Preparing for the next pandemic - and dealing with the current one

A new strain of virus is airborne. Veer Arjun Singh reports on the debate that follows the inevitable outbreaks

Our guard is up. Security officials in protective suits, some equipped only with face masks, are India’s first line of defence at major airports. They are armed with thermal guns, a non-contact, infrared thermometer to screen passengers. Thermal imaging cameras that detect heat in a crowd back them up at strategic checkpoints. The protocol directs officials to identify and isolate people arriving from China who record a body temperature above 100.4 degree Fahrenheit and quarantine the ones who have more pronounced symptoms of a general flu — a cough, body ache, shortness of breath, etc. More than 40,000 people at 21 major airports have been screened, over 200 have been tested and at least one person in Kerala has been infected with a new strain of coronavirus, a pathogen from a known family of viruses, which had killed over 200 people and infected more than 8,000 people in 18 countries — most of them in Wuhan, the epicentre of the outbreak in China — at the time of writing this report.

The World Health Organization (WHO) recommends that the new outbreak be called “2019-nCov acute respiratory illness” and has declared it a Public Health Emergency of International Concern (PHEIC) at the second meeting of its International Health Regulations Emergency Committee. Novel coronavirus, or nCov, causes an infection of the upper respiratory tract. But its source and virulence remain elusive.

What we have learned from the related MERS-Cov (Middle East Respiratory Syndrome coronavirus), which caused 854 deaths, and SARS-Cov (Severe Acute Respiratory Syndrome coronavirus), which killed 774 people, according to WHO, is that the source of 2019-nCov may remain uncertain, a definitive cure may never be found and a preventive vaccination may not see the light of day. Most pharmaceutical companies shelved the development of vaccines for both SARS and MERS after the outbreaks were contained. The priority remains to contain this one, too. 

But the new strain that is likely to have first surfaced in mid-December in Wuhan has already surpassed the number of confirmed cases during the MERS outbreak in 2012 (2,494) and the 17-month-long SARS pandemic between 2002 and 2003 (8,098), according to WHO figures. Even if it is more contagious, the only silver lining is that 2019-nCov appears to be less fatal. Its case-fatality ratio of 2 per cent is below 9.5 per cent in SARS and much lower than 37 per cent in MERS. But like other viral outbreaks, 2019-nCov could mutate to become more lethal. 

“It’s like the flu. And it’s causing deaths much like swine flu (a subtype of influenza A denoted H1N1) did initially,” says Kirti Sabnis, Infectious Disease Specialist & HIV Physician, Fortis Hospital, Mulund & Kalyan, Mumbai. Over 200 people died in India during the swine flu outbreak in 2015. This time, hospitals across the country have been directed by the government to isolate any patients exhibiting symptoms of Influenza-like Illness (ILI). 

“Suspected patients are supposed to be kept in negative-pressure rooms, which allow air to flow in but not escape,” says Sabnis. Hospitals can also keep the patients in rooms that have separate air-conditioning ducts.  

“At least there should be a minimum distance of one metre between two beds in a hospital,” says Rajiv Dang, senior director and head of department, internal medicine, and medical director, Max Hospital, Gurugram. There’s no doubt that a contagious outbreak of the magnitude that China is facing could put serious pressure on India’s ailing health infrastructure. India, like China, is also at a greater risk of an epidemic because of a high population density.

Worse still, the outbreak that is fast spreading around the globe seems difficult to contain. “An infected person may not even show any symptoms but still be a carrier,” says Dang. A 10-year-old boy in Wuhan on Wednesday tested positive for the infection even though he appeared healthy.

The infection appears to be spreading through person-to-person contact and through droplets excreted while sneezing and coughing. Researchers estimate that the infection could stay alive within a host body for about 14 days. But the Indian health ministry has directed health officials to quarantine suspected cases, who have been to Wuhan in the last two weeks, for 28 days.

But in case 2019-nCov continues to spread further, and faster, in the absence of clinical data on treatment, doctors will have no choice but to treat it symptomatically. “Patients could have breathing difficulties or have high fever and they will be treated accordingly. But there’s no anti-viral that could be administered,” says Sabnis.

Virus mutations are inevitable. Even WHO recognises that a new outbreak is not a question of if but when. It monitors seasonal flu infections around the world, analyses clinical data and publishes recommendations to deal with them every year. Even so, between 250,000 and 650,000 people die in a year of the many strains of influenza globally.

Twice a year, WHO predicts the flu strains that are likely to be active during the winter seasons in the northern and southern hemispheres and recommends pharmaceutical companies to create a new flu vaccine. It says the vaccination takes two weeks to come into effect. In India, it means one shot every September for children older than six months and all adults.

But a considerable body of evidence argues against the yearly shot even as health departments of most developed countries recommend it. Most notably, Tom Jefferson, a British epidemiologist based in Rome, who works with the non-profit Cochrane Collaboration, has campaigned extensively to review the effectiveness of flu vaccinations through randomised clinical trials. He recently also sued Roche, the company behind the anti-viral Tamiflu (oseltamivir) for claims that it can slow down the flu epidemic. Tamiflu is widely administered in India during the treatment of swine flu. 

“We only recommend the flu shots to the most vulnerable lot — people over the age of 65 and suffering from critical illnesses who have a weakened immunity,” says a Delhi-based ENT specialist, who did not wish to be named. “It’s a waste of money otherwise. It does not work on anyone else,” he adds. Many general practitioners advise against the flu shot, especially for children. 

Yatin Mehta, chairman, Institute of Critical Care and Anesthesiology, Medanta — The Medicity in Gurugram argues that while the flu shot is not perfect, it saves many lives every year. 

“I have administered it to myself, my nursing staff and even my children. It helps the immune system in fighting particular strains and does not have any major side effects,” he says. There’s no reason to not take it, he says. The specialists from Max and Fortis quoted above agree with Mehta’s assessment. WHO estimates that the flu shot, which it says helps against some Influenza A and B strains (including H1N1), was about 40 to 60 per cent effective in 2018-19.

Researchers say that even if creating vaccination for 2019-nCov follows a different trajectory than it did during SARS and MERS outbreaks and is more effective than the generic flu shots, it will take at least a year before it completes human trials.

After 100 years of the 1918 Influenza pandemic, dubbed Spanish Flu, which killed somewhere between 50 and 100 million people and infected one-third of the world’s population at the time, it appears that a strict protocol to contain viral infections remains the only effective tool in the face of an approaching pandemic.