Suspected plague cases come for tests to an infectious diseases hospital in Delhi (Express Photo: Ravi Batra)
As COVID-19 spreads across the globe, infecting over 6.07 lakh people and killing more than 28,000, India appears to have fared better with 873 coronavirus positive cases and 19 deaths recorded so far.
While the current pandemic is unprecedented, considering the scale of the ensuing countrywide lockdown, India has battled several epidemic situations, with each testing the country’s health systems — from the suspected pneumonic plague of September 1994 to the Nipah outbreaks of 2018 and 2019, besides the pandemic influenza H1N1, bird flu or A(H5N1), the Zika virus outbreak, as well as Middle East Respiratory Syndrome Coronavirus or MERS, Congo fever and a few others.
A look at some of these epidemics and the lessons that were drawn:
Pneumonic plague, 1994
On September 16, Surat woke up to heavy rainfall, with its low-lying areas getting flooded within hours. By the time the waters receded, carcasses of cattle and rats lay across Surat, particularly the Ved Road area, inhabited mostly by cattle-herders.
Five days later, a patient who reported at a hospital near Ved Road with fever and pneumonia died, followed by eight other deaths with similar symptoms there. Soon, news of more deaths came in from other hospitals.
Professors of medicine at the Government Medical College in Surat, approached with the consent of the government, concluded that the victims had pneumonic plague. The news left the country stunned. The last India had heard of the disease was between 1896 and 1930, when 12 million were reported to have died of bubonic plague.
By the time the waters receded, carcasses of cattle and rats lay across Surat, particularly the Ved Road area, inhabited mostly by cattle-herders. Express archive photo
By September 26, 1994, 49 were dead in Surat, a city with a population of 25 lakh then, with 1,391 suspected cases. By then, the Central government had alerted the World Health Organization (WHO). By October-November, cases were being reported from Delhi, Mumbai and Kolkata, with numbers climbing to 5,150 suspected cases and four deaths. The WHO sent an investigative team.
Then Deputy Municipal Commissioner (Health) S K Mohanty, among the officials who led the fightback, recalls that he first deployed epidemiological surveillance teams to check on around 500 families living in the Ved Road area, roping in primary schoolteachers, cancelling leave of municipal staff, and recruiting help from Rajkot, Vadodara and Ahmedabad. One of the first tasks was clearing animal carcasses, and spraying germicide in the flood-affected areas.
Time to invest in public health
While every outbreak in the last couple of decades has forced a significant upgrade in India’s capacity to respond to a public health emergency, the health infrastructure in the smaller towns and villages continues to remain abysmally inadequate. In that context, the current coronavirus pandemic could be the best opportunity for India to transform its health infrastructure and invest in public health.
Mohanty, now 73, says officials moved into a municipal school and ate from a centralised kitchen as hotels had shut down. They also battled public wrath, as rumours spread that rats had caused the plague. “People accused the Surat Municipal Corporation of not keeping the city clean,” says Mohanty.
To create awareness in the times before Internet, officials moved around the city in vehicles, making announcements to the public to keep their areas clean, and to avoid coming out of their houses. As textile and diamond units shut down and migrant labourers left Surat in droves, with around 3.5 lakh crowding the highways at one point, the government used the paramilitary to stop the exodus.
A drug used for the plague was bought in bulk by people. While there was no lockdown, essential items like vegetables, farm produce and milk ran out.
Talking about the measures they took, then Police Commissioner P C Pande says, “People were asked to refrain from discarding leftovers in the open. Police were deployed at hospitals to ensure patients stayed, did not leave midway through treatment, and their relatives did not visit them.”
In just over a fortnight, Surat was back on its feet, with the water and dead animals cleared, and Ved Road area disinfected.
In March 1995, S R Rao, who took over as Municipal Commissioner, started a fresh cleanliness drive, including awareness against throwing garbage on the street. Private contractors were hired to sweep roads during night-time. Rao also demolished encroachments to widen Surat’s narrow lanes, earning him the moniker of ‘Surat’s demolition man’ and the city the tag of ‘India’s cleanest’.
