The world is waiting in fear as the deadly Ebola outbreak marches on. Is the Indian healthcare system ready should it reach our shores?
The world is waiting in fear as the deadly Ebola outbreak marches on.
Let Ebola come to India. Why are you panicking before that?" Dr M.C. Misra, director, All India Institute of Medical Sciences, Delhi, rebukes. It's nine in the morning. The housekeeping staff is hard at work. Corridors smell of antiseptic. Doctors go about purposefully, white coats flying. Patients stream in. A man lies motionless on a gurney, staring at the ceiling. A little boy sits with a forlorn expression. His mother strokes his shaven head. Just a normal day in the life of a hospital.
But these are not normal times. The world is waiting in fear as the deadly Ebola outbreak marches on. No cure or vaccine exists. The virus that spreads through body fluids, even dead bodies, bleeds its victims to death. It has killed 4,500 people since February 2014, nearly 50 per cent of all infected. No country is safe from it, says the World Health Organization, predicting 10,000 new cases a week by early December. Ebola "is running faster than us and it is winning the race," the United Nations has sent out a warning to the world. If it is not contained within the next 60 days, "we face an entirely unprecedented situation for which we do not have a plan".
From Africa
The outbreak began in the village of Gueckedou in south-eastern Guinea, where a two-year-old boy, dubbed Child Zero, died in December 2013. Named after the Ebola river valley, where the first reported outbreak occurred, the virus has broken out at various times since 1976. The root of the disease lies in cultural practices of Africa: diet to death rites. Bushmeat or meat of wild animals-antelopes, chimpanzees, fruit bats, rats, porcupines or snakes-is a traditional delicacy. But these animals can carry the disease: Child Zero's family hunted fruit bats. Ebola also spread like wildfire with African death rituals of washing, touching and kissing dead bodies: the germ is most active right after death. With past outbreaks resulting in a maximum of a few hundred cases, international attention on the outbreak was cursory, until the WHO declared an international health emergency in August.
The threat
What if it hits India? Ebola patients need to be kept in isolation. With relatively few hospitals with such facilities, can India manage that? A big danger is that very sick patients bleed. Body fluids and blood are extremely contagious. Can a crowded country like India ensure segregation? Tests on fluid samples of suspected Ebola patients must be conducted in conditions of maximum security: can India ensure this? The highest incidence of infection, about 10 per cent, has been among healthcare workers, with doctors and nurses catching the virus despite advanced protective gear: disposable gowns, face masks and double latex gloves. Is India equipped to handle a situation like this?
Risk analysis
The risks seem to be changing every day as the epidemic continues. How worried should India be? First, the bad news: "If the infection rate in West Africa continues as is, there is a high likelihood that cases will begin to arrive in India," says Dr Ashish Jha, professor of International Health at Harvard's School of Public Health and director of Harvard Global Health Institute, in an email interview. In that case, the chances of it spreading, especially to healthcare workers, would be substantial. "Obviously, one would worry about the infection becoming widespread but it would take a while."
The good news is, India is not as yet on the list of 15 countries on the WHO's emergency radar. Going by air traffic numbers to and from the Ebola epicenter in Africa-Sierra Leone, Guinea and Liberia-along with disease transmission patterns, India is at low risk, 24th in a list of 30 nations most likely to see an Ebola case in the near future.
Scientists from Boston's Northeastern University have done the computer modelling based on the fact that India has fewer direct flights to and out of West Africa. But beware: India is just four places below Spain on the list. And Spain recorded the first case of Ebola virus disease (EVD) outside Africa.
Fear stalks
How ready are we should Ebola reach our shores? India's "underfinanced and overwhelmed" hospitals are suddenly under scrutiny by the international community. "India's most troubling threat is not abroad, but at home: the crippled public health system," warned an opinion piece in the New York Times on October 17. To professor Peter Piot, director of London School of Hygiene and Tropical Medicine, who discovered the Ebola virus back in 1976, even a single occurrence could spell trouble for a tropical, relatively poor and densely populated country like India. And the most likely source of an outbreak would be Indians working abroad.
As the new destination for trade and investment-it has about $55 billion worth of trade with India-Africa hosts over 200 Indian companies. Over 45,000 Indians work in West Africa alone. It's common for them to work seven days a week at a stretch and then come home for a few weeks. Anyone returning home during the virus' incubation period (up to 21 days) can set off a major episode. That's how the swine flu pandemic had started in India in 2009, with a 23-year-old travelling home to Hyderabad from the US. "Doctors and nurses in India often don't wear protective gloves. They would immediately become infected and spread the virus," Piot has pointed out. Dr Jha agrees: "I am very worried about whether the Indian healthcare system is ready and capable of identifying, treating and preventing the spread of this deadly infection.
I fear it is not ready to do that yet." 'Be very afraid, India'. That was the buzzword, too, when the deadly Severe Acute Respiratory Syndrome (SARS) started spreading across the world in 2003. Questions were raised on Indian healthcare's inadequacies: from lack of isolation rooms and ventilators in public hospitals, lack of trained doctors and paramedics to lack of mass awareness on infectious diseases. But the predicted SARS pandemic just did not happen in India. Even the 2009 swine flu was expected to spread like wild fire, resulting in an avalanche of positive cases. Nothing like that happened.
Different virus
"I don't understand why India should be at higher risk," says virologist Dr Lalit Dar, faculty at the department of microbiology, AIIMS. "Wherever it has spread, be it the US or Spain, it has been imported directly from Africa." If people coming to India from West Africa are responsible enough to report as soon as they see any signs, the virus can't get into the community, he explains. "There is no need to panic." Ebola is different in the way it spreads. Viral diseases can spread through contact, water, food or air.
