As the coronavirus disease spreads across the world, vulnerable countries like India with weak public health systems must be doubly cautious
By Nissim Jacob
With the number of cases of coronavirus outside China spiking recently in countries as far apart as South Korea, Italy and Iran, India must prepare itself for a possible outbreak of the disease.
The disease, classified as Covid 19,has caused over 4,000 deaths across the world, with most of the deaths occurring in China. It is now threatening to cause a global pandemic, is claimed to have originated at a wet market in the city of Wuhan in the Hubei province of China. The largest number of deaths in China have occurred in Hubei and China has taken drastic measures to contain the spread of the disease by putting the entire province under a lockdown.
In India, over eighty cases were confirmed by the Central government. The first cases identified in India were in Kerala among students studying at Wuhan University. Since then several cases were detected across the country and the health authorities are now scrambling to contain the outbreak. The number of cases in India is steadily rising. There had been a lull after the detection of the initial cases in Kerala, but with the steady rise in the number of infected patients the Central government has been compelled to take tough measures. The Central government has suspended all existing visas excluding diplomatic, official, UN, project and employment visas. India has imposed restrictions on the export of medical equipment to China due to shortage in domestic supply.
State governments have also ordered shutting down of several places of mass gathering as part of their efforts to contain the spread of the disease. Apart from directing malls, theatres and pubs to suspend services, exhibitions, summer camps, sports events and large weddings will also have to be called off. Schools, colleges and universities have also been closed and some industries like the IT sector have asked their employees to work from home.
Kerala activated the Integrated Disease Surveillance programme and set up district surveillance teams. Every district was directed to set up tertiary care facilities such as ventilator support and intensive care unit in at least two government run hospitals and one private run hospital. A control cell was established at the state’s ministry of health for surveillance and containment of Covid19. To monitor implementation, hospital admission and surveillance teams are set up by the state government. Guidelines were established for surveillance, management of clinics, and carrying out laboratory tests.
When the first case of Covid 19 was confirmed in the state, it took contact-tracing exercises. The importance of tracing contacts was realized during the Nipah virus outbreak which occurred in 2018. Kerala has also taken into consideration the possibility of asymptomatic transmission, although there is no scientific evidence for the same. This was done by closely monitored and rigorous surveillance of all patients arriving from Wuhan, including those arriving from other parts of China. The incubation period as set by the health authorities is longer than the standards sets by the World Health Organisation (WHO).
The effective management of the Nipah virus outbreak has been the basis for containing the spread of the novel Coronavirus disease. Units which were set up for monitoring the disease spread during the Nipah virus outbreak, have been reactivated. Infection-control protocols for the state’s health workers were introduced during the Nipah virus outbreak after it was learnt that the disease which lead to 17 deaths in the state also spread at hospitals.
While the number of deaths in Kerala has been limited to three, it is too early to celebrate. Information about the dynamics of transmission and virus reservoirs are still unknown. There are also fears that if the disease spread to other states, then the task ahead will be much difficult as they do not have the same public health infrastructure. Says Gautam Menon, professor of Physics and Biology at Ashoka University, “With the Nipah virus, the number of infected cases was small and thus we were able to deal with the disease. However the reproductive rate of the coronavirus is higher and India doesn’t have the ability to deal with the pandemic when the number of infected cases is higher. Because of its political structure, China was able to impose a lockdown in Wuhan and restrict the movement of people. India will not be able to do the same.”
India has responded quickly by evacuating its citizens from Hubei province. It has implemented screening procedures for the evacuees upon arrival at Indian airports followed by surveillance of the arrived persons. It has responded by directing government hospitals to set up isolation wards and creating awareness among health workers and stocking protective gear. The National Institute of Virology at Pune, which is the country’s premier research institution of viruses, has established a methodology on sample collection and testing facility with the aid of the Indian Council of Medical Research (ICMR).
The Health Ministry has set up an Emergency Medical Response Unit while a 24×7 helpline was rolled out by the National Centre of Disease Control for self declaration by persons who suspect that they may be infected. Several labs have been identified across the country by the Union health ministry for testing samples of suspected coronavirus cases.Camps were set up by the Armed Forces Medical services in Haryana to quarantine such cases.
Says Dr. GB Shantala, who is heading the testing of coronavirus samples in Virus and Research Development Lab at the Department of Microbiology in Bangalore Medical College and Research Institute, “So far all cases screened have been tested negative for novel coronavirus. The people who have been screened have a history of travel to China and South East Asia. These patients had symptoms like cold, cough and fever. On testing the samples we found that the patients only suffered from respiratory tract infections.” The testing procedure is as per the guidelines established by ICMR. “We use real time PCR which is a molecular detection test that looks for specific marker for Covid 19,” adds Dr.Shantala. Polyremase chain reaction(PCR) tests analyse the RNA of the sample to test for infectious agents. It is the same test that is used for HIV, measles and mumps.
However India’s response has been confused. Despite taking constructive steps towards containing the disease,India has also made the flawed decision of promoting AYUSH products for preventing the disease. No tests have been done on the Unani, Ayurveda and homeopathy medicines that the Ministry of AYUSH is recommending and the efficiency of these medicines is also questionable.
The ICMR’s decision to suspend the study bats in Nagaland as well as its decision to shut down a research at Manipal University relating to Nipah virus, is also likely to discourage further research in our country. India lacks an effective research infrastructure which is necessary to find solutions during epidemics. Says Professor Menon, “The government’s decision to shut down research at Manipal University was unfortunate. International collaboration becomes important more than ever as coronavirus pandemic spreads across the globe.”
Despite initially being in denial about the possibility of large scale epidemic occurring in their country, going so far as to penalize health providers who sought to alert the public regarding the epidemic, the Chinese government has since then taken proactive steps to combat the disease by sharing information with other countries to create a cure for the infected patients as well as a vaccine to prevent the spread of the disease. The WHO has identified the outbreak as a global threat, declaring it to be a Public Health Emergency of International Concern.
Coronaviruses are a family of viruses, some of which are less harmful such as common cold while others are more menacing and can cause respiratory and intestinal problems. The 2003 SARS (Severe Acute Respiratory Syndrome) epidemic in China and MERS (Middle East Respiratory Syndrome) are linked to the coronavirus family and cause severe respiratory problems. Bats are suspected to be the hosts of the virus and it is believed that virus was transmitted to an intermediate host and then passed onto humans when they came in close contact with the infected animal. It then passes through human to human contact via coughing or sneezing.
One of the problems with the disease is the uncertainty regarding its spread. While initially it was suspected by scientists that coronavirus may spread during the incubation period itself, WHO has since iterated that the spread of diseases under asymptomatic cases to be rare as was the case in MERS syndrome. While the main driver of the disease is due to overt symptoms such as that of viral pneumonia, mild symptoms similar to common cold may also spread the disease. People with mild symptoms go undetected, thus the actual number of infected persons may be much higher. It has been found that several people whose test results were found to be ‘negative’ were found to be infected at a later date of testing.
Thus the spread of the disease is difficult to contain. More studies are required in this area and the testing procedures need to be made precise. These are early days and the though little is known, it’s likely that Covid 19 will spread far and wide and become the principal health challenge the world faces in 2020.