Joint effort

AS 2020 SET in, a virus managed to confound everyone, including experts from the redoubtable World Health Organization. On January 26, about 20 days after Chinese authorities identified the virus of “unknown etiology” causing pneumonia as the novel coronavirus (2019-nCoV), the WHO admitted it had made a mistake in assessing the global risk posed by the virus as “moderate”. It clarified that the virus that had killed over 50 persons by then—the toll is 132 now—was classified as “high-risk” globally.

In India, despite no confirmed 2019-nCoV case till January 29, its health authorities continue to remain on high alert. Apart from issuing an advisory against travelling to China, senior officials at the Union health ministry and the department of health research continued to hold meetings, monitoring especially the situation in states that share a border with Nepal (which confirmed its first 2019-nCoV case)—Uttarakhand, Uttar Pradesh, Bihar, West Bengal and Sikkim. Kolkata recently had a scare following the death of a Thai woman who was admitted to a private hospital with fever and respiratory illness. A Chinese woman, too, was admitted to a hospital with respiratory illness around the same time. “The woman was released after she felt better,” said Ajay Chakraborty, director of health services, Kolkata. “Prima facie, the Thai woman had also not died of coronavirus [infection] because she came to Kolkata in November, before the outbreak in China.” Taking no chances though, the Union health ministry swung into action, setting up health kiosks at three places along the Indo-Nepal border with the help of the Sashastra Seema Bal.

Health ministry officials said they were confident of India’s capabilities to screen, test and respond to the situation, with enough isolation wards and close monitoring of asymptomatic persons who had come back from China. In Bengaluru, for instance, no passenger with a history of a visit to Wuhan in the last 14 days had tested positive during the thermal scanning, as per a statement by the Kempegowda International Airport unit of the Airport Health Organisation, Bengaluru. Six passengers—four Chinese and two Indians—are under 28-day quarantine; they are asymptomatic, it stated. “The state health department held a meeting of all hospital representatives to take stock of the preparedness to tackle an outbreak,” said Dr C. Nagaraj, director, Rajiv Gandhi Institute of Chest Diseases. A central team visited the hospital that has a 17-bed isolation ward.

But experts said that more needs to be done in case of a potential outbreak. “The National Institute of Virology has developed a polymerase chain reaction test (which helps produce billions of copies of a specific DNA or RNA sequence; nCoV is an RNA virus) and distributed it to a limited number of laboratories within the government ecosystem,” said Dr Gagandeep Kang, director, Translational Health Science and Technology Institute, an autonomous centre under the department of biotechnology. “This is great, but it would be even better if every laboratory that can provide quality services—such as those that are accredited by national authorities, both in the public and private sector—were allowed to provide testing, and then there was a reference function served by national labs.”

While India’s overburdened health systems get overwhelmed even while dealing with diseases such as dengue and chikungunya that cause limited outbreaks because they need mosquitoes to spread, the situation could be difficult with nCoV as it spreads fast. “The genome of the novel coronavirus shared by China tells us that it is closer to the one that caused the SARS pandemic in 2002-2003. Though the deaths caused by the virus are fewer than SARS virus, we now know that it spreads faster than the SARS virus,” said Professor G. Arunkumar, director, Manipal Institute of Virology.

Though the virus spreads fast, its incubation period is longer—2-10 days, as per WHO—rendering it a challenge to catch it early, said Arunkumar. “In China, though several people are being treated, few have been discharged from the hospital. More information on these issues would help us tackle the disease better,” he said. As far as containing the virus is concerned, he said that initial management would be easy by way of isolating the patient. “It is only once the virus gets into the community and establishes sustained transmission that the issue of bed strength and trained staff will begin to arise,” he said. With stringent public health measures in China, including exit screening, international spread may not escalate quickly.

Kang emphasises on the need for a robust infrastructure to deal with an outbreak. “We need beds; we need trained health care staff, not just trained doctors. We also need protocols for clinical management and for prevention of infection,” she said. While the government’s preparedness meeting on January 28 focused on all these issues, she said the ability to handle emergencies varies by state, location and facility. “Guidance and process from government is great, but we need to focus on communication and also be open, transparent and inclusive of the private sector which provides the bulk of health care in India,” said Kang, who is also vice chair, Coalition for Epidemic Preparedness Innovations.

When it comes to lessons in dealing with an outbreak, most experts cite Kerala’s efficiency in dealing with the Nipah virus outbreak in 2018. Professor Vinod Thomas, former senior vice president, World Bank, said that fewer than 20 people died of Nipah because of the high degree of education, awareness, health facilities and health workers on which the state had invested in over decades. “There was coordination and information exchange from Kerala professionals with NIV, Pune, and WHO, backed by an army of frontline workers and awareness campaigns,” he said.

Thomas, professor at National University, Singapore, said the government’s top priority must be to “raise the spending and do so efficiently on health and education”. “Spending on health and education, especially by the government, has been low for a country with India’s per capita income,” said Thomas. “India underspends on education and health with government spending on health a fifth of the global average, and below that of Nepal and China as a percentage of GDP.”

Large-scale outbreaks such as the 2019-nCoV are inevitable. “In an increasingly connected world and one where climate change and urbanisation are driving habitat change, outbreaks with unknown and known pathogens will happen. It is just a question of when and with which organism,” said Kang. The issue of preparedness then requires a new thinking about public health that brings together not just medical specialists, but also economists, trade experts, sociologists, anthropologists and ecologists. Every speciality is needed to build a comprehensive preparation and response strategy, said Kang.

—With Rabi Banerjee and Prathima Nandakumar