How not to fight a virus
Till Sunday, 1,436 cases of swine were registered in Mumbai, of which 11 people have died.
March 12, four people died of swine flu – the highest in a day since the disease showed up in Mumbai this year. In 2009, when the virus first made significant impact, the state declared a pandemic after 1,497 people were infected in Mumbai, and 30 died.
“Pandemic is a term used when all the continents are affected. This year, the spurt is being seen only in India and no where else,” said the state’s epidemiologist Dr Pradeep Awate. The state government is treating it simply as an outbreak, he said.
A week later we visited another such family, in Thane. This household of four had passed on the virus to each other; they were quarantined in cramped quarters. They too were turned away by several hospitals. “My younger sister was the first one to test positive. We tried to admit her in Fortis, Hiranandani, and Jaslok but none of them had sufficient isolation beds,” said the family’s younger daughter. Her mother also contracted the disease, followed by her father and elder sister.
“We’re fortunate to have recovered, but what’s worrying is that three of us could have remained virus-free if only the hospitals had enough room.”
That is why Mumbai continues to reel from swine flu – its effects have greatly multiplied following a demand-supply mismatch: hastily assembled emergency measures, and lack of isolation wards.
Swine flu is an airborne respiratory disease transmitted by droplets released primarily by coughing or sneezing (and spitting). It sets in when the temperature begins to fall and eases as summer takes hold. The safest containment strategy is to isolate the patient in a special ward, with the following protocols in place:
» Restricted visitor access
» Restricted movement within the facility » Enforced respiratory hygiene » Use of personal protective equipment » Deployment of closed suctioning systems in isolation wards During visits to four city hospitals, Mirror found that most were illequipped to fight the virus.
PVT HOSPITALS LACK BEDS
Mulund’s Fortis Hospital offers a case in point. “We have three or four isolation beds, occupied by patients suffering from highly infectious diseases like tuberculosis and neutropenia [marked by a severe shortage of white blood cells],” said S Narayani, the hospital’s facility director. “We did admit a few swine flu patients this season and those whom we couldn’t accommodate, we directed to other facilities.”
South Mumbai’s Jaslok Hospital, a very near the Breach Candy family’s bungalow, has an isolation facility of just two beds, both occupied. This is one among two hospitals that adhere to prescribed quarantine norms. The other is Kokilaben Dhirubhai Ambani Hospital in Andheri, with its 17-bed isolation ward and five-bed isolation intensive care unit. “With the spurt in swine flu cases, we have dedicated the ward for the disease,” said Dr Ram Narain, the hospital’s chief operating officer. “As the incidence drops, we accommodate other patients.”
The influx of patients from outside Mumbai hasn’t helped. Over 148 non-Mumbaikars have been admitted to city hospitals this year for swine flu. The state has made a feeble, belated attempt at addressing the problem – this, well into swine flu season – by announcing that no new hospital plans will be sanctioned without budgeting for adequate isolation facilities.
State Health Minister Deepak Sawant said that he has now made it mandatory for all hospitals with more than 50 beds to set aside 2 to 5 per cent of the beds for isolation. “This will help us to deal with such outbreaks in a better way,” Sawant said.
CIVIC-RUN ISOLATION WARD OVERFLOWS
February 19, a 43-year-old man from Khopoli died of swine flu in Kasturba Hospital on Arthur Road. He occupied one of 40 beds available in the city’s only government-run segregation facility. At the hospital, we found that “isolation” is a joke. The ward has serried rows of beds along its walls, with nothing to separate one from the other. Patients use the same washroom. Relatives walk in and out with nothing more than a facemask on.
According to infectious disease specialist Dr Om Shrivastav, an isolation zone must have an airhandling system separate from the rest of the hospital’s ventilation. An isolation room must hold a single patient and should be maintained at negative pressure to prevent cross-contamination.
High Efficiency Particulate Air filters for air purification and ultraviolet radiation filters should be integrated into the ventilation system to kill bacteria and pathogens. The isolation ward’s airconditioning should function at a rate of 40 cycles per hour.
Kasturba’s facility does none of these. The BMC’s chief epidemiologist, Dr Mangala Gomara, admitted deviation from World Health Organisation (WHO) norms. “However, the H1N1 virus is now very much in the air and home quarantine is enough if the patient is under proper medication,” she said. “We are planning to make a proper isolation facility as per WHO norms and a proposal has been sent to the state government.”
