With 3-tier surveillance, top Indian scientist gets ready to battle typhoid

Gagandeep Kang is obsessed with data.

From her early days as a student in Vellore’s Christian Medical College (CMC) in the 90s to building a nationwide network of surveillance centres for rotavirus, one of the major causes of diarrhoea in India, through the 2000s,the 56-year-old scientist has long identified the need for quality data to build medical public policy.

Now, Kang – who in April became the first woman from India to become a fellow of the prestigious Royal Society in London – is building the disease burden case for typhoid, which kills around 200,000 people annually, most of them in India.

Kang and her associates at CMC and Translational Health Science and Technology Institute, Faridabad, have built a three-tier surveillance system, spanning small catchment hospitals in rural areas to major cities.

The first tier deals with 24,000 children in four sites between six months and 15 years of age, and checks for fever that lasts for more than three days. The second stage is in rural hospitals with a catchment of 100,000 people each. “The idea is that most fevers will go to these hospitals; any fever that gets admitted gets a blood culture, we measure how severe typhoid is in that community,” she said.

The third stage is in motion in hospitals in big cities that tracks possible complications and antibiotics resistance at a time.

“We are already generating preliminary data that shows the incidence of typhoid in India is among highest in world, between 500-600 per 100,000 people – a big big number,” she said. The World Health Organisation calls a disease highly endemic to an area if the incidence is above 200 per 100,000 people.

The work is urgent, Kang notes, because it comes at a time a strain of typhoid resistant to all but one oral antibiotic has broken out in Pakistan, with 5000-odd cases since 2016. “We are hoping doesn’t spread to India because if it does, we are in deep trouble,” she added.

UNGLAM BEGINNINGS

Her name may have been splashed across major publications this year, but Kang consciously chose a low-key life at the beginning of her career. “I chose to study gut infections; it was about as unglamorous as you could get. Everyone wanted to study cancer, neurosciences and save the world with fundamental discoveries. Poor diarrhea was nothing in front of them.”

Diarrhea is the second-leading cause of deaths among children under the age of five years, and one of the biggest killers in India. Kang’s research soon led her to discover that Indian children have lower response to gut vaccines than their counterparts in foreign countries – a result of exposure to toxins and infections at very early stages that inflame their guts.

“Our children have guts with higher levels of inflammatory bio markers than people in the west with inflammatory bowel diseases – like those with Crohn’s Disease. This constant inflammation likely damages the gut and induces lower immune response to vaccines given orally,” she said. Kang also found the difference between rich and poor Indian children was similarly large with the latter susceptible to lower immune responses.

Kang’s tryst with big data began in 2005, when in association with the Indian Council for Medical Research, she started building a national network for surveillance of the rotavirus. “For public health policy, quality data systems are a priority but it is a huge challenge. With each disease, we have to reinvent the wheel because we haven’t invested enough in data quality,” she said.

The research culminated in the discovery of the rotavirus vaccine, as part of her work under the Newton-Bhabha fund, a partnership to bring together UK and Indian scientists and researchers and spanning PhD partnerships, fellowships and research projects with a focus on food-water-energy, public health and urbanisation.

Her project focused on improving rotavirus vaccination to reduce infant mortality in sub-saharan Africa and India where vaccine effectiveness is 43-66%. The project was also launched in the UK where the vaccine effectiveness is high.

This work later won her the 2016 Infosys Prize in Life Sciences. The vaccine is now part of Mission Indradhanush, a central government programme that aims at full immunisation.

Ann Mathew of Delhi’s St. Stephen’s Hospital and a collaborator, remembers how Kang would criss-cross the country building the network. “She was hard working and was great at building a team, often encouraging younger colleagues.”

Kang rates her work on the rotavirus vaccine, Rotavact, as the most exciting of her career but admits that her current research on the typhoid disease burden is more challenging. “There is a vaccine for typhoid by Bharat Biotech [a Bengaluru-based firm], but we are not using it because we haven’t updated our own disease burden data. Typhoid is more difficult to measure than rotavirus because the scale is much smaller,” she added.

VACCINES, HEALTHCARE AND GENDER

As one of India’s foremost medical scientists, two things worry Kang.

The first is health coverage. In her work, Kang says she found one diarrhoea hospitalization cost poor families 5% of their annual income and almost three-fourths of health expenses are met from people’s pockets, according to the Household Health Expenditure In India 2013-14, a report published by the Union health ministry. “This kind of catastrophic expenditure pushes people into extreme poverty,” she said.

Ayushman Bharat, the central government’s insurance scheme, is a good start but Kang argues for universal health coverage by strengthening primary healthcare. “I grew up in 60s and 70s. I am about as socialist as one can get. The government has a responsibility to provide healthcare to people,” she added.

Her other concern is about India’s growing anti-vaccine sentiment, which in the past three years has made its presence felt in Kerala, Tamil Nadu and even Mumbai, and is fuelled by videos and posters circulating on WhatsApp. Kang notes that the videos are clever, translated into multiple regional languages and make convincing arguments. “If you tell people that effects of the vaccine won’t show up now, but will result in your children having fewer children, it is difficult to refute that because those are the secular trends,” she said.

Though the anti-vaccine sentiment is not as widespread as it is in the US, where diseases such as measles have made a ferocious comeback, Kang worries that India’s higher population density will mean that an outbreak will wreak havoc. “If we have a large number of unimmunised children, we are setting ourselves up for a disaster.”

Her long stints in India and abroad have alerted her to questions of hierarchy and inflexibility, which, she argues, has hurt women scientists and stopped their ascent. “When I went to the UK, people told me I was good. I found it hard to believe because in 15 years, no one in India has ever said that. We don’t realise how much hierarchy damages us – even PhD students don’t question.”

To many of her students and peers, Kang’s easy manner is a change from familiar pedagogy.

Samarasimha Reddy, an investigator under Kang at CMC, said her mentor helped her in thinking positively and figuring out the right way to handle difficult situations. Working with Dr Kang, I have learnt the different aspects of research… now I am confident to be an Independent researcher,” she said.

Partha P Majumder, president of the Indian Academy of Sciences, said talking to Kang was always learning experience because of her deep insights on diarrhoeal and other infectious diseases. “It’s a lot of fun to talk to Gagandeep. She can chat on a wide variety of topics because she is a voracious reader.”

Her hope of Indian science is a more flexible, responsive system that doesn’t stymie curiosity and the advancement of women. “In our cultures, women rarely put themselves forward and those who do get called nasty women. This is changing with time but it needs to change a whole lot faster.”