How would India deal with an outbreak of the deadly Ebola virus that has already left a devastating trail across West Africa and claimed victims in parts of the United States and Europe?

On Thursday, India’s Health Ministry said it would start conducting mock drills simulating treatment for a potentially infected patient, after a meeting with state health officials to assess the country’s preparedness.

So how likely is Ebola to reach India and what would be the consequences if it does?

The World Health Organization has said no country is safe from the virus and this week predicted as many as 10,000 new cases could be identified weekly around the globe by early December.

By Oct. 12, the WHO said there had been almost 9,000 confirmed, probable and suspected cases of the disease, for which there is no approved vaccine or treatment. Around half of those cases have been fatal, almost all of them in Guinea, Sierra Leone and Liberia.

A map showing where confirmed Ebola cases from the current outbreak have been treated. The Wall Street Journal

One set of predictions of where the disease is likely to travel is based on flight data to and from West Africa and modeling of the behavior of the virus.

A team of scientists including academics from Northeastern University and the University of Florida, analyzed air traffic numbers to and from the three worst-affected countries along with the pattern of transmission of the disease.

They plotted its likely next course -- if containment measures don’t curtail the outbreak in Africa -- to the United Kingdom, France and Belgium.

Their predictions say that India is less at risk of importing the infection than those countries because it has fewer direct flights into and out of West Africa, but they add that, as of Oct. 14, the country is 21st in a list of 30 nations most likely to see an Ebola case, even if air traffic is reduced by 80%.

That’s two places below Spain but more likely than countries including Uganda, Mauritania and Cameroon of importing the virus.

Since the outbreak began, the frequency of flights from effected countries has fallen by 64% in the year to Oct. 10, according to airline data provider OAG.

Despite the relatively low risk and no confirmed cases in India to date, fears remain that even a single occurrence of the disease could spell catastrophe.

The country’s huge and densely-packed population, often rudimentary public healthcare system and lack of adequate sanitation each pose challenges to the containment of a disease like Ebola, health experts say. Combined, they could make it uncontrollable.

“An outbreak in Europe or North America would quickly be brought under control. I am more worried about the many people from India who work in trade or industry in West Africa,” virologist Peter Piot, the man who helped identify the Ebola virus in 1976, was quoted as saying by German news magazine Der Spiegel in an interview published in September.

Around 4,700 Indians live in Guinea, Liberia and Sierra Leone. Another 40,000 live in Nigeria, where eight people have died after 20 cases of Ebola were detected.

“It would only take one of them to become infected, travel to India to visit relatives during the virus' incubation period and then, once he becomes sick, go to a public hospital there,” Dr. Piot, who is director of the London School of Hygiene and Tropical Medicine, was quoted as saying in the interview. “Doctors and nurses in India, too, often don’t wear protective gloves. They would immediately become infected and spread the virus.”

Large cities with over-populated slums like those in India make it “virtually impossible to find those who had contact with patients, no matter how great the effort,” Dr. Piot said, according to the magazine.

Ebola containment involves identifying and finding every person who comes into contact with an infected patient in a process known as contact tracing.

India’s Health Ministry said Thursday that three days of training for healthcare teachers would take place in Delhi starting Sunday, including how to put on and remove protective wear safely, how to contact trace and how to collect and transport blood samples without spreading infection.

The virus is transmitted by direct contact with a patient's bodily fluids such as sweat, blood, urine and feces.

That’s why in Nigeria’s largest city Lagos, where the majority of the country’s 20 cases were discovered, authorities urged people not to urinate or defecate in drains, dump sites and open spaces. The move is perhaps one reason why Nigeria has successfully contained the epidemic, with no new cases since Sept. 8.

In India, around 600 million people defecate in the open, a lack of toilets and in some parts a cultural preference for going outdoors would make it almost impossible for similar public health advice to have the same effect.

Dr. Ashish Jha, director of the Harvard Global Health Institute, said that he would be surprised if there wasn’t a confirmed case in India by the end of the year. If his prediction comes true, it would potentially “set off a cascade” of the disease, which could spread very quickly, Dr. Jha added.

“Within a matter of days to weeks, you could start seeing dozens of people, rising into the hundreds within a couple of months if it is not checked," he said.

The Indian government has put a number of precautionary measures in place to quell these fears, including screening passengers at airports and seaports to look for symptoms of the disease, which include vomiting, fatigue and bleeding, in travelers arriving from infected regions.

Low risk passengers are given general advice about the virus, while medium and high risk passengers are kept under observation and their blood samples tested for a further period of 30 days since it can take 21 days for symptoms to manifest.

Around 1,128 passengers are currently being tracked, mostly in the capital Delhi and the states of Maharashtra, Kerala, Tamil Nadu, Gujarat and West Bengal, the Health Ministry said Monday.

“No checking and screening can be 100% foolproof. But by doing so, we’re reducing the probability of an outbreak,” Anshu Prakash, joint secretary at the Health Ministry, told The Wall Street Journal.

“We’re taking this very seriously. The entire world is at risk and so is India,” Mr. Prakash added.

Since August, flights arriving in India have given onboard announcements about the virus and its symptoms. A national control room with three emergency lines is also in operation.

Pre-emptively, the government cancelled a trade and investment summit between India and Africa scheduled for early December in Delhi because of the threat from Ebola. More than 1,000 delegates were expected, including heads of states, from across the continent.

As well as preventing the virus arriving, India also needs to train healthcare workers adequately in what to do if it does appear. Problems faced by the U.S. and Spain where three staff treating Ebola patients have recently contracted the disease themselves, are chastening reminders of the need to be prepared.

Dr. Jha, of the Harvard Global Health Institute, said "the training and infection control practices are not that hard.”

“The real question is whether these hospitals will make it a priority,” something the Spanish and U.S. hospitals didn’t do, Dr. Jha added.

State authorities have designated hospitals, which will be checked by inspectors from the federal government, with isolation wards to treat suspected cases and store protective equipment. Some 50,000 kits containing “personal protective equipment” to prevent healthcare workers from contracting and spreading the disease will also be distributed among the states, the Health Ministry said Thursday, and senior government officials from each state must hold regular crisis management groups to monitor their states’ ability to cope should an outbreak occur.

Still, successfully containing an Ebola case in India would depend in large part on where the disease emerged, according to Dr. Jha.

If it happened in Kerala, for example, where the public health infrastructure is more advanced, containment would be easier than in states such as Bihar, where medical facilities are more akin to those in sub-Saharan Africa, he pointed out.

Another concern is when the outbreak occurs. India’s already overburdened public hospitals are normally stretched further in October because of a seasonal peak in cases of dengue fever and typhoid.

These illnesses carry similar symptoms to Ebola including fever meaning the deadly virus could go undetected.

Only two public centers - the National Institute of Virology in Pune and the National Centre for Disease Control in Delhi – can currently diagnose the disease. The health ministry said both have so far tested 96 blood samples for Ebola and none has been found positive. On Thursday, the ministry announced that 10 more laboratories across India “would be strengthened to handle this work.”

For now, India's government is conducting daily assessments of the risk from Ebola, the Health Minister Harsh Vardhan said Thursday. “We are keeping a vigilant eye on it.”

--Vibhuti Agarwal contributed to this post.

Atish Patel is a multimedia journalist based in Delhi. You can follow him on Twitter@atishpatel.

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