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India’s Central Government Tasks 15 Viral Research and Clinical Laboratories to Perform Monkeypox Surveillance Testing

South Asian nation aims to do what US, UK, and Europe failed to do during start of COVID-19 pandemic and slow spread of disease while case counts are low

With monkeypox quickly spreading around the world, India may be taking a lesson from western nations’ delayed response to COVID-19—including a sometimes slow availability of clinical lab testing for monkeypox—and preemptively increasing its national surveillance of the deadly social disease.

On Aug. 29, the Hindustan Times reported that in an attempt to slow the spread of monkeypox, India’s central government “has designated 15 viral research and diagnostic laboratories (VRDLs) spread across 13 states to monitor the incidence of monkeypox in the country.”

In the United States, the disease has spread with alarming speed, reaching all 50 states, as well as Washington, DC, and Puerto Rico. At 23,893 confirmed cases as of Sept. 14, the US now has the most cases in the world, according to the federal Centers for Disease Control and Prevention (CDC).

Reuters reported on Aug. 4 that the US Department of Health and Human Services (HHS) had declared a public health emergency. It was in May when monkeypox was detected in the United Kingdom (UK). Both the UK and several countries in Europe have struggled to control spread of the disease.

India hopes its decision to designate 15 VRDLs across 13 states to monitor the disease’s spread will enable it to do a better job than other countries at containing or eradicating monkeypox in the nation of 1.4 billion people, the Hindustan Times reported.

Anne Rimoin, PhD

“The probability of containment is diminishing daily,” American infectious disease epidemiologist Anne Rimoin, PhD, a monkeypox expert at the UCLA Fielding School of Public Health, told STAT. “It’s really unfortunate because we do have the tools. This is not an unknown virus … We have vaccines that are already available, even vaccines with indications for monkeypox. Therapeutics. And we know what’s needed to be done.’’ Clinical laboratory testing for monkeypox will certainly increase over the coming months. (Photo copyright: KTLA.)

Keeping Up Their Guard

“Fortunately, India has not seen a surge in cases and the situation here is well under control. However, we cannot drop the guard just as yet. Therefore, a network of VRDLs has been established for surveillance purposes,” a top government expert told the Hindustan Times, seeking anonymity. “It will help pick signs early in case more cases get reported.”

As of Sept. 19, 2022, India reported just 12 cases of monkeypox resulting in one death, while, as noted above, the US had 23,892 confirmed cases and one death, according to CDC statistics. In the UK, confirmed cases totaled 3,552 with no deaths. And, as of that date, the European Union reported 19,379 confirmed cases.

Until recently, monkeypox was endemic only in West and Central Africa. India reported its first case of monkeypox on July 14. So far, most, but not all, of its cases have been related to international travel.

“The isolated cases of monkeypox reported in Delhi with no prior travel history emphasize the importance of tracing the source of the infection, perhaps transmission through rodent population,” Diwakar Kulkarni, PhD, former Director and Principal Scientist at the Indian Council of Agricultural Research, National Institute of High Security Animal Diseases, told Think Global Health.

Homosexuality a Vector in India

While India’s scientists are focused on containing the monkeypox outbreak, the country’s government may encounter societal roadblocks because of the disease’s connection with homosexuality. Gay sex is believed to be fueling the spread of the disease, ABC News reported. Until a Supreme Court of India ruling in 2018, gay sex was punishable by up to 10 years in prison in India.

Virologist and noted HIV expert Ishwar Gilada, MD, who opened India’s first AIDS clinic in 1986, told Bloomberg “anti-gay stigma” in India is causing male patients to avoid getting tested and treated for the disease. He said even before the first monkeypox cases were reported in India, two of his patients—a gay man and a man who identified as bisexual—refused to get tested because they feared being the first monkeypox case in the country.

“They are going underground,” Gilada told Bloomberg.

Did the US Wait Too Long to Begin Testing for Monkeypox?

The rapid growth in cases worldwide and the geographic spread of the disease has left global health experts pessimistic monkeypox can be contained.