However, what remains most remarkable about the 1994 outbreak was the confusion that followed later over what exactly had hit Surat. The Gujarat Plague Committee Report eventually ruled, “Not plague at all but lower respiratory tract infection or possibly, meliodosis — due to squalor, industrialization and a recent dam break & floods. No bubonic plague definitively proved at Surat and no infectious secondary cases either.”
Despite the confusion, the outbreak was to be a turning point for India’s public health system.
“It was then that we started thinking in terms of better preparedness to deal with such outbreaks. Surveillance systems were established but needed a greater push,” recalls Dr A C Mishra, who headed the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV) from 2002-2013 and is now Director, Interactive Research School of Health Affairs, Bharati Vidyapeeth, in Pune.
A(H5N1) or Avian flu, 2005-06
Maharashtra, Madhya Pradesh
That “push” to the surveillance system, which Dr Mishra speaks about, came when bird flu outbreaks were reported in 2005-06.
WHO data shows that from January 2003 till March 2020, there were 861 cases of human infection by H5N1 across 17 countries. Though India hasn’t seen a single case, panic buttons were pressed early on.
In India, the first outbreak of the highly pathogenic avian influenza occurred in Maharashtra in 2005, followed by an outbreak in 2006 in Madhya Pradesh. Smaller outbreaks were later registered at poultry farms in Manipur, West Bengal and Assam.
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At an isolation ward in Government Medical College in Ernakulam, where Nipah virus patients were admitted;
Over a million birds were culled at the time and, according to reports, 25 episodes of bird flu followed in 15 states and Union Territories till January 2015. A total of 7.2 million birds were culled and over Rs 24 crore paid as compensation to farmers.
Vijay Singhal who, as municipal commissioner, is leading the battle against COVID-19 in Thane now, was in March 2006 the district collector of Jalgaon and led its fight against avian influenza in four affected zones (blocks). Under him, the administration quarantined a 3-km area around each of the zones.
“The effort was to restrict transit of infected material,” Singhal says. “As a result, around 21 bus stands were shifted outside the 3-km radius, weekly markets were shut down temporarily in 19 villages, and health workers were deployed to track symptoms of bird flu.”
Besides, farmers were told to hand over their birds to the Animal Husbandry Department for culling, and disinfectants sprayed in homes where poultry had been kept. Special observation wards were opened in hospitals across the five affected tehsils and police sealed the borders of all the infected villages and those under surveillance.
The modus operandi for COVID-19 may not be the same, but Singhal says he has learnt some useful lessons: “We should be ready with a contingency plan, track, test and treat people, stay focused, not panic and know exactly what to do.”
Away from Jalgaon, such was the scare that larger wheels of the government machinery came into operation, with the ICMR, which is leading the pushback against coronavirus now, and the Council of Scientific and Industrial Research laying emphasis on building capacities and strengthening laboratories.
In 2012, two labs — BSL-3 and BSL 4 — were set up at the National Institute of Virology’s microbial containment complex. (BSL-3 and BSL-4 indicate biosafety levels that measure the level of containment precautions required to isolate dangerous biological agents, ranging from the lowest
BSL-1 to the highest BSL-4). In heavily guarded vaults, these labs store highly infectious pathogenic agents of diseases such as Ebola, anthrax, Lassa, haemorrhagic fever and smallpox to enable research and testing.
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Students wear masks during an HINI virus scare in Mumbai. (Express Photo: A Srinivas)
Pandemic influenza A(H1N1) or swine flu, 2009
The first case of this virus was detected in Mexico in April 2009 and spread to 74 other countries. In India, the first case was reported on May 16, 2009, from Hyderabad, and the virus went on to kill 981 people the same year.
The 2009 influenza A(H1N1) was a game changer for India’s public health response and ensured that surveillance systems adhered to the three Rs — real-time reporting, recognition of the pathogen and response to the outbreak — that involved diagnosing and managing each case, and developing a network of isolation wards, says Dr Pradeep Awate, Maharashtra’s surveillance officer.
“To deal with any kind of outbreak, there should be robust surveillance systems to understand the magnitude of the problem and strategically position the resources. While the plague outbreak was among the major reasons for setting up the country’s Integrated Disease Surveillance Programme in 2004-05, it was only after H1N1 that influenza cases were reported in the health system,” he adds.
