How prepared is India to tackle a potential novel coronavirus outbreak?

According to the World Health Organization, we are eight weeks into the COVID-19 outbreak. What started with the Hubei Province in Central China in December 2019, the coronavirus has spread to more than 83 countries in the world till date.

The signs of infection as per the WHO include fever, cough, shortness of breath and breathing difficulties. In more severe cases, it leads to pneumonia, kidney failure and even death.

As of today, March 6th, over 95,000 people have been affected with coronavirus, and over 3287 have lost their lives to this disease. Of these 53700 people have recovered worldwide. In India, as of March 6th 2020 , 30 cases of COVID-19 have been confirmed. . With the increasing concerns and panic in the country, the Health Minister, Dr Harsh Vardhan said “India is fully prepared to fight COVID-19”.

On February 14, 2020 Suno India Editor Padma Priya reached out to Dr G Arun Kumar, Director, Manipal Institute of Virology to understand more about the virus, its spread and how prepared India is to tackle an outbreak.

Produced below is the full transcript of the interview. You can also listen to this episode here: How prepared is India to tackle a potential novel coronavirus outbreak?

How to prevent getting infected by Coronavirus? Listen to Dr G Arun Kumar here!

What is Coronavirus? Was this coronavirus known earlier to mankind or is it new and why is it being called novel coronavirus? What does this nomenclature mean?

Coronavirus is a family of RNA virus and this coronavirus has been known for us. For Example- 50 coronaviruses have been identified from animals of various types and apart from the current one 6 corona virus has been circulated and has been found to be infectious in humans. Among them 4 corona viruses are endemic in the world and causing infection in humans. They mostly cause common cold like mild infections and they are named as coronavirus NL-63, 229E, OC-43 and HKU1. And, apart from these, two other coronavirus cause serious disease in humans. The first one was identified from China in 2003, that’s called as Severe Acute Respiratory Syndrome Coronavirus or SARS Coronavirus which was believed to be transferred from cats to human and in 2005 from Saudi Arabia, there is another coronavirus identified that is named as Middle East Acute Respiratory Syndrome or MERS coronavirus which is believed to have come from camels to humans. So, this is the 7th coronavirus which is found to cause infections in humans and why this is called novel coronavirus because this particular coronavirus is being described for the 1st time. So, it is called a Novel Coronavirus.

Why is so little known about this virus?

The majority of the corona viruses are found in animals, very few coronaviruses are seen in humans. So, this particular coronavirus initially showed cases from the seafood market in Wuhan. Like any other corona viruses which cause illness like SARS coronaviruses or MERS coronaviruses. Originally, this would have been a virus of anyone. So, at some point, this virus from animals should have jumped into humans. Once it jumps into humans some of the viruses they will not be able to transmit or human to human transmission may not be efficient. For example- MERS coronavirus, in 2012, it has been detected it is able to transfer from Human to human only in a very limited manner. However, this particular coronavirus has the ability to sustain transfer among humans. So, there is no confusion. It is only that originally the virus has come from animals. Once it entered the human community it started spreading human to human and that has been our major concern and that’s why it has caused a large number of cases.

Entire cities in China have been put under lockdown. How effective a measure is this? Is it actually recommended by health professionals to stop the spread?

The moment this was realized that it was transmitting human to human, in fact the original report which came out from China in the first week of January or last week of December mentioned that there is no evidence of human to human transmission. So that was not recognized at that point of time. So, when you deal with an epidemic or outbreak, the first thing public health response is to contain the disease. To contain the disease, the step is to restrict the movement of people because of the larger nature of this disease before people could move to other parts of the country and interact that is the reason why the locking down of cities has been taken. Of course, it is an unprecedented scale of activity. In the past also to deal with plague or other outbreaks, which have happened earlier also might have used this type of measure to a limited time because the population in those days was less. So you can see that in China, the Wuhan city it started and then the disease has now reached all parts of china. Studies have shown that at least this locking down has helped to limit the spread to some extent. Also future assessment is required to prove that but we see cases in other parts of China but not in the same number. It might help initially to save more time because otherwise, if every city has the same type of outbreak happening at same point of time, the response missionary will collapse. So, this is exactly what other countries are also now doing by screening travellers at the airports etc. So that, they could contain the disease to the origin and even if we fail in absolute containment but you get more time to prepare ourselves to act. Infact, we should appreciate this type of activities in China definitely have helped to reduce the number of cases in other countries. Had containment measures were not taken by China we could have had much more cases outside China.

There are news reports coming out that the virus could spread through the faecal material, what could this potentially mean in terms of combating the virus?

There is no scientific proof for aerosol transmission or the transmission is droplet. So the disease has not become airborne and there is no evidence for telling that. That’s what WHO is also telling. The studies have shown coronavirus RNA in faecal. So, again that doesn’t mean that presence of RNA is not equivalent to infectious virus. So, we don’t have sufficient data, on that at this point of time whether the virus in the faeces is also transmitting. So, we don’t have information on the fact that only the RNA has been detected in faecal. So, it remains to be more of a droplet transmission and fomite transmission at this point of time.

So that is when somebody coughs or someone who is infected nearby they coughs or you know or it is through that or sneezes?

Yes, when someone sneezes or coughs, the larger droplets may fall on a solid surface and it can remain there for a longer time and the virus can remain there for a longer time. Some studies earlier have shown that other coronaviruses can remain for 48 hours but for this particular coronavirus we still need additional data or