NPR reported in June that some experts believe public health agencies ran too few tests in the early months of the outbreak because state health officials used a narrow definition of monkeypox when determining who qualified for testing, and that the US had “dropped the ball” on monkeypox testing.

“I think we missed that train at this point,” Gary Kobinger, PhD, told STAT in mid-July when the number of cases outside of Africa had reached roughly 15,000. Kobinger is Director of the Galveston National Laboratory at the University of Texas Medical Branch and a member of an expert committee that advises the World Health Organization’s Emergencies Program.

And in “New Monkeypox Challenges Abound for Public Health Agencies as Virus Travels Beyond Traditional Hotspots,” Dark Daily reported on how monkeypox has spread beyond its traditional geography and that health officials are worried that diminishing smallpox vaccinations, which offered people some protection against the infectious disease, is contributing to increased spread of monkeypox.

As of Sept. 19, 2022, there were 62,406 confirmed cases worldwide, according to the CDC.

As clinical laboratories attempt to recover from the workload created by the COVID-19 pandemic, monkeypox appears to be the next endemic to test the mettle of lab professionals. Only time will tell if America and other western nations failed to act as expeditiously as India in curbing spread of this latest deadly disease.

Andrea Downing Peck

Related Information:

Monkeypox: 15 Virology Labs Designated for Surveillance of the Virus

US Declares Monkeypox Outbreak a Public Health Emergency

ECDC: Monkeypox Situation Update, as of 13 September 2022

With Monkeypox Spreading Globally, Many Experts Believe the Virus Can’t Be Contained

Determination That a Public Health Emergency Exists

Epidemiological Data on the 2022 Monkeypox Outbreak

CDC: Monkeypox 2022 Global Map and Case Count

Monkeypox Outbreak: Epidemiological Overview, 30 August 2022

Monkeypox in India—Facing the World’s Latest Health Threat

Monkeypox Cases Driven ‘Underground’ by Anti-Gay Stigma in India

Sex Between Men, Not Skin Contact, Is Fueling Monkeypox, New Research Suggests

Monkeypox Outbreak in US Is Bigger than the CDC Reports. Testing Is ‘Abysmal’

Doctors in India Sound Alarm: CRE Infections are Becoming Common in India and Killing Two-Thirds of Patients Who Contract Them While Undergoing Cancer Treatment!

As infectious bacteria become even more resistant to antibiotics, chronic disease patients with weakened immune systems are in particular danger

Microbiologists and clinical laboratory managers in the United States may find it useful to learn that exceptionally virulent strains of bacteria are causing increasing numbers of cancer patient deaths in India. Given the speed with which infectious diseases spread throughout the world, it’s not surprising that deaths due to similar hospital-acquired infections (HAIs) are increasing in the US as well.

Recent news reporting indicates that an ever-growing number of cancer patients in the world’s second most populous nation are struggling to survive these infections while undergoing chemotherapy and other treatments for their cancers.

In some ways, this situation is the result of more powerful antibiotics. Today’s modern antibiotics help physicians, pathologists, and clinical laboratories protect patients from infectious disease. However, it’s a tragic fact that those same powerful drugs are making patients with chronic diseases, such as cancer, more susceptible to death from HAIs caused by bacteria that are becoming increasingly resistant to those same antibiotics.

India is a prime example of that devastating dichotomy. Bloomberg reported that a study conducted by Abdul Ghafur, MD, an infectious disease physician with Apollo Hospitals in Chennai, India, et al, concluded that “Almost two-thirds of cancer patients with a carbapenem-resistant infection are dead within four weeks, vs. a 28-day mortality rate of 38% in patients whose infections are curable.”

This news should serve as an alert to pathologists, microbiologists, and clinical laboratory leaders in the US as these same superbugs—which resist not only antibiotics but other drugs as well—may become more prevalent in this country.

 ‘We Don’t Know What to Do’

The dire challenge facing India’s cancer patients is due to escalating bloodstream infections associated with carbapenem-resistant enterobacteriaceae (CRE), a particularly deadly bacteria that has become resistant to even the most potent carbapenem antibiotics, generally considered drugs of last resort for dealing with life-threatening infections.

