India is at high risk of Ebola. How prepared are we?



On 4 October, in an interview with The Guardian newspaper, Belgian virologist Peter Piot expressed his concerns over the possibility of an Ebola pandemic. “An outbreak in Europe or North America would quickly be brought under control. I am more worried about the many people in India who work in trade or industry in West Africa,” he said. “It would only take one of them to get infected, travel to India to visit relatives during the virus’ incubation period, and then once he becomes sick, go to a public hospital there,” added the man who helped discover the virus in 1976 as a 27-year-old scientist in Antwerp. That year, Piot and his team had received a blue thermos with the blood sample of a Belgian nun who had mysteriously fallen ill in a nondescript town called Yambuku in Zaire. They identified the pathogen involved and named it after Ebola, a river in Congo. Back then, there had been simultaneous outbreaks in Sudan and Congo.

The 2014 outbreak of this disease, reported in Africa since March and marked by a high fatality rate, could be the worst ever on record—with the World Health Organisation (WHO) noting 9,000 cases and about 4,500 deaths, almost all of them in Guinea, Sierra Leone and Liberia, which are believed to be the epicentre of its outward spread this time. The outbreak was officially declared in Guinea on 22 March; and, as feared, there are signs of its having reached other continents. The WHO recently announced that no country is safe from the virus and predicted that as many as 10,000 new cases could be identified around the globe every week by December this year.

According to an academic team from the US-based Northeastern University and University of Florida that is studying Ebola, international air travel is one of the main causes of its spread. Based on flight data analysis, India is 21st on a list of 30 countries likely to witness an Ebola case. High-risk countries across the world include the UK, France and Belgium, which see the most flights coming in from West Africa.

While India is classified as a low-risk country, it cannot afford to take Piot’s warning lightly. The country’s poor healthcare system, hygiene practices and dense population together make it vulnerable to its rapid spread if it happens to reach Indian shores. By figures provided by the Indian Government, 4,700 Indians live in Guinea, Liberia and Sierra Leone, and about 40,000 people live in Nigeria alone, where eight of its 20 reported cases so far have died.

So, how prepared is India?

Alarmed by the WHO wake-up call earlier this month, Union Cabinet Secretary Ajit Seth met health secretaries of 19 states to assess India’s preparedness to deal with the spread of the virus. Each state has been asked to identify one state hospital with an isolation ward and other requirements like isolated lifts and trained and dedicated staff. While the Government is seeking the participation of airlines in screening passengers, it has identified nine international airports that will be equipped with thermo scanners and thermo guns. Currently, the travel records of inbound passengers are being examined and they are also being screened for symptoms, on the basis of which they may be quarantined if need be.

In the words of Health Minister Harsh Vardhan, who is monitoring the country’s preparation measures, “We have a thorough screening mechanism in place at all airports and are carefully monitoring all possibilities. We hope to detect cases before [patients] enter the country.” At Delhi’s Indira Gandhi International Airport, for example, passengers are being asked to declare if they have any flu-like symptoms. If they do, they are put to the test of a thermo screen that records body temperature. The airport has an Ebola cell that serves as a special quarantine. All passengers arriving from West African countries are compulsorily screened.

According to the Government, about 22,150 passengers have been screened since August across India, of which about 1,000 were categorised as suspect cases and 63 were placed in the high- or medium-risk category. While low-risk passengers are given general advice on the disease and allowed to leave, mid- and high-risk passengers are observed for 30 days and lab tested for the Ebola virus. So far, no case has tested positive in India. Still, even the suspect passengers who have been allowed to go are being tracked—mostly in Delhi, Maharashtra, Tamil Nadu, Gujarat and West Bengal— by special personnel who keep calling them for health updates.

If the numbers rise, screening efficiency will need to reach US levels. The five American airports that have been marked out as high-risk entry points are equipped with handheld thermo guns that can detect body temperature swiftly without any physical contact. According to Indian government officials, India is in the process of procuring these handy devices at a cost of about Rs 10 lakh apiece.

The Ebola virus disease, formerly known as Ebola haemorrhagic fever, is highly infectious. The initial symptoms are like any other flu—namely, nausea, vomiting and a headache. Once the virus takes hold of the infected person, it raises the body temperature and often results in multiple organ failure with internal and external bleeding. A zoonotic virus, Ebola is believed to be carried by fruit bats in Africa. Though it is not an airborne disease, the virus is easily contracted through an infected person’s bodily fluids such as blood, saliva, sweat, urine and faeces.

