The virus, according to one theory, was transmitted to humans via snakes (again, we do not know). But we do know that China, the epicentre of this bio-earthquake, is quietening down. Its massively organised state apparatus has helped taper off the threat, after over 3,000 deaths. Can India likewise marshal a counterforce? About 10 days into their semester break in mid-January, a group of Indian medical students fled Wuhan just before the shutdown. From that populous capital of the central Chinese province of Hubei, where the metaphorical snake first bit, they made the seven-hour high-speed rail journey to bustling Kunming, in the southwestern province of Yunnan, and caught a flight out to Calcutta. “It was a tense few hours of waiting in the train and then in the airport terminal. We had tickets, but didn’t know if we would be sent back,” recollects one of them, a third-year medical student who subsequently became India’s first case of the novel coronavirus infection that causes the flu-like COVID-19 disease. She hadn’t planned on coming back for the break, but the growing uncertainty convinced her of the need to go home to her parents. Now, she has recovered and completed a 28-day quarantine. All three infected people in Kerala have recovered, as the state put its famed healthcare system on high alert. All over the globe, about 50,000 people have recovered.
But February’s lull seems to be over, and suddenly alarm bells are ringing all over India. All the new cases—in Delhi, Hyderabad and Jaipur—were travel-related. One person who tested positive was a tech worker who had recently been to Dubai—where he met engineers from Hong Kong—and got on to a Hyderabad-bound bus from Bangalore. There were 23 others on the bus. Another dined at La Piazza restaurant in Hyatt Regency, a five-star hotel in south Delhi. Then, an elderly Italian couple, part of a 23-member tourist group that visited many sites in Rajasthan, have tested positive. The chain effect naturally set off precautions—some exams are being deferred, schools being shut and Holi celebrations, including by the government, called off.
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So how are health authorities responding? Across cities, they have swung into action to trace the people—family, friends, flatmates, colleagues—the infected may have come into contact with, for testing and segregation. Speed is the watchword, experts say. On China’s success in stanching the crisis, a WHO expert spoke of unprecedented lockdowns and cordon sanitaires. Indeed, everything about COVID-19 has been about breakneck speed. It was just two months ago, on New Year’s Eve, that the WHO was notified of a cluster of cases of pneumonia of unknown cause in Wuhan. A week later, we had a new strain—from the same family of viruses that cause a common cold, but different from those that had previously gone on a worldwide rampage. As the count of infected people in Wuhan rose alarmingly in mid-January, the Chinese system pulled off a stunning feat—a 1,000-bed hospital built in 10 days.
Kakinada district officials interact with a suspected carrier.
In similar scorching pace, researchers decoded the virus’s genome sequence, crucial to zeroing in on a treatment. The non-medical fallout has been unravelling as rapidly—Chinese manufacturing accounts for more than a fourth of the world’s output and the shutdown is sending global markets into a tailspin. Trade fairs and big events across the world are being cancelled. India itself imports a bulk of some pharma raw material from China, and a looming domestic scarcity has prompted the government to suspend exports.
Between lockdowns and quarantines, the COVID-19 epidemic in China peaked and plateaued by early February, to even decline from there.
But by month-end, the worry was about how the number of new cases being reported daily outside China had, for the first time, exceeded those being reported from within that country. By March 1, the new hotspots were South Korea, Italy and Iran. In South Korea, a fringe Christian cult called the Shincheonji Church is at the centre of a controversy: it had apparently withheld knowledge of infection among its devouts. About half of that country’s 3,700-odd cases are directly related to its members. Iran has asked people not to travel to its holy city Qom and, last heard, Singapore churches were advocating live-streaming of Masses to homes, as a precautionary measure.
“We’re at a decisive point,” Tedros Adhanom Ghebreyesus, director-general, WHO, said at a briefing last weekend. To countries reporting first-time cases, his advice was to move swiftly and nip it in the bud. “Every country must be ready for its first case, its first cluster, the first evidence of community transmission, and for dealing with sustained community transmission.”
India can’t afford to loosen the vigil. But how prepared is India, with its health system already battling infectious diseases from TB to H1N1? “India’s initial response to the importation of three infected persons from Wuhan, as well as a larger group of uninfected Indians, was good, with all the correct public health actions,” WHO chief scientist Dr Soumya Swaminathan told Outlook over email on March 1. “Now that transmission events in many countries are occurring in people without any history of travel or contact with an infected person, testing must expand and surveillance must be strengthened.” The set of actions to be taken ranges from ensuring laboratory capacity, availability of testing kits, protection of frontline healthcare workers, infection control in health facilities, case management protocols, oxygen supplies, ventilators and facilities for treating a large number of patients. Equally, risk communication and engagement.
The trick will be to implement while being on a learning curve. “We are learning about the virus every day,” says Swaminathan, who headed the Indian Council for Medical Research (ICMR) before moving to WHO two years ago. Though it belongs to the family of Severe Acute Respiratory Syndrome (SARS)-related viruses, novel coronavirus behaves quite differently—it appears to be more easily transmissible, but milder. The fatality rate is 3.4 per cent compared to nearly 10 per cent for SARS. “The world was able to contain SARS using known public health measures. We should still aim to do the same here,” she says. “We know that over 80 per cent of infections are mild and 15 per cent result in severe disease, while 3-5 per cent are critical. We know that the virus is stable so far, and has not mutated.”
The lessons from Kerala’s previous experience with the 2018 Nipah virus came in handy, especially in contact-tracing, creating isolation facilities quickly and deploying teams to counsel quarantined people. Visas of travellers from the top affected countries have been suspended and screening has intensified at airports and ports, while screening is going on at land borders. Around 10 lakh people have been screened along the Nepal border and authorities have organised nearly 4,000 gram sabhas in border villages for awareness. “We are monitoring the evolving global scenario. Restrictions may be further extended to other countries as per the situation,” Union health minister Harsh Vardhan said at a recent press conference. The government, he said, is also trying to set up a lab in Iran to screen Indians stranded there before they are brought back.
So far, India has carried out the highest number of evacuation of citizens from Wuhan and Japan, according to ICMR chief Balram Bhargav. “The government is well prepared, and isolation facilities are identified. In fact, those evacuated have been tested, kept in isolation and released. All are doing fine and we are still keeping check on them. The evacuees from Japan are still in isolation,” he said. The health ministry said 16 of the Italian tourists who visited Jaipur and their Indian driver have tested positive, and are being treated.
“We are taking ample precautions,” Rajasthan’s health secretary Rohit Singh tells Outlook. “Rapid Response Teams are in place in all districts. Sanitisation of hotels where this Italian group stayed is underway. We are also screening the hotel staff and others who could have come in contact with the group members.” The group had travelled across six districts—Mandawa, Bikaner, Jaisalmer, Jodhpur, Udaipur and Jaipur. “We are advising people to not panic, but remain vigilant and follow basic hygiene on a daily basis,” says Singh. But panic, despite the advice, was evident. In Bangalore, for instance, a WhatsApp forward of the health department’s letter to an apartment complex, where the Hyderabad techie had briefly stayed on his return from Dubai, did the rounds.
Between the H1N1 swine flu pandemic a decade ago and now, India’s diagnostic capacity has seen a ramp-up—there’s now a wider network of functional viral research and diagnostics laboratories (VRDL) across the country than before. Currently, 15 labs are functional and 19 more will be made operational, the health ministry says. Reagents to test up to 25,000 samples have been made available. “Since mid-January, we have been preparing to deal with any number of cases. Reagents and supplies were provided and courier agencies identified to help transfer samples in cold chain,” says an official at a nodal VRDL in Bangalore. It takes 6-8 hours to test a sample. If a positive case is found, the sample is sent to the National Institute of Virology in Pune for further confirmation.
Most experts stress on the need to assess the health systems. “The healthcare you get in Kerala is not the same as you can get in Assam or Bihar. And there is no mechanism to ensure all states are able to deliver a certain quality of care in case of an outbreak,” says Prof Gagandeep Kang who heads the Faridabad-based Translational Health Science and Technology Institute, and is a Fellow of the Royal Society. “So the ability to have a surge capacity is something the healthcare system needs to do for preparedness, not for this predicament alone, but for all epidemics.” So far, the standing instructions to private hospitals for COVID-19 are to quickly inform public health authorities once they suspect somebody based on symptoms and history of travel, explains Prof O.C. Abraham at Christian Medical College, Vellore. “Our job, once someone is suspected, is making sure they are segregated and inform public health authorities, and they will take over,” he says.
The Union health ministry is currently working out detailed standard operating procedures (SOPs) for COVID-19 management in private hospitals. The cabinet secretary’s coordination meeting on March 3 decided to involve district collectors in cluster management in their areas, while the message to states was to identify possible quarantine facilities, and augment isolation wards by including facilities of the labour department, armed forces and paramilitary forces, medical colleges and public sector units within their jurisdiction.
Indians airlifted from Wuhan at an ITBP facility in Delhi.
When it comes to tackling any epidemic, Abraham reckons that only a general strengthening of the health system will help rather than disease-specific programmes. “I’m glad that the lessons learnt from the Nipah outbreak were not forgotten. These things are not one of a kind, but unless we strengthen from the primary level we are going to be in serious trouble,” he says. But what surely needs to be avoided, Abraham says, is the spread of misinformation, and the panic and stigmatisation it sets off. Or even exploitation—take masks and hand sanitisers that now cost a premium. “Walking around with a mask doesn’t make any sense; it’s for people who look after suspected COVID-19 cases. The thing is social distancing...if you are sick with cough and cold, stay at home. If you are feeling really unwell, immediately seek medical attention. If you see somebody sick, maintain your distance and don’t shake hands or hug even if it is your immediate family,” adds Abraham.
The COVID-19 scenario, as the WHO director-general puts it, is unchartered territory. “We have never before seen a respiratory pathogen that is capable of community transmission, but which can also be contained with the right measures,” he said at a March 2 briefing. There is a global race to develop a vaccine besides attempts to repurpose existing antiviral drugs for which clinical trials are under way. It would likely take 6-8 weeks for vaccine candidates to complete the animal tests, says Kang, who is on the board of the Norway-based Coalition for Epidemic Preparedness Innovations, which is supporting some of the companies developing these vaccines. The Translational Health Science and Technology Institute in Faridabad is working towards a point-of-care diagnostic test by adapting ongoing work on febrile illness, to speed up screening. But that, Kang says, could take six months.
“If you look at how connected the world is, be it flight patterns or densities of populations—things have changed a lot. Diseases can emerge in one part of the world and spread rapidly to other parts,” says Kang. “We will keep seeing new diseases as viruses keep evolving. Most infections that cause these outbreaks are viruses, but there is a worry that there are certain kinds of bacteria as well that will become antibiotic-resistant and then become public health problems. These are all things we need to be concerned about for the future.”