Infectious Diseases Specialty in India Today and the Vision for the Future

The specialty field of infectious diseases (IDs), a relatively recent addition to India’s medical landscape, took root approximately 15 years ago. Since its inception, this medical discipline has undergone rapid evolution to tackle a broad spectrum of formidable challenges presented by the high burden of infections in the country. They include the management of diseases such as tuberculosis, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome, drug-resistant infections, tropical ailments such as dengue, scrub typhus, malaria, and typhoid, and infections in immunocompromised individuals. IDs have played an undeniable role in human history, leaving a profound impact on societies, shaping political decisions, and driving advancements in the field of medicine. India, characterized by its diverse population and intricate health-care landscape, is no stranger to these historical and contemporary challenges. The nation grapples with complex issues stemming from a significant burden of IDs. In India, diseases such as pneumonia, tuberculosis, and enteric infections continue to be the leading causes of mortality. IDs pose a significant burden on the nation’s health-care system. There were over 50 million estimated cases of IDs and 3 million annual deaths attributed to them. In 2019, IDs contributed to a staggering 80.77 million disability-adjusted life years.[1] The yoke of IDs is further made heavy by the inadvertent and unique complications resulting from modern health-care innovations, including cancer therapy, organ transplantation, and advanced intensive care treatments. It is in response to these conundrums that the field of ID specialty has emerged in India and has since undergone substantial evolution. This write-up endeavors to delve into the present state of this specialty and envision its future trajectory. A HISTORICAL PERSPECTIVE As we entered the 21st century, India found itself facing daunting questions with regard to IDs. Tuberculosis, a centuries-old affliction, remained a pervasive concern. Indian patients accounted for nearly one-third of the world’s prevalent cases and approximately two million individuals were affected annually. Obstinately, tuberculosis continued to be the leading infectious cause of death, claiming the lives of close to 500,000 people each year in the early 2000s.[2] Simultaneously, a relatively new scourge, HIV, spread relentlessly across the country. The combination of HIV and tuberculosis proved to be deadly and resulted in the loss of millions of lives. The diagnosis and management of opportunistic infections, coupled with antiretroviral therapy – often administered alongside antituberculous treatment – came with unique and intricate requirements, including the ability to navigate drug interactions, manage additional toxicities, and grapple with immune reconstitution inflammatory syndromes. Meanwhile, the escalating threat of nosocomial infections, coupled with the silent menace of antimicrobial resistance, further complicated the clinical management of patients. It became imperative that we understood the pathways of bacterial evolution and unraveled the complex mechanisms of bacterial resistance. In response to these pressing threats, a few institutions in the country, such as Christian Medical College, Vellore, Apollo Hospitals, Chennai, and Hinduja Hospital, Mumbai, pioneered to lay the foundation for the establishment of dedicated IDs departments. The luminaries who founded the field of IDs in India included doctors Dilip Mathai, George K Varghese, OC Abraham, Ram Gopalakrishnan, FD Dastur, Rajiv Soman, and V Ramasubramanian. Inspired by their vision and dedication, a few of us who had completed ID training abroad returned to India with the aim of furthering their legacy. In 2008, the National Board of Examinations took the monumental step of launching the country’s first 2-year postdoctoral fellowship program in ID. This was followed by the introduction of several university-recognized fellowship programs. Eventually, in 2016, the Medical Council of India officially recognized the 3-year postdoctoral training program, doctorate in medicine, and solidifying the specialty’s place within the country’s medical landscape. SETTING THE STAGE FOR CHANGE The ever-evolving problems posed by IDs in India highlighted the pressing need for a collective and specialized response. Driven by this need and the desire to usher in transformative change, the groundwork was laid for the establishment of a society committed to advancing and disseminating knowledge in the field of ID. The primary objective was clear to wage a concerted battle against ID. This ambitious endeavor took shape in 2010 and culminated in the formation of the Clinical ID Society (CIDS). The society emerged as a beacon of hope, a collaborative platform, and a repository of expertise dedicated to comprehensively addressing the burden of ID. At its core, CIDS embodies the commitment of its founders and members to leverage knowledge, research, and collaboration as powerful tools in the ongoing fight against IDs. Its formation was not merely an administrative event but represented a pivotal moment in India’s health-care landscape that signified a collective resolve to confront IDs with unity, innovation, and scientific rigor. CIDS was envisioned as a dynamic force capable of driving positive change, fostering research, and disseminating critical insights to health-care professionals, researchers, and policymakers across the nation. Through its mission and activities, CIDS aims to continually strengthen the country’s capacity to combat ID, promote best practices in patient care, and contribute to the global effort to control and eliminate dangerous infections. THE DIVERSE SCOPE AND PROFESSIONAL FULFILLMENT OF INFECTIOUS DISEASE PHYSICIANS In the field of ID, there exists a remarkable diversity of cases affecting all organs and systems, which requires a distinctive intellectual acuity among physicians. The opportunity and need to grow professionally as well as the positive outcomes or cure seen from effectively managing infections is satisfying. ID specialists undergo rigorous training to become equipped to undertake a multitude of critical roles within the health-care system. At the heart of IDs, the physician’s role lies the responsibility to solve intricate infection-related clinical puzzles. Given the ubiquity of infections, ID specialists routinely offer a spectrum of services, encompassing inpatient and outpatient care, providing ID consultations, and conducting antimicrobial stewardship ward rounds in intensive care units. Furthermore, their outreach extends to secondary care hospitals and private health-care facilities that lack in-house ID specialists. Beyond direct patient care, ID specialists frequently serve as expert advisors to various committees, especially those dedicated to infection prevention and control (IPC) and antimicrobial stewardship within hospitals. Moreover, ID specialists lend their expertise to state and national committees that make crucial policy decisions in dealing with infections, such as HIV, tuberculosis, antibiotic resistance, vaccines, and emerging and re-emerging infections. ID specialists also contribute to training the next generation of health-care professionals, including doctors specializing in ID, those in diverse medical fields, nurses, and pharmacists. Overwhelming evidence supports the impact of ID specialists on the health-care system. ID consultations yield substantial benefits, including shorter hospital stays, reduced antimicrobial prescription, lower readmission rates, decreased mortality rates, and increased cost savings.