While this reduces the risk of contracting the virus without contact—unlike the airborne SARS or H1N1—what worries experts is the country’s poor healthcare system. “The key in controlling the disease is early screening, detection and prevention,” says Professor K Sreenath Reddy, president of Delhi-based think- tank Public Health Foundation of India (PHFI). “For this, we need our primary healthcare system in order. With just one nurse available for every 1,000 patients in India, compared to 10 nurses for every 1,000 in the US, we are in trouble,” he says. “There are some states like say Tamil Nadu that have a very sound system of healthcare, but what would happen, say, in the case of Bihar or Uttar Pradesh?”

Adding to Dr Reddy’s point, says Dr Manish Kakkar, head of infectious and zoonoses diseases at PHFI: “If the disease could spread in the US, which undoubtedly has a better healthcare system in place, you can well imagine what could happen in India.” Healthcare workers in the US who handled its first Ebola case were reported to have contracted the virus themselves, and this is a serious problem. Healthcare workers in India need to be trained to handle such cases with care, says Kakkar. “We are short on the number of healthcare personnel and you don’t want a situation like in Africa, where healthcare workers have refused to attend to patients for fear of contracting the disease,” he adds. Citing the example of a Nipah outbreak in West Bengal in the early 2000s, he says that delays in detection resulted in healthcare workers falling prey to it in large numbers. “The training and protection of primary healthcare workers like nurses is imperative,” he adds.

Agrees Narendra Saini, general secretary of the Indian Medical Association. “We have poor personal and public hygiene systems in India,” he says, “Practices as basic as washing one’s hands and not defecating in the open are not practised in India. We need to spread information and keep a tight vigil on any case reported.”

Experts say that this may be how Nigeria has managed to contain the epidemic; no new case has been reported there since 8 September. Nigerian authorities are believed to have urged people not to urinate or defecate in drains, dump sites and open spaces in Lagos, the city that had most of its cases.

According to Dr Ashish Jha, director of Harvard Global Health Institute, even one infection in India may lead to a ‘cascade’ of infections, with the numbers multiplying by ‘dozens’ in no time. “I would be surprised if there is not one confirmed case in India by the end of the year.”

Apart from screening passengers and trying to maintain a vigil at airports, the Government has also begun distributing protective gear that includes masks and gloves to doctors and healthcare workers. Mock drills and workshops conducted by the WHO and other NGOs are being planned in order to train health personnel adequately. Medecins Sans Frontieres (MSF), which has been at the forefront in tackling the disease in Sierra Leone, has been sharing information on Ebola with the National Institute of Virology in Pune and Municipal Corporation of Greater Mumbai in Mumbai.

Global organisations like Save The Children and MSF have played a vital role in setting up institutional care posts in West Africa to tackle the outbreak. “We are looking at getting health experts together and training our health personnel. It will be done soon,” says a senior official in the Health Ministry, “It is very important to train health workers on how to quarantine a patient, collect blood samples and tackle a patient without contracting the disease.” With just two lab testing centres available in India, in Delhi and Pune (which have together tested 96 samples so far), the Government is looking at setting up 10 more labs across the country.

While the world woke up to Ebola only about six months after the outbreak was first reported in Guinea, observers allege that even the WHO took too long to recognise the danger of its spread. This was reportedly because of bureaucratic hurdles like lack of funds in Geneva and lack of adequate staff in Africa. It was only in August that the Organization took adequate note of Ebola.

As the Health Minister has made clear, the Indian Government does not want to be caught napping. Thankfully, it is not too late. At the time of going to press, Open had no report of any Ebola case in India yet. Also, the incubation period for the disease is such that it offers an opportunity to block the disease out. “The incubation period is anywhere between two and 21 days, and the patient is not contagious till the visible symptoms are not visible,” says Dr Kakkar, “This gives us enough time for screening and quarantining the patient. And because it can be contracted only when in contact with body fluids, precautions and care can do the trick.”

However, Martin Sloot, director general of MSF India, says that the current strain of Ebola, known as the Zaire strain, is “unpredictable, constantly evolving and requires a robust and fluid response”. In his words, “The trend is difficult to follow—we have seen a lull in cases in one area only to see numbers spike again later. Isolation centres with trained staff are essential.”

As Dr Saini says, “We need to include private hospitals and have them work in tandem with the Government.” If India mounts a well coordinated response to the threat, the country could yet escape.