On January 31, as a special Air India flight evacuated 324 Indians from Wuhan, Monika Sethuraman, 31, broke down in tears realising that she wouldn’t be on the plane. “I couldn’t breathe for a few seconds…I am stuck here in the city, and it’s now turned into a huge prison,” she says over the phone from her one-room dormitory. The doctoral scholar in international relations at Wuhan’s Central China Normal University had been instrumental in contacting the Indian embassy and arranging the evacuation of fellow Indians following an outbreak of the new novel coronavirus (2019-nCoV).
For Sethuraman herself, leaving Wuhan won’t be easy now. “I didn’t go to the airport because I knew I would not be cleared for the flight out. Even if I recover from the cold, once you are on the blacklist, you will not be allowed to fly out,” she laments. Since the transport lockdown on January 23, Sethuraman has stocked up on essentials. According to her, stepping out is futile. One will be spotted by a drone, the building security cameras or police, and sent back indoors. “The authorities aren’t interested in testing or verifying if you have the virus. They are only interested in control…it doesn’t matter if we live or die so as long as the virus is contained,” she says. “I am following WHO (World Health Organization) guidelines, but there is no human interface to connect to. If people see you wiping your nose, they run from you, including the officials. That’s the kind of panic and desperation here.”
First batch of Indian evacuees arriving at the quarantine centre in Delhi (Photo: ANI)
The travails of Vinay Ahuja, 38, who was visiting business associates in the region when the city went into a lockdown, are no different. “Nobody expected it to escalate so quickly,” he says, as he marks time before he gets permission to fly out. What Ahuja and many others are wondering is whether India would be able to replicate China’s iron-fisted attempts to control the outbreak in a similar situation. China has been criticised by human rights groups, but received praise from WHO for its aggressive approach to control 2019-nCoV. The country built a 645,000 sq. ft emergency hospital in Wuhan in just 10 days. The two-storeyed hospital has 30 intensive care units (ICUs), 1,000 beds and special corridors to limit patient-nurse contact. A second hospital could be up by February 5.
Medical officials screening the 323 Indians and 7 Maldivians at the airport (Photo: ANI)
Seldom has an illness-largely a little-known respiratory disease-aroused such apprehensions as the ‘corona’, now part of the popular lexicon as a dreaded threat, eclipsing the pleasant connotations of being the aura around the Sun and a branded cold brew. First detected in December 2019, 2019-nCoV is a previously unidentified strain. It comes from the same family of viruses as the Severe Acute Respiratory Syndrome (SARS-CoV), which claimed 774 lives, including three Indians in 2002-03.
The situation in India is nowhere as grim as at epicentre Wuhan, though three cases had been confirmed until February 5, while 3,935 were under observation at isolation wards across the country, apart from the special camps for Wuhan returnees near Delhi airport. So, how prepared is India to handle the coronavirus in case the numbers spike?
Considering there is no vaccine or trial-proven drug therapy yet, affected patients are being treated symptomatically based on clinical severity. “Serious cases who have viral pneumonia will need supportive intensive care, including mechanical ventilation when required. Hospitals in large cities can provide this, if the numbers are not overwhelming. Small towns and rural areas in most states will be ill-equipped if the virus spreads further,” says Dr K. Srinath Reddy, president, Public Health Foundation of India (PHFI).
Is it spreading? A doctor reads the CT scan of a quarantined patient in Wuhan (Photo: Feature China/Getty Images)
The public health system will have to go the extra mile to check the potential spread of the virus. Entry points to the country are being closely monitored to assess incoming travellers. There is still the danger of infected persons slipping through in the asymptomatic but infectious phase of the illness. Isolation of clinically-suspected cases is essential even where a specific virological diagnosis is not immediately available. Close contacts of affected persons are being advised clinical assessment and restricted mobility till the incubation period (up to two weeks) is over. “Since the symptoms are not specific to this virus, a high index of suspicion is needed based on history of exposure to a proven/ likely case, even where laboratory facilities for a specific viral diagnosis are not readily available,” explains Reddy. “We have to educate the public with well-framed risk communication messaging and health advice, and all healthcare providers must follow the correct diagnostic/ clinical protocols.”
