#dnaEdit: Public health challenges

With over 25,000 people affected by swine flu caused by the Influenza A H1N1 virus and the death toll touching 1,370, India’s preparedness in dealing with seasonal viral outbreaks has been called into question. The current outbreak appears to have begun in December, but until mid-January the public health infrastructure was not suitably geared towards tackling the spurt in H1N1 cases. While Gujarat and Rajasthan are the worst affected, Delhi, Madhya Pradesh, Telangana and Maharashtra have also recorded high H1N1 incidence. In fact, the outbreak exhibits an all-India pattern with fatalities recorded from Jammu and Kashmir to Kerala. Among the major reasons cited for the fatalities are the delay in identifying symptoms, hospitalising patients, and administering the medicine, Oseltamivir, better known by its trade name, Tamiflu. What this signifies is the failure of the public awareness mechanisms. In fact, the Union health ministry’s first press release on January 5 had a complacent ring to it, noting that “seasonal influenza cases are reported every year between January-March and decline immediately after the winter season is over”.

One of the reasons cited for the sluggish response to the outbreak was that a similar sudden spurt had not occurred since the 2009-10 H1N1 pandemic. While nearly 50,000 cases were reported in that pandemic which lasted several months, the current outbreak has witnessed half as many cases in just three months. When the 2009-10 pandemic was tided over, the World Health Organization (WHO) had warned that H1N1 would continue to circulate as a seasonal influenza virus. The WHO had advised that surveillance for influenza-like illnesses and acute respiratory infections was necessary to identify mutations and disease patterns. In fact, the disease patterns have followed a trajectory as predicted by the WHO. After falling to 603 cases in 2011 because of heightened surveillance, the guard was let down and H1N1 has come to stay with the number of cases averaging 5,000 in 2012 and 2013. In between, there was also an unseasonal spurt in Influenza A (H1N1) cases in May and June of 2014 with fatality rates higher than previous years. 

In the ongoing outbreak, state and central governments were caught napping on several counts. Initially, many states had difficulty procuring Tamiflu for its hospital network because of stagnant production systems. However, the supply chain is reported to be functioning smoothly now. With limited laboratories under central and state health departments to conduct the swine flu tests, which requires a high level of skill and knowledge of genetics, private laboratories could make a killing. In Delhi, the health minister had to intervene on reports of private labs charging up to  Rs10,000 per test and set a ceiling of Rs4,500. Even billboards and other audio-visual media campaigns advocating basic precautions like covering one’s mouth during coughing and sneezing or washing hands and avoiding contact with those exhibiting symptoms were initiated belatedly. 

The WHO has recommended annual vaccination based on updating vaccines through continuous study of circulating influenza virus types and their mutations. But such an approach will require a nimble-footed health-care system and facilities that can scale rapidly to meet large public health challenges. Considering India’s huge population, non-existent vaccination policies, limited health and research budgets, and costs of vaccine development, a large-scale vaccination programme may not take off any time soon. But there is no excuse for failures to upgrade the emergency response systems or continuous surveillance of influenza strains. These can be easily seeded from the existing public health infrastructure.