LAST-MINUTE INTERVENTION
While vaccination remains the best defence, antiviral agents zanamivir (Relenza) and oseltamivir (Tamiflu) reduce swine flu's effects. As this year’s flu season set in, the government discovered that its oseltamivir stock had depleted “Many patients received delayed treatment as the swine flu drug went out of stock initially,” said a doctor at a Vile Parle nursing home. “The demand also went up as there is a protocol to put healthcare staff handling a swine flu patient on a 10-day-long prophylactic course. So, even if a hospital took in one swine flu patient, at least 3-4 healthcare staff had to be put on preventive dosage.”
Alarmingly, the BMC’s swine flu drug procurement policy was governed by precedent, not by a perceived outbreak. “We had Tamiflu stocks to last us till 2013. However due to lack of cases, a huge number of tablets had to be destroyed as they expired and there were no takers,” said Dr Gomare. “We had limited stocks when cases of swine flu began to be reported this season, due to which an initial shortage was felt. But now we have enough stocks.”
LACK OF PREVENTIVE CARE
Zanamivir and oseltamivir have limited efficacy in eliminating the virus in infected patients. According to the US Food and Drug Administration, Tamiflu, discovered and developed by Gilead Sciences in that country, “has been shown to lessen the amount of time people are sick with the flu”. The seasonal flu vaccine remains the most effective means to combat the virus – it protects against three strains of flu, including H1N1.
Infectious disease specialist Dr Vasant Nagvekar, who consults at Lilavati and Fortis hospitals, said that vaccination should be promoted especially for people with co-morbid conditions such as diabetes, hypertension, asthma and chronic obstructive pulmonary disease, whose immune system is already affected. “Annual vaccination will not only reduce the incidence of this flu but it will also reduce the load on hospitals during such seasons,” said Nagvekar.
Awate said that the government of India has not devised any mass flu vaccination strategy. “There are limited benefits of vaccination. Even after vaccination, a person develops only 80 per cent immunity,” Awate said, adding that the virus differs every season and it's hard to predict which strain will be dominant.
The state government is, however, discussing a vaccination programme. “We have now made vaccination mandatory for healthcare workers before the monsoon begins, and in October before winter starts,” said Sawant. Discussions are also on whether a fluvaccination programme should be started for everyone.
March 12, four people died of swine flu – the highest in a day since the disease showed up in Mumbai this year. In 2009, when the virus first made significant impact, the state declared a pandemic after 1,497 people were infected in Mumbai, and 30 died.
“Pandemic is a term used when all the continents are affected. This year, the spurt is being seen only in India and no where else,” said the state’s epidemiologist Dr Pradeep Awate. The state government is treating it simply as an outbreak, he said.
As the disease spread this year, survivors quarantined themselves at home. February 25, this newspaper reported about a family where all seven members were sequestered in various corners of their expansive bungalow near Breach Candy because no city hospital – private or otherwise – had adequate isolation facilities.
A week later we visited another such family, in Thane. This household of four had passed on the virus to each other; they were quarantined in cramped quarters. They too were turned away by several hospitals. “My younger sister was the first one to test positive. We tried to admit her in Fortis, Hiranandani, and Jaslok but none of them had sufficient isolation beds,” said the family’s younger daughter. Her mother also contracted the disease, followed by her father and elder sister.
“We’re fortunate to have recovered, but what’s worrying is that three of us could have remained virus-free if only the hospitals had enough room.”
That is why Mumbai continues to reel from swine flu – its effects have greatly multiplied following a demand-supply mismatch: hastily assembled emergency measures, and lack of isolation wards.
Swine flu is an airborne respiratory disease transmitted by droplets released primarily by coughing or sneezing (and spitting). It sets in when the temperature begins to fall and eases as summer takes hold. The safest containment strategy is to isolate the patient in a special ward, with the following protocols in place:
» Restricted visitor access
» Restricted movement within the facility » Enforced respiratory hygiene » Use of personal protective equipment » Deployment of closed suctioning systems in isolation wards During visits to four city hospitals, Mirror found that most were illequipped to fight the virus.
PVT HOSPITALS LACK BEDS
Mulund’s Fortis Hospital offers a case in point. “We have three or four isolation beds, occupied by patients suffering from highly infectious diseases like tuberculosis and neutropenia [marked by a severe shortage of white blood cells],” said S Narayani, the hospital’s facility director. “We did admit a few swine flu patients this season and those whom we couldn’t accommodate, we directed to other facilities.”
