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Is India ready for outbreaks like coronavirus ?

India needs a central research institute like Centre for Disease Control and Prevention (CDC), Atlanta, USA, to monitor and control newly emerging infectious diseases in a well-coordinated way with number of small research station.

By Abhinay Sharma, Ph.D.

The latest outbreak of coronavirus killing around 560 and infecting 28,000 people in China till 6 February (latest figures), is the example of global spread of pathogens especially viruses. Frequent outbreaks of Ebola, Bird flu, SARS and MERS in last decade killing thousands and affected millions of people worldwide shows the consequences of climate change, increasing urban population density, international travelling and social gatherings. Impossibility of controlling the fast globalization imposes threats of such recurrent outbreaks on human race. Medical and scientific world needs to be much more prepared than ever in history to cope up these threats. The ongoing outbreak of coronavirus needs to be understood in bits and pieces.

Coronaviruses are single stranded RNA viruses with 120-160 nm in size. They are spherical enveloped particles with spikes like structures (like crown) on its surface. Being zoonotic in nature, they are transmitted between animals and people causing almost 30% of cold infections in humans with 10% fatality. Their infections might be more severe such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). Detailed investigations found that SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several known coronaviruses are circulating in animals that have not yet infected humans.

The latest coronavirus, a novel strain (nCoV), was first time reported in December, 2019 in Wuhan metropolitan city of China with population of 11 million. This virus has not been previously identified in humans.

Identification of probable animal source is still a matter of detailed research. The common symptoms after its infection can look like a common cold including cough, fever, and troubled breathing. Severe cases can lead to pneumonia, kidney failure and even death. Its incubation period is one week after getting infected before showing any symptoms. It can be transmitted through contact as well as water droplets, through your hands to your eyes or nose. Due to lack of vaccine against the virus, the protection measures should be considered which include (1) avoidance of close contact with anyone showing symptoms like coughing and sneezing; (2) frequent hand washing with soap and water; (3) covering mouth and nose when you cough or sneeze; (4) wearing a surgical mask; (5) disinfect surfaces you touch; (6) consumption of well cooked food and (7) avoidance of visiting live animal markets. The public should be cautious but need not to be panicked. Till so far, the mortality rate has been observed to be about 2-3% which is lower than SARS at 10%, or Middle East Respiratory Syndrome at 34%.

The global response towards the outbreak looks prompt and satisfactory till now that can be exemplified by recent measures taken by Global health agencies like WHO. It has been already declared global health emergency by WHO, which should be tackled at war footing. Once China understood the gravity of outbreak, quick multiple actions were taken like imposing intercity and intra-city movement restrictions, even complete lockdown of their big cities. Furthermore, they built new hospitals at record speed and deployed large number of medical staff at different sensitive locations to diagnose new cases and giving possible treatment. Overall the efforts are being implemented in well-coordinated manner; still the outbreak is not getting controlled. Neighboring countries of China are stopping movements across borders. Different countries are taking preventive measures by monitoring of foreign travelers on airports for possible infection. Evacuation process of foreign citizens in China has already been started. This quick response is the outcome of experience earned through previous global outbreaks.

Researchers worldwide are waiting to work on samples of the coronavirus, to understand the pathogen’s pathobiology and to test drugs and develop vaccines. Virologists in China isolated the virus but did not share the virus with international researchers.

They shared only the virus’s genome sequence which shows 80% similarity with the coronavirus responsible for the SARS outbreak. It indicates that pre-trial vaccines aimed at treating SARS could be effective against the new coronavirus. Furthermore, they found that it can kill cultured human cells and it enters cells through the same molecular receptor on host cells as the SARS coronavirus. Researchers in Melbourne, Australia, were the first outside China to grow the new coronavirus in cell culture. The group at the Peter Doherty Institute for Infection and Immunity says it isolated the virus from the first person diagnosed with the infection in Australia, on 25 January. The team will now share the virus with research labs around the world recommended by the WHO to help the development of more accurate diagnostic tests and vaccines. Labs in the United States, France, Germany and Hong Kong are also isolating and preparing to share virus samples taken from local patients. Scientists argue that virus culture is advantageous to be used in comparison to genome sequences. It can help to engineer animal models of the infection and to understand its pathophysiology and how the pathogen spreads in details.

Chinese administration showed their preparedness and capabilities of already developed good health infrastructure to tackle this kind of threat at big scale. Unfortunately, most countries, including India, are under prepared for outbreaks of major infectious diseases, with Asian countries facing significant risks, according to the Global Health Security Index 2019. Thailand and South Korea were among the best-performing Asian countries, while India was at 57th rank out of 195 countries with a composite score of 46.5 out of 100 and categorized under more prepared countries (other categories were either most and or least prepared), the report said. If we look at scores in different categories separately, India ranks 87 in prevention, 67 in detection, 32 in response, 36 in health, 100 in norms and 103 in risks showing the poor performance. In comparison to many countries, India is not doing well in the area of antimicrobial resistance, zoonotic diseases, biosafety, immunization, access to communication infrastructure, medical countermeasures and personnel deployment, healthcare access, cross-border agreements on public health emergency response, infrastructure adequacy and public health vulnerabilities.