[3–5] The multifaceted contributions of ID specialists not only enhance patient care but also optimize the utilization of health-care resources. THE CURRENT LANDSCAPE AND CHALLENGES Currently, IDs in India are wide-ranging and include vector-borne illnesses, such as dengue, scrub typhus, and malaria, age-old scourges, such as tuberculosis and typhoid, daily battles against nosocomial infections, and daunting new threats as exemplified by COVID-19. Simultaneously, India’s health-care landscape is convoluted by factors such as population density, sanitation disparities, and inequitable access to health-care services, especially in rural areas, which render the nation particularly susceptible to infectious disease outbreaks. The diverse and shifting national and microbial landscapes urgently necessitate that the field of IDs expands in significance and sophistication. Currently, fewer than 10 medical colleges out of the approximately 700 medical colleges across India offer infectious disease training programs. Even among this limited number of programs, a majority are making do without dedicated and adequately trained infectious disease faculty and departments. To effectively combat IDs in India, it is imperative to address this imbalance between the need and the training and expertise available. Strengthening IDs training programs and fostering the development of dedicated infectious disease departments within medical colleges can significantly enhance the nation’s capacity to respond to infectious disease threats comprehensively. VISION FOR THE FUTURE The future of IDs in India presents both challenges and opportunities, underscoring the need for a well-defined vision to address these issues effectively. Below are five avenues within which the field of ID needs to grow. Addressing shortages of infectious diseases specialists India faces a shortage of infectious disease specialists. Quality training programs and their equitable distribution across the country are imperative. To meet the growing needs of the health-care system in areas such as clinical care, IPC, and antimicrobial stewardship, young ID specialists should be employed not only in urban tertiary hospital settings but also in rural secondary health-care facilities. This approach has demonstrated the potential to substantially reduce morbidity, mortality, and health-care costs, as witnessed globally. Strengthening training and education To meet the evolving challenges posed by IDs, India must make strategic investments in medical training. A multipronged approach that not only equips health-care professionals with the necessary expertise but also fosters collaboration, faculty development, and responsible antimicrobial use are necessary to collectively contribute to a more resilient and knowledgeable health-care workforce. For high-quality training in ID specialty, it is necessary that the curricula is robust and keep pace with the latest advancements in ID. Collaborations between institutions within the country and with international counterparts need to be fostered to leverage the wealth of expertise and resources already available. Furthermore, ID departments must be established in every institution which offers training programs and serve as specialized hubs of knowledge and expertise. Within them, it is pivotal to ensure that a cadre of well-trained faculty members is available. Their continuous professional development should be facilitated through inter-institutional collaboration and partnerships with organizations such as the CIDS and ID Society of America. Simultaneously, it is essential that both undergraduate and postgraduate training in infection management are strengthened such that all health-care professionals are proficient in addressing IDs comprehensively. The battle against antimicrobial resistance demands that curriculum enhancements are made at the undergraduate and postgraduate levels as well to emphasize and promote judicious antibiotic use. Further, professional organizations such as CIDS should collaborate with the national government in expanding mentorship opportunities and scholarship initiatives for students. Enhanced research and innovation Investment in research and innovation is paramount for understanding emerging pathogens and developing new diagnostics, treatments, and vaccines. Collaboration between academia, industries, and governments is necessary to drive progress. We urge universities and other funding bodies to support programs in ID-related research. Recognizing India’s significant burden of community-acquired and hospital-acquired infections, government and research funders should urgently expand their portfolios to address these problems. Improved surveillance and epidemiology Surveillance systems must be strengthened to detect outbreaks early and respond effectively. The utilization of advanced epidemiological tools and data analysis can enable the prediction of infectious disease trends, facilitating more efficient preventive measures. Building resilience in health-care systems The COVID-19 pandemic has exposed vulnerabilities in health-care systems worldwide. India, too, must invest in upgrading its health-care infrastructure while ensuring equitable access to care, and reinforcing IPC measures. These efforts will both enhance the nation’s preparedness for future pandemics and contribute to the overall well-being of its population. CONCLUSION The threads of ID, deeply intertwined in the sociocultural fabric, have created an enduring and altering pattern in Indian history. In response, the field of ID in the country has undergone a remarkable evolution, adapting to the ever-changing scene of health challenges. At present, infectious disease specialists occupy pivotal roles in confronting the extensive range of IDs. Despite significant progress, the field of ID still wrestles against emergent diseases with few specialists trained professionally and limited resources. The future of the field of ID in India hinges on a strategic vision that addresses these shortcomings comprehensively. Central to this vision is the imperative to strengthen training and education in infectious disease management, advance research and innovation, fortify surveillance and epidemiological capabilities, and reinforce health-care systems. By taking decisive and collaborative actions in these key areas, India cannot only navigate the perturbing challenges posed by IDs but also harness opportunities for progress and enhance public health outcomes. IDs will continue to shape the tapestry of India’s health care, but with investments in expertise, resources, and infrastructure, the nation can mitigate the impact and ensure better health for all its citizens.