South Mumbai’s Jaslok Hospital, a very near the Breach Candy family’s bungalow, has an isolation facility of just two beds, both occupied. This is one among two hospitals that adhere to prescribed quarantine norms. The other is Kokilaben Dhirubhai Ambani Hospital in Andheri, with its 17-bed isolation ward and five-bed isolation intensive care unit. “With the spurt in swine flu cases, we have dedicated the ward for the disease,” said Dr Ram Narain, the hospital’s chief operating officer. “As the incidence drops, we accommodate other patients.”
The influx of patients from outside Mumbai hasn’t helped. Over 148 non-Mumbaikars have been admitted to city hospitals this year for swine flu. The state has made a feeble, belated attempt at addressing the problem – this, well into swine flu season – by announcing that no new hospital plans will be sanctioned without budgeting for adequate isolation facilities.
State Health Minister Deepak Sawant said that he has now made it mandatory for all hospitals with more than 50 beds to set aside 2 to 5 per cent of the beds for isolation. “This will help us to deal with such outbreaks in a better way,” Sawant said.
CIVIC-RUN ISOLATION WARD OVERFLOWS
February 19, a 43-year-old man from Khopoli died of swine flu in Kasturba Hospital on Arthur Road. He occupied one of 40 beds available in the city’s only government-run segregation facility. At the hospital, we found that “isolation” is a joke. The ward has serried rows of beds along its walls, with nothing to separate one from the other. Patients use the same washroom. Relatives walk in and out with nothing more than a facemask on.
According to infectious disease specialist Dr Om Shrivastav, an isolation zone must have an airhandling system separate from the rest of the hospital’s ventilation. An isolation room must hold a single patient and should be maintained at negative pressure to prevent cross-contamination.
High Efficiency Particulate Air filters for air purification and ultraviolet radiation filters should be integrated into the ventilation system to kill bacteria and pathogens. The isolation ward’s airconditioning should function at a rate of 40 cycles per hour.
Kasturba’s facility does none of these. The BMC’s chief epidemiologist, Dr Mangala Gomara, admitted deviation from World Health Organisation (WHO) norms. “However, the H1N1 virus is now very much in the air and home quarantine is enough if the patient is under proper medication,” she said. “We are planning to make a proper isolation facility as per WHO norms and a proposal has been sent to the state government.”
LAST-MINUTE INTERVENTION
While vaccination remains the best defence, antiviral agents zanamivir (Relenza) and oseltamivir (Tamiflu) reduce swine flu's effects. As this year’s flu season set in, the government discovered that its oseltamivir stock had depleted “Many patients received delayed treatment as the swine flu drug went out of stock initially,” said a doctor at a Vile Parle nursing home. “The demand also went up as there is a protocol to put healthcare staff handling a swine flu patient on a 10-day-long prophylactic course. So, even if a hospital took in one swine flu patient, at least 3-4 healthcare staff had to be put on preventive dosage.”
Alarmingly, the BMC’s swine flu drug procurement policy was governed by precedent, not by a perceived outbreak. “We had Tamiflu stocks to last us till 2013. However due to lack of cases, a huge number of tablets had to be destroyed as they expired and there were no takers,” said Dr Gomare. “We had limited stocks when cases of swine flu began to be reported this season, due to which an initial shortage was felt. But now we have enough stocks.”
LACK OF PREVENTIVE CARE
Zanamivir and oseltamivir have limited efficacy in eliminating the virus in infected patients. According to the US Food and Drug Administration, Tamiflu, discovered and developed by Gilead Sciences in that country, “has been shown to lessen the amount of time people are sick with the flu”. The seasonal flu vaccine remains the most effective means to combat the virus – it protects against three strains of flu, including H1N1.
Infectious disease specialist Dr Vasant Nagvekar, who consults at Lilavati and Fortis hospitals, said that vaccination should be promoted especially for people with co-morbid conditions such as diabetes, hypertension, asthma and chronic obstructive pulmonary disease, whose immune system is already affected. “Annual vaccination will not only reduce the incidence of this flu but it will also reduce the load on hospitals during such seasons,” said Nagvekar.
Awate said that the government of India has not devised any mass flu vaccination strategy. “There are limited benefits of vaccination. Even after vaccination, a person develops only 80 per cent immunity,” Awate said, adding that the virus differs every season and it's hard to predict which strain will be dominant.
The state government is, however, discussing a vaccination programme. “We have now made vaccination mandatory for healthcare workers before the monsoon begins, and in October before winter starts,” said Sawant. Discussions are also on whether a fluvaccination programme should be started for everyone.
