“The current diphtheria situation is alarming. There are deaths and cases all across Pakistan. Lab positivity is reported as well. But at the moment, we don’t have the actual number of deaths and cases,” an NIH official said as the body issued its second advisory on the disease spread a day earlier.

The development comes as the ongoing diphtheria outbreak in Pakistan, and particularly the tragic loss of over 100 lives in Karachi, demands decisive action.

Diphtheria, a toxin-driven disease caused by Corynebacterium diphtheriae, primarily affects the respiratory system and can lead to severe respiratory distress and death if untreated.

Health authorities are under pressure to strengthen preventive and treatment protocols while intensifying awareness campaigns.

Without a concerted national response to increase vaccination coverage and public health education, experts warn that the Pakistan risks facing further outbreaks of this entirely preventable disease, threatening the lives of countless children and vulnerable populations.

The NIH issued a second advisory, underscoring the urgency of immediate preventive and control measures as cases surge across multiple regions, threatening to overwhelm healthcare systems already under strain.

It also adds that with diphtheria’s heightened transmissibility during the cool and dry season, swift intervention is essential to curb its spread.

Authorities have categorised it as a priority reportable disease under Pakistan’s Integrated Disease Surveillance and Response System (IDSRS).

The current outbreak, resulting in a troubling mortality rate, particularly among un-vaccinated or partially vaccinated children, raises questions about the country’s preparedness and response capabilities.

The NIH advisory emphasises the need for enhanced vaccination coverage, improved surveillance for early detection and response, and proper case management in public and private healthcare facilities.

However, vaccine shortages and lack of public awareness remain significant hurdles. Many affected children have not received the standard three-dose diphtheria-tetanus-pertussis (DTP) vaccine, due to limited outreach, vaccine hesitancy, and inconsistent access to healthcare.

With Karachi particularly hard-hit-where around 100 deaths were reported this year, health experts warn that urgent improvements in vaccination infrastructure and public health awareness are crucial.

The advisory notes that diphtheria spreads quickly in crowded, unhygienic conditions often found in urban slums, schools, and public gatherings, with transmission occurring via respiratory droplets or contact with open sores and contaminated objects.

Infected individuals are highly contagious, capable of spreading the bacteria for up to four weeks, with chronic carriers remaining infectious for several months.

Symptoms range from mild sore throats to life-threatening complications, often involving the respiratory system. A thick, greyish membrane on the throat, a hallmark of the disease, can block airways and lead to fatal respiratory failure.

Without prompt administration of the diphtheria antitoxin (DAT) and appropriate antibiotic treatment, patients face a significant risk of severe complications, including myocarditis, paralysis, and, in many cases, death.

NIH’s advisory instructs healthcare providers to start treatment upon clinical suspicion to avoid fatal delays, with laboratory tests confirming the diagnosis and guiding further intervention.

To reduce fatalities, the NIH is urging healthcare facilities to stock sufficient quantities of DAT and recommended antibiotics, such as erythromycin and penicillin, which are essential for both treatment and containment. The antitoxin is particularly critical, neutralising the circulating toxin before it can invade cells and cause irreversible damage.

Recognising the importance of preparedness, the NIH has highlighted the need for healthcare providers to receive training on early diagnosis, patient isolation protocols, and the management of respiratory complications.

Monitoring cardiac activity to detect diphtheria-induced heart complications is also critical. Preventive measures for contacts of confirmed cases include immediate administration of prophylactic antibiotics and regular surveillance.

Close contacts, such as household members and caregivers, are advised to be vigilant, and healthcare personnel interacting with suspected cases are encouraged to use personal protective equipment rigorously.

Additionally, the advisory advocates for public health campaigns to educate communities about the symptoms of diphtheria, stressing the importance of seeking prompt medical attention and adhering to recommended vaccination schedules.

Laboratory support for diagnosing diphtheria is being expanded through NIH, enabling the testing of nasopharyngeal and throat swabs, which is crucial for confirming cases and guiding treatment strategies.

Vaccination history, however, is a prerequisite for testing to ensure precise diagnosis and management, underscoring the need for maintaining accurate medical records and public health data.

The Centre plans to pursue only high-value cases—where banks’ claims are more than ₹100 crore—in the tribunals, according to two people aware of the development. Such cases will be aggressively pushed to get early order from the tribunals.