The surveillance system ensured that the samples sent from a particular hospital or civic-run facility were tested for H1N1, and the reports emailed to the hospital — a practice that is being stuck to while reporting COVID-19 cases.
People wearing masks as precautionary measure of Swine Flu near Swine Flu ward in RML Hospital in New Delhi (Express photo/File)
This data collection and analysis helped identify the high-risk groups who succumbed to H1N1. An analysis between 2009 and 2015 showed that pregnant women accounted for 9.84 per cent (214 out of 2,175) of all influenza-related deaths in Maharashtra, with 97 per cent of the deaths during the second and third trimesters of their pregnancies.
It was to reduce mortality among such high-risk groups, also including diabetics, that Maharashtra introduced vaccination for them. Dr Awate says Maharashtra offered free voluntary vaccinations for women in their second and third trimesters.
Dr V M Katoch, who was Director General of the ICMR during the H1N1 pandemic,
says the good news for those tackling the disease was the presence of a very effective drug — Oseltamivir.
A decision was also taken at the time to expand the network of laboratories to check for H1N1 from the two nodal laboratories at the helm of the affairs — the ICMR-NIV in Pune and the National Centre for Disease Control (NCDC) in New Delhi.
Nipah, 2001, 2018-19
West Bengal, Kerala
Much before the Nipah virus spread panic in Kerala, killing 17 people in 2018 and causing another 16 deaths in 2019, a team of scientists led by Dr Mandeep Chadha, then deputy director of the NIV, had visited Siliguri in 2001 to identify a mysterious infection that had caused 45 deaths.
“We went to North Bengal Medical College Hospital. I clearly remember it was a ghost town due to the deaths. We took medical records and visited the houses of the patients who had died. We struggled for clues to understand what was causing the symptoms. We were also literally praying that we do not get the infection ourselves,” recalls Dr Chadha, adding that two doctors, several nurses and paramedics succumbed to the disease.
“At that time, the only way to contain this was by washing hands and wearing double masks. We had disposable gowns. The epidemic was battled eventually due to barrier nursing and distancing and it was much later that we were able to identify that the infection was due to Nipah virus.”
Years later, when the virus struck again, this time in faraway Kerala, a state with one of the best healthcare systems in the country, the response was much swifter.
Health officials remove waste from an isolation ward of Ernakulam Medical College in Kochi. (PTI)
The strategies the state Health Department put in place for COVID-19 — mainly contact tracing and management of persons under home quarantine — are derived from the days of its management of the Nipah outbreak.
The first cases of Nipah were reported from a village under Changaroth panchayat in Kozhikode district, when a youth with symptoms similar to that of encephalitis was admitted to Baby Memorial Hospital in Kozhikode on May 17. When Dr Anoop Kumar, head of the Critical Medicine Department at the hospital, learned that the patient’s brother had died of a ‘mysterious’ disease and that two others in the family had similar symptoms, he rushed their samples to the Manipal Centre for Virus Research, which confirmed the presence of Nipah virus.
The Health Department acted swiftly — a control room was opened in Kozhikode, where Health Minister K K Shailaja camped for days to coordinate the activities.
Talking of the state government’s outbreak containment plan for Nipah, an official in the Health Department says, “We simply followed the protocol established by the WHO for Ebola. All those who had come in contact with every positive case were traced and put under surveillance for 21 days.’’
In Kozhikode alone, where the first case was detected, around 2,400 people were put under observation and in neighbouring Malappuram, around 300 remained under home quarantine. Still, by the end of a month, by which time the outbreak was contained, the virus had claimed 17 lives in Kerala out of 18 confirmed cases.
The 2018 outbreak, followed by one in 2019, helped the government learn invaluable lessons. “Now our health staff, right down to the village level, are very aware about infection-control measures. The message is clear: all fever cases with unusual symptoms are to be sent for investigation,’’ said the official.
Another significant fallout of the Nipah fight was that Kerala decided to focus on improving lab facilities. Besides strengthening facilities at the NIV’s Alappuzha centre, a new Institute of Advanced Virology has been set up in Thiruvananthapuram with ICMR support.