A comprehensive nationwide surveillance system is still a work in progress. While this network has expanded since the H1N1 virus threat loomed large a decade ago, competent labs are needed at more locations. In 2012, there was a proposal to set up 150 diagnostic and research labs with virology-related expertise. Of these, 80 are operable now, but this number is far from adequate. These are also not linked to the public health response system and only serve as support for ad hoc reporting.
Though India has an integrated disease surveillance programme in each district, this is done at a micro level and largely follows a symptomatic approach. “We need case-based surveillance-where any suspicious disease outbreaks are reported to labs for real-time confirmation. What we have is reporting at district levels based on extreme symptoms,” says Dr G. Arun Kumar, head, Manipal Institute of Virology, one of four diagnostic labs under the Indian Council of Medical Research (ICMR).
Detailed investigations found that the SARS-CoV was transmitted from palm civets to humans in China in 2002 and the Middle East Respiratory Syndrome (MERS-CoV) from dromedary camels to humans in Saudi Arabia in 2012. The animal source of the 2019-nCoV is yet to be identified. It’s likely the source is a live animal market in China.
Labs and the health system have also largely overlooked animal research and the risk mapping of India. There are several types of animal to human transmitted (zoonotic) diseases. They vary in terms of pathogen diversity (viruses, bacteria, fungi, protozoa, helminths) and animal sources (bats, pigs, chickens, other birds, palm civets, dogs, fishes, crustaceans and snakes). India has fairly well-established programmes for monitoring zoonotic diseases like rabies, brucellosis and Japanese encephalitis. It is the threat of newer viruses, transmitted from wild or captive bred animals, that is most worrisome.
“To identify the emergence and spread patterns of zoonotic pathogens, we need a ‘one-health’ approach, combining research data from wildlife, veterinary and human populations involving biology, epidemiology and clinical studies. Surveillance of wet markets, involving sale of animal foods, has to be strengthened. At the same time, research needs to identify entry points of zoonotic pathogens from outbreaks in other countries,” explains Dr Reddy.
Agencies such as the National Centre for Disease Control (NCDC) and the ICMR have advanced efforts in these areas. Yet, India is unequal to the task, be it handling an emergency or pursuing priority research. The weak links lie in inadequately integrated epidemiological surveillance of zoonotic pathogens in forests, close-bred veterinary clusters and human population groups. This is one of the reasons why Nipah claimed 17 lives in Kerala in 2018. The dearth of virologic and taxonomic studies on native bats made it difficult to understand the nature of the virus. However, the state has learnt from the tragedy. Kerala has declared 2019-nCoV a state calamity and has kept over 2,000 people under surveillance at their homes. “This is to tighten vigil rather than create panic. We do not want to miss out on any case,” says state health minister K.K. Shailaja.
This level of vigilance has not been replicated elsewhere. Despite India being in the top 30 countries at risk from the virus, there has been no statement from the minister of health and no central guidelines for detecting and controlling infection. In contrast, European countries began tracking down visitors from China and putting out strong public advisories two weeks after the outbreak. Precautionary guidelines for the public in India are yet to be widely disseminated, in English or in local languages.
“There are all kinds of misleading reports giving the public incorrect information to help cure the virus. Most people also do not know how to protect themselves, which masks to wear, and so on. Public education has been entirely neglected so far,” says Chapal Mehra, a public health specialist in Delhi. “We need a proactive approach, not a reactionary one. Large-scale screening of risk individuals has to be a priority. It’s a challenge for our public health system, which is yet to come out with a strategic approach to the issue,” he adds.
A concerted multi-agency response, led by a competent public health system, is the need of the hour, but it is currently hampered by the limited expertise in the country. In the medium term, agile outbreak response systems have to be built, primary healthcare facilities (where clinical assessments take place) strengthened and vaccine development efforts advanced.
If the virus does spread here in the same magnitude as in Wuhan, the impact on the economy, healthcare and public morale could be catastrophic. With one of the world’s highest population densities, especially in urban cities like Delhi and Mumbai, maintaining three-feet distance between individuals (as recommended by the WHO) will be impossible, nor will the lockdown of an entire city be feasible. Meanwhile, social media broadcasts by individuals in Wuhan paint a grim picture. Shortage of food and medicines, panic and misinformation, depression, even theft-the virus doesn’t just destroy health, it destroys society. It’s already visible in Kerala. There are media reports of families of China returnees being ‘ostracised’.