It has been observed that the non-communicable diseases dominate over communicable in the total disease burden of the country.

In a recent report of India Council of Medical Research (ICMR), titled India: Health of the Nation’s States: The India State-Level Disease Burden Initiative (2017), it is observed that the burden due to communicable, maternal, neonatal, and nutritional diseases, as measured using Disability-adjusted life years (DALYs), dropped from 61 per cent to 33 percent between 1990 and 2016. In the same period, burden from non-communicable diseases increased from 30 percent to 55 percent. Government opted to incline towards allocating more budgetary fund for non-communicable diseases, which is truly justified data driven health care policy. The focus is already existing communicable diseases like malaria, TB, Dengue, Kala azar, AIDS and other infections. When unpredictable and unknown pathogenic outbreaks come into scenario, it is imperative to assess the current situation of health infrastructure and research support in our country to contain any such outbreaks as soon as possible.

Health infrastructure and human resources are the main components for the delivery of public health activities. According to the National Health Profile 2018, with 23,582 government hospitals (710,761 beds) in the country, total of 19,810 hospitals (with 279,588 beds) in rural areas and 3,772 hospitals (with 431,173 beds) in urban areas are functional. More than 70% of India’s population lives in rural areas and there are 156,231 sub centers, 25,650 primary health centers and 5,624 community health centers to cater to their needs, according to figures from 31 March 2017. There are a total of 2,903 blood banks, which means less than three blood banks for every 1 million population, as of March 2018, according to the latest government data.

There is one doctor for every 1,457 people as per the country's current population estimate of 1.35 billion, which is lower than the World Health Organization (WHO) norm of 1:1000.

There are more than one million doctors in India. Rural areas have a shortage of medical professionals. More than 70% of doctors are in urban areas that serve the other 30% of the population. As per Indian Nursing Council (INC) records, there are around 30.4 lakh nursing personnel registered in the country as on December 31, 2018.

Although there is grim picture of healthcare infrastructure access and facilities in India, but if we look at the response of present political regime and administration towards the current outbreak, it gives positive hopes for better preparedness to handle this kind of threat. Air India already evacuated 324 and 330 of its citizens from China in its two flights. They have been housed at quarantine facilities set up by ITBP camp and the army’s Manesar facility. Not a single person found to be positive among all evacuated Indian citizens. Till 3rd February, there are three positive cases of the outbreak in India, all from the state of Kerala. They have been kept in isolation in government hospital.

The present government of India (GOI) is taking initiatives to fill the gap of access to healthcare facilities by reducing social and regional inequality.

Till the year 2017-18, around 4800 million individuals were covered under any health insurance in India. This amounts to 37.2% of the total population of the country. Government is planning to provide health insurance to poor people covering around 50% of total population under the new scheme "Aayushman Bharat" which will financially empower poor citizens to access better health care.

On the other hand, GOI is also working on filling up the gap of regional inequality. In the current financial budget, GOI has planned to expand the reach of Prime Minister Jan Arogya Yojana (PMJAY) in Tier 2 and Tier 3 cities, FM Sitharaman said PMJAY currently has more than 20K empanelled hospitals. The minister also proposed to expand Jan Aushadhi Kendra Scheme to all districts offering 2000 medicines and 300 surgical instruments by 2024.

eHealth is another initiative of GOI that uses the information and communication technology (ICT) in health. As India has a strong presence in IT, the eHealth system serves the needs of all stake-holders with a vision to deliver better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens. Broadly the intent is to cover online medical consultation, online medical records, online medicine supply management and pan-India exchange for patient information but not limited to the said services.

On one hand, many countries already have started research work to explore and understand coronavirus, unfortunately there is no report of any such initiative in India. If India aspires to lead in healthcare and research, it should come up with much improved and coordinated research infrastructure. ICMR and its different research institutes are constantly busy in research work on different aspects of local communicable diseases in India. Considering the population size, geographical and climatic diversity and aspiration to be included in world leader countries in medical research, India needs stronger and integrated research infrastructure to support it’s healthcare infrastructure. It requires a central research institute like Centre for Disease Control and Prevention (CDC), Atlanta, USA, to monitor and control newly emerging infectious diseases in a well-coordinated way with number of small research stations which should be established in all parts of India. These research stations should work on different aspects of pathogens like their epidemiology, pathogenesis, cure and vaccine development. All the research facts should be passed on to central research institute which can be used to device strategies to cope up any future possible outbreaks like coronavirus.

(PBC fellow (Current), Alexander Von Humboldt Fellow (Past), Department of Microbiology and Molecular Genetics, The Institute for Medical Research – Israel-Canada (IMRIC) The Hebrew University, Faculty of Medicine, Jerusalem, Israel)



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