Those that spread via the aerial route can have devastating consequences. But India did not see a single case of SARS, which was airborne and hence more contagious. Ebola does not even spread through air. In Ebola, an infected person can contaminate 1-2 others while in SARS 3-4 and in measles 15-18. "Had Ebola been that infectious, we would have seen 30,000-40,000 deaths by now," he says.
Ebola is a filovirus with a tiny string of proteins coating a single strand of genetic material. Particles of the virus live in an infected person's blood, saliva, mucous, sweat, semen and vomit, somewhat like HIV. But while an untreated HIV patient has just 50,000 to 100,000 viral particles in his body, a teaspoon of blood from an Ebola patient can carry 10 billion particles.
"Ebola cannot spread unless those particles find an entry point, say a cut or gash, or if someone touches one's nose, mouth, or eyes with fluids that contain them," says Dr Dar. Hence those living in the same household or tending to patients are typically at risk. "Only those who have gone to Africa and have had that type of contact, have visited a hospital or interacted directly with an infected person or gone for somebody's funeral rites, need to be monitored really closely," says Dr Dar.
Ebola also doesn't spread when an infected person is asymptomatic and in the incubation period. Unlike HIV, the disease will have to be manifested in Ebola for it to be contagious. There can be some clinical confusion with dengue, since both start with high fever, headaches and extreme fatigue. But what distinguishes Ebola are vomiting and diarrhoea. Viral haemorrhagic fevers are also associated with bleeding. "But the current strains of Ebola are not greatly haemorrhagic," he says. "Mortality rates are also lower this time, about 50 per cent."
Ebola drill
On August 26, when 112 Indians took off from Liberia, no one knew their fate. With Ebola raging in the country, the employees of Indian infrastructure company Afcons were desperate to return to India. As International SOS helped them out, they came back home: 71 passengers landing in Mumbai and 17 in Delhi. What they faced was India's 'Ebola drill', in place at 19 airports since early August. They were made to fill up forms on possible symptoms and pass through thermal scanners for body temperature and fever.
All were declared Ebola-free, except one Delhi man who had fever and a sore throat, although he had shown no symptoms earlier. Doctors instantly whisked him away to an isolation ward at the airport. He was released a few days later after testing negative.
India has screened over 22,000 passengers in the last few months, quarantined over 450 for suspected symptoms. As per health ministry guidelines, those with symptoms are isolated at the airport, those with history of contact with an Ebola case are prioritised for active surveillance, and those without symptoms or contact history are informed about helpline numbers, to be contacted in case they develop any symptoms later.
Meantime, contact tracers, or public health professionals who track down those who came in contact with an Ebola patient, are hard at work- to contain the virus before it spreads. Personnel protection equipment for healthcare providers are being sent to states. The ministry has started Ebola 'master classes' to train physicians and nurses of district hospitals.
Lessons learnt
That confidence, ironically, has been provided by Ebola's predecessor: the swine flu outbreak of 2009. "We have learnt from it," says Dr Misra. "We have the infrastructure to provide isolation, we can handle supportive treatment, we have the necessary personnel protective gear." Touch is integral to patient care. For Ebola, chances of transmission are reduced if care-givers know how to take care of themselves. "Our doctors routinely carry out dangerous surgeries on proven HIV or Hepatitis-C patients."
In case Ebola turns into an epidemic in India, Dr Misra, an expert in emergency medicine, recommends portable 'container hospitals'. In international emergency medicine, mobile operation theatres in prefabricated huts, away from the community, are emerging as the technology of the future, with Norway, the US and Israel taking the lead. "India can easily set these up with the help of the army."
POLITICALPANIC Ebola is evoking unwarranted overreaction everywhere. "Take the US. One person dies, two nurses are infected, and the country gets hysterical," says Ramanan Laxminarayan, director of Center For Disease Dynamics, Economics and Policy in Washington, who is also a top functionary of Public Health Foundation of India. But no one is talking about the five people who had gone to the US for treatment, did not die and did not infect anybody.
"With the mid-term elections looming, American politics is coming into play over Ebola, in campaigns or debates." India's problem, he feels, is that we echo a lot of what the US says. "If there is finger-pointing at India's public health, we also do the same. Truth is, despite variability, India is not a weak health system: The country has successfully coped with the highly contagious avian and swine flu outbreaks."
Ebola is not a very transmissible disease in comparison: "In a weak health system, one person will infect two people. In a strong system, it's even less." Whatever be the progression of the disease, infection control is likely to succeed in India. "Political awareness is very high here. The health minister is personally taking interest in it."
Take care
Ebola is dangerous and expensive. It needs more state surveillance, more beds for the sick, more staff to treat them, more treatment facilities, more efforts to monitor patient contacts. That doesn't come cheap: the bill for an Ebola patient in the US is about $1,000 per hour. The World Bank has warned that the economic costs of an Ebola epidemic will reach $32.6 billion by the end of 2015. "Preparing for Ebola will be expensive but India has no choice," says Dr Jha. "The cost of not doing so, if India is unlucky enough to get Ebola, will be far greater than any cost of preparation."
In a country where that sort of money isn't available for everyone, doctors recommend citizens should boost their immunity: the virus kills by tripping up the immune system. Get enough rest, eat healthy food, exercise regularly, consume immune strengthening foods, herbs and nutrients, fresh fruits, vitamins C, D and zinc, cut down on sugar, alcohol, highly processed foods, excess animal protein and flour, include garlic, onion, turmeric, ginger, lemons and cloves in your diet.
Remember, lakhs of people die of malaria, HIV, diarrhoea and tuberculosis in India every year. Ebola is novel and unusual but it's a very small threat compared to these killers.