Lately, the problem has only escalated. “We are facing a difficult scenario—to give chemotherapy and cure the cancer and get a drug-resistant infection and the patient dying of infections.” Ghafur told Bloomberg. “We don’t know what to do. The world doesn’t know what to do in this scenario.”

Ghafur added, “However wonderful the developments in the field of oncology, they are not going to be useful, because we know cancer patients die of infections.”

Abdul Ghafur, MD (above), an infectious disease physician with Apollo Hospitals in Chennai, India, told The Better India that, “Indians, are obsessed with antibiotics and believe that they can cure almost all infections, including viral infections! Moreover, at least half of the prescriptions by Indian doctors include an antibiotic. Sadly, the public believes that whenever we get cold and cough, we need to swallow antibiotics for three days along with paracetamol [acetaminophen]! This is a myth that urgently needs to disappear!” (Photo copyright: Longitude Prize.)

The problem in India, Bloomberg reports, is exacerbated by contaminated food and water. “Germs acquired through ingesting contaminated food and water become part of the normal gut microbiome, but they can turn deadly if they escape the bowel and infect the urinary tract, blood, and other tissues.” And chemotherapy patients, who likely have weakened digestive tracts, suffer most when the deadly germs reach the urinary tract, blood, and surrounding tissues.

“Ten years ago, carbapenem-resistant superbug infections were rare. Now, infections such as carbapenem-resistant klebsiella bloodstream infection, urinary infection, pneumonia, and surgical site infections are a day-to-day problem in our (Indian) hospitals. Even healthy adults in the community may carry these bacteria in their gut in Indian metropolitan cities; up to 5% of people carry these superbugs in their intestines,” Ghafur told The Better India.

What are CRE and Why Are They So Deadly?

CRE are part of the enterobacteriaceae bacterial family, which also includes Escherichia coli (E. coli) and Klebsiella pneumoniae. CRE, according to the Centers for Disease Control and Prevention (CDC), are considered “antibiotic-resistant” because antibiotic agents known as carbapenems are becoming increasing less effective at treating enterobacteriaceae.

In fact, a 2018 study conducted by the All India Institute of Medical Sciences (AIIMS) in New Delhi, which was published in the Journal of Global Infectious Diseases (JGID), found that bloodstream infections due to CRE were the “leading cause” of illness and death in patients with hematological malignancies, such as leukemia.

“These patients receive chemotherapy during treatment, which lead to severe mucositis of gastrointestinal tract and myelosuppression. It was hypothesized that the gut colonizer translocate into blood circulation causing [bloodstream infection],” the AIIMS paper states.

US Cases of C. auris Also Linked to CRE

Deaths in the US involving the fungus Candida auris (C. auris) have been linked to CRE as well. And, people who were hospitalized outside the US may be at particular risk.

The CDC reported on a Maryland resident who was hospitalized in Kenya with a carbapenemase-producing infection, which was later diagnosed as C. auris. The CDC describes C. auris as “an emerging drug-resistant yeast of high public concern … C auris frequently co-occurs with carbapenemase-producing organisms like CRE.”

The graphic above, developed by the NYT from CDC data, shows that Candida auris is found globally and not restricted to poor or resource-strapped nations. “The fungus seems to have emerged in several locations at once, not from a single source,” the NYT reports. This means clinical laboratories can expect to be processing more tests to identify the deadly fungus. (Graphic copyright: New York Times/CDC.)

Drug-resistant germs are a public health threat that has grown beyond overuse of antibiotics to an “explosion of resistant fungi,” reported the New York Times (NYT).

“It’s an enormous problem. We depend on being able to treat those patients with antifungals,” Matthew Fisher, PhD, Professor of Fungal Disease Epidemiology at Imperial College London, told the NYT

The NYT article states that “Nearly half of patients who contract C. auris die within 90 days, according to the CDC. Yet the world’s experts have not nailed down where it came from in the first place.”

Cases of C. auris in the US are showing up in New York, New Jersey, and Illinois and is arriving on travelers from many countries, including India, Pakistan, South Africa, Spain, United Kingdom, and Venezuela.  

“It is a creature from the black lagoon,” Tom Chiller, MD, Chief of the Mycotic Diseases Branch at the CDC told the NYT. “It bubbled up and now it is everywhere.”

Since antibiotics are used heavily in agriculture and farming worldwide, the numbers of antibiotic-resistant infections will likely increase. Things may get worse, before they get better.

Pathologists, microbiologists, oncologists, and clinical laboratories involved in caring for patients with antibiotic-resistant infections will want to fully understand the dangers involved, not just to patients, but to healthcare workers as well.

—Donna Marie Pocius

Related Information:

Superbugs Deadlier than Cancer Put Chemotherapy into Question

Taking Antibiotics for a Viral Infection? A Doc Shares Why You Should Think Twice

Healthcare-Associated Infections: CRE

Rectal Carriage of Carbapenem-resistant enterobacteriaceae: A Menace to Highly Vulnerable Patients

Clinical Study of Carbapenem Sensitive and Resistant Gram-negative Bacteria in Neutropenic and Nonneutropenic Patients: The First Series from India

Candida Auris in a U.S. Patient with Carbapenemase-Producing Organisms and Recent Hospitalization in Kenya

Deadly Germs, Lost Cures: A Mysterious Infection, Spanning the Globe in a Climate of Secrecy

University of Edinburgh Study Finds Antimicrobial Bacteria in Hospital Wastewater in Research That Has Implications for Microbiologists

Pathologists and Clinical Laboratories to Play Critical Role in Developing New Tools to Fight Antibiotic Resistance

Lurking Below: NIH Study Reveals Surprising New Source of Antibiotic Resistance That Will Interest Microbiologists and Medical Laboratory Scientists

Shortage of Registered Pathologists in India Continues to Put Patients at Risk in Illegal Labs that Defy Bombay Court Orders

Professional pathologist’s organization in Maharashtra, India, demands that the government’s Directorate of Medical Education and Research intensify enforcement of laws regulating clinical pathology labs, or suspend the director for failing to comply

There are thousands more medical laboratories in India than there are certified pathologists to supervise and direct them. This is becoming a source of conflict. On one side are consumers who want quality medical laboratory testing services they can trust and government regulators who want to enforce the law. On the other side are tens of thousands of lab companies that continue to operate without certified pathologists and other trained lab scientists.

This is why India continues its struggle to provide licensed and registered clinical pathology services to its more than 1.2 billion residents amid a sea of illegal pathology clinics and a government that seems increasingly ineffectual in its ability to protect patients. Frustrations with government organizations and law enforcement has led many professional pathology and microbiology organizations to speak out. (more…)

Critical Shortage of Pathologists in Africa Triggers Calls for More Training Programs and Incentives to Increase the Number of Skilled Histopathologists

A critical shortage of pathologists in southern Africa is hindering the ability of medical laboratories in the region to properly diagnose and classify diseases

Countries in the Southern Africa Development Community (SADC) are currently dealing with a severe scarcity of pathologists. More pathologists are needed in the region to examine samples and interpret medical laboratory tests in order to ensure patients receive proper treatment.

There are a total of fifteen countries in SADC: Angola, Botswana, Democratic Republic of the Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Tanzania, Zambia, and Zimbabwe.

Dark Daily has regularly written about the issues affecting medical laboratory testing in developing nations throughout the world. There are three challenges that are common to most of these countries: (more…)

Pathologists and Medical Laboratory Scientists in India Call for Active Government Regulation in Response to Ongoing Problems with Quality of Medical Laboratory Tests

In the $5 billion a year Indian diagnostics laboratory industry, only 1% of laboratories are accredited

Pathology and clinical laboratory testing in India is growing at a double-digit pace. However, pathologists and medical laboratory scientists are raising the alarm about a disturbing lack of quality and accuracy that exposes patients to unnecessary harm.

In fact, there are loud voices within the pathology profession in India who are urging government officials to more actively regulate the country’s diagnostics industry, according to a story published by the Business Standard, a national newspaper in India. (more…)