the truckers’ community—know to be highly susceptible to HIV/AIDs— and there are no Rajasthani victims either.
Some 30 per cent of the town’s medical practice depends on Rajasthanis, says Dr Dinesh Patel, president of the local unit of the Indian Medical Association. But of the total number of people affected—171 so far—only one patient from Rajasthan has tested positive, and he has survived. Many infected people are in the isolation ward of Modasa’s lone grant-in-aid hospital, others are at the Ahmedabad Civil Hospital 100 km away. And all share a residential address within a 10-km radius of Modasa or have some clear Modasa connection.
Why is it happening only in and around Modasa, why are only Modasa residents dying? Dr Vidya Arankale of the National Institute of Virology (NIV), who was in Modasa after the outbreak was discovered, says HBV is normally a bloodborne infection, which spreads through transfusion of infected blood, sexual contact or infected needles/syringes. Lab tests at NIV and other national institutes confirm that HBV in Modasa has mutated to a dangerous strain—killing quickly. Patients develop fever and stomach ache and then deteriorate fast, going into a coma. Few last more than two to three days.
The mutated HBV does not infect family members, neighbours or the medical attendants of the victims. All the spouses and family members of the dead, without exception, have tested negative for HBV. There have been just two reported cases of infection within a family—a father and his 18-year-old daughter, a mother and her newborn.
In Varutha village, two, apart from Daxa, have died— housewife Premila Patel on February 23 and potter Rama Prajapati on February 14. The three families live in different corners of the village and don’t have anything in common. They never interacted socially or knew each other.
Gujarat Health Minister Jay Narayan Vyas rules out other modes of infection and says the outbreak is a result of infected syringes/needles. “We don’t know the extent of the infected population at large. The virus has mutated dangerously. There is no previous record of such an epidemic. We are trying to do everything possible,” says Dr Amarjit Singh, Gujarat health commissioner.
HBV incubates for around six months and the vaccine takes three doses and 90 days to work. But there has been no let up in the daily deaths since early February even after the state government went for the world’s largest-ever mass vaccination drive for HBV, lasting three days, in Modasa, vaccinating over 77,000 people. Dr Mira Shiva, international health activist and Asia’s sole Olle Hanson award winner, is sceptical, “We don’t know if HBV vaccination can help in this case, as the virus has mutated. The issue is being discussed within the medical fraternity.” Rushing to Modasa town to get vaccinated, Premila’s husband in Varutha says: “I must have spent more than a lakh of rupees. I took her to a good private hospital, but after she went into a coma she never came back.” Even if you don’t ask them, families show you their medical reports, prescriptions, and especially the SGPT test count (a liver function test for HBV), with photocopies kept ready. Health officials, experts from Pune, Delhi and Lucknow and local cops snoop around town, hoping to pin the source of the mysterious virus. They sift through family narratives, medical histories, details of all doctors consulted, laboratories visited in the last six months, in a massive data collection exercise.
So far, two names have cropped up—Dr Govind Prajapati and his son Dr Chintan Patel.
Both are MBBS graduates who ran a clinic right outside Modasa Primary Health Centre, and have since absconded. Their residence and clinic have been sealed, after the Health Department pressed charges of culpable homicide. “Their name seems to figure in most of the case histories—the patients had either taken injections or were put on IV (intravenous) drip sometime during the past six months,” says Sabarkantha chief health officer Dr H.F. Patel.
But if the infection spread out of Dr Govind’s clinic through unsafe syringes or needles, did the virus mutate there in some freak accident?
In Varutha village, two of the three dead had taken injections or IV drips for common ailments in the last six months from his clinic. Similarly, in Bherunda village, south of Modasa, all the three dead—housewife Bhikhiben Patel, B.Ed student Alpesh Vankar and farm labourer Dinesh Raval—had been injected in Dr Govind Patel’s clinic. But the dead Bhikhiben’s nephew, his husband and the mourning womenfolk shake their head in disbelief. “He is our family doctor, why would his injection infect only one of us?” says Ishwarlal, her husband, a farmer.
It was a block health officer, Dr R.L. Zeparkar, who stumbled on the outbreak early this month, at a casual family conversation. Someone mentioned a very atypical HBV case. Zeparkar began checking hospitals in Modasa and reported to his seniors that something was seriously wrong. Soon, they began fleshing out the contours of a major, inexplicable blight stalking Modasa.
After the government advisory to all hospitals and labs in and around Modasa, everyone with an unusual HbsAg test report—a confirmatory test for HBV—is being reported to the health department. SGPT and HbsAg have become the new household terms in Modasa, not only among the 100-odd medical consults and experts scouring the area, but also among semi-literate Modasa residents, like labourer Jitu Raval, who lost his brother to the deadly virus.
“There is no known treatment for this mutated strain,” says Dr Jamil Khanji, superintendent of the Ghanchi Arogya Trust Hospital in Modasa town. The larger Sarvajanik Trust Hospital—a grant-in-aid facility—has been made the focal point for treatment by the state government. Modasa taluk has two fully equipped community health centres, but curiously, these are not located in Modasa town, but in neighbouring villages. They are now referring patients to the Sarvajanik Trust Hospital or to the Ahmedabad Civil Hospital.
Dr D.M. Dave, the hospital superintendent, says that in addition to other tests, the Elisa Test—a preliminary test to screen for HIV and AIDS—is now mandatory for every patient suspected of being infected with the unusual HBV strain.
As the toll mounts, the Health Department is busy cracking down on homeopaths and ayurvedic doctors practising allopathy—police cases have been registered against six doctors for not conforming to rules on safe biomedical waste disposal. Used syringes and needles have been confiscated from scrap dealers. Private doctors, labs and chemists in Modasa have gone on strike against the crackdown—patients are being turned away.
The fear is palpable, and Laxmi Guest House, the largest, located opposite Modasa bus stand, is now desolate. “Business has gone bust. People are scared, they are going to other towns. My rooms are empty. Why only Modasa?” asks Karsan Patel, the owner, like thousands of others in the town. Crackdowns, mass vaccination and health ordinance The state government first issued an advisory in local dailies asking people to avoid all kind of “pricks”—injections, IV drips, dental visits—as far as possible. Gujarat is perhaps the only state where the Health Department has not opted for auto disabled (AD) syringes, using disposable ones, even as the Central Health Ministry has made it mandatory for all health programmes. State Health Minister Jay Narayan Vyas says it is the price factor between the two—the syringe industry denies it. The state undertook the largest-ever mass vaccination drive for HBV, vaccinating 77, 259 in Modasa.
Is mass vaccination for normal HBV the way to fight a deadly mutant strain? Dr Sudhir Gandhi, deputy director (epidemics), with the state government, says: “The experts advised us to go for it hoping to break the secondary chain of infection.” It is a three-dose vaccine to be taken over the course of three months.
Caught in a bind, the Gujarat Government is bringing an ordinance to rein in private doctors. The official admission is frightening—“Without any legal obligation and no punitive measures for dereliction, the medical practitioners have been using substandard facilities,” Vyas says. The ordinance will make it mandatory for doctors to maintain proper records of patients and their case histories and take all measures to prevent infection.