Between September and December 2018, Jaipur saw a major outbreak of the Zika virus, concentrated in three areas — Shastri Nagar, Vidhyadhar Nagar and Sindhi Camp, dense localities with poor sanitation facilities.
The disease, whose symptoms include fever, rashes, joint pain, muscle pain and headache, poses the highest risk to pregnant women. The country’s first case of Zika virus was reported in Jaipur on September 23, 2018, following which, on September 26, tests established traces of the virus in Aedes aegypti mosquitoes.
By December, the disease was finally controlled, but by then, Rajasthan had become the state with the highest number of Zika-positive cases in India.
By December, the disease was finally controlled, but by then, Rajasthan had become the state with the highest number of Zika-positive cases in India. The Union Ministry of Health and Family Welfare, in an answer to a question in the Rajya Sabha in July last year, said that of the 294 Zika cases which India saw between 2016 and 2018, Rajasthan had the highest number — 159 cases, all in 2018. Madhya Pradesh stood next, with 130 cases of Zika.
After the first positive case of Zika was reported, an expert team from the NCDC rushed to the city and found that the second Zika-positive case lived a mere four houses from the first case, that is, within the flying range of the mosquito that had possibly spread the virus to the first patient.
Following the outbreak, the Rajasthan Health Department, under the leadership of then additional chief secretary, health, Veenu Gupta, went on a massive drive to destroy mosquito larvae and identified pregnant women who could be at risk.
Though several pregnant women tested positive for the virus, no cases of microcephaly and Guillain-Barre syndrome — diseases Zika is known to cause — were detected.
By mid-October 2018, the department completed a door-to-door survey of more than 1 lakh homes and nearly 2.5 lakh containers were tested for mosquito larvae.
Health Department officials say that following the Zika outbreak, in March 2019, a detailed action plan was created, keeping in mind future contingencies.
“The major lessons learned from Zika include understanding the importance of training of health staff, significance of house-to-house surveys, ensuring coordination between departments. We are now employing the same method to deal with the coronavirus outbreak,” says Dr Ravi Prakash Sharma, Additional Director, Rural Health, Rajasthan.
It was in 2013 that the government expanded the network of public health laboratories to enhance capacity for diagnosis and detection of viruses. Over the years, more than a hundred Virus Research and Diagnostic Laboratories (VRDLs) have been established throughout the country.
It’s a measure of the technological progress India has made, with lessons learnt from every major outbreak, that it now takes less than three hours to identify the virus in case of COVID-19.
Yet, says Dr Mishra, there are unanswered epidemiological questions and challenges that India will have to be prepared for. “One is forced to wonder what will happen if a virus like H1N1, which has high transmissibility, and another like H5N1, with high fatality, combine. How will humanity face such a situation?” wonders Dr Mishra. “We are still gasping,” he says, adding that India needs more investment in biological sciences, better health infrastructure, ventilators and isolation beds.
Pneumonic Plague, 1994: south-central, western India; 693 suspected cases, 50-plus deaths
Nipah: first outbreak among pig farmers in Malaysia. Since then, at least 12 outbreaks, all in South Asia; Siliguri (West Bengal, 2001, 62 affected, 45 deaths); Nadia (West Bengal, 2007, 5 deaths); Kozhikode, Malappuram (Kerala, 2018, 21 deaths)
Crimean Congo Haemorrhagic Fever (CCHF), 2011-2015: 39 people affected in Gujarat, Rajasthan, Uttar Pradesh; 19 deaths
Avian influenza A (H5N1), 1997: first reported in Hong Kong. Cases of bird flu reported in Nandurbar district in Maharashtra. No humans infected in India.
A(H1N1, Swine Flu), 2009: first reported in Mexico. All states of India affected; from 2010 to Feb 2020, approximately 1,60,826 affected and 11,048 deaths
Zika Virus, 2018: 4 cases reported in India in 2016–17; in late 2018, 159 cases of virus infection reported in Rajasthan, 127 in Madhya Pradesh
(With Kamaal Saiyed in Surat, Deep Mukherjee in Jaipur & Shaju Philip in Thiruvananthapuram)