As for low-value cases, they will be closed or withdrawn, the first person cited above said. These are cases that have been pending for long, where the default amount is low, and where the transaction cost of pursuing them is higher than the recovery itself.

Some low-value cases may even be moved to Lok Adalats or other frameworks devised by banks with willing borrowers, the people cited above added on condition of anonymity.

To be sure, government data shows that more than 75% of pending cases in DRTs are low-value ones, which involve claim amounts between ₹20 lakh (the jurisdictional value for reference of cases to DRTs) and ₹1 crore. Withdrawal of such cases from the tribunal framework would significantly ease the load on DRTs.

As part of this plan, the Union finance ministry has asked state-run banks to prepare two lists of debtor entities to separate high-value cases from low-value ones, according to the first person cited above.

Also read | Supreme Court pulls up finance ministry for burdening debt recovery tribunals

Banks would also put in place a monitoring and oversight mechanism for efficient management of these high-value pending cases in DRTs while the tribunals itself have been asked to the process more effective and less time consuming, the first person added.

Queries sent to the finance ministry and department of financial services remained unanswered till press time.

Big-sized problem

More than 200,000 cases are awaiting judgement at different DRTs involving claim amounts of an aggregate value of ₹18 trillion, according to data from the finance ministry.

About 50,000-60,000 new cases involving claim amounts of around ₹4 trillion get added every year while DRTs on average have been able to close only about 30,000 cases per year for the past five years.

“A resolution-based approach and not being solely focused on maximising the recovery is required to be adopted for resolution of large cases,” said Divyanshu Pandey, partner at law firm JSA Advocates & Solicitors, adding that this requires assessing whose skin is in the game and whether efficient resources and strategy are being deployed by public sector banks to deal with such cases.

To be sure, government data shows that more than 75% of pending cases in DRTs are low-value ones, which involve claim amounts between ₹20 lakh (the jurisdictional value for reference of cases to DRTs) and ₹1 crore.

“This needs to be complemented by improving the infrastructure at DRTs, strengthening the DRT benches and the legal teams of the banks,” Pandey said.

Currently, there are 39 DRTs and five DRATs (debt recovery appellate tribunals) with each tribunal addressing around 900 cases annually for the past five years while more than 1,500 fresh cases were getting added to them every year.

Also read | Government considers tweaks to reduce huge backlog at debt recovery tribunals

Government data shows that recovery through DRTs stood at ₹12,879 crore in FY22, ₹7,669 crore in FY23 and ₹11,117 crore in FY24.

Mukesh Chand, senior counsel at law firm Economic Laws Practice said that banks often file cases in DRTs where recovery is unlikely, especially in situations where there is no security or the security has been disposed of, leaving little to enforce through decrees. As a result, these cases remain unresolved, contributing to the backlog.

“Also, while the banks do prudential write-offs of cases, there is no actual write-off and these accounts also remain in the books (though not accounted). Unless the banks also have a clear policy of actual write-offs, such cases would keep pending in DRTs without recovery,” he added.

A prudential or technical write-off is the amount of non-performing assets (NPAs) or loans that are outstanding in the books of the branches, but have been written off at the head office level.

The NCLT-IBC angle

Another issue that is keeping DRTs occupied with cases that run endlessly in the tribunals is shift in focus of banks to NCLTs for cases involving larger companies and complex resolutions under the Insolvency and Bankruptcy Code (IBC). DRTs now mostly handle routine filings to protect limitation periods or cases that do not qualify for IBC. This lack of focus on cases with DRTs is often responsible for delays in getting orders on payment default.

In eight years since 2016, 31,394 corporate debtors involving a value of ₹13.9 trillion have been disposed of under IBC, as of March 2024. Comparatively, over the past five financial years, ₹72,708 crore has been recovered by scheduled commercial banks through DRTs from around 150,000 cases.

Also read | Banks to take Future to debt recovery tribunal

“Reduction of cases pending in DRTs will have a direct impact on the balance sheets of banks,” said Abhishek Swaroop, Partner at Saraf and Partners, adding that banks will be able to improve recovery rates, liquidity and financial health, and lend more effectively.

“Importantly, quicker resolutions will also reduce the legal and administrative costs associated with prolonged litigation,” he added. “The de-clogging of the existing DRTs coupled with the establishment of additional DRT benches, as announced in the 2024 budget, will cumulatively lead to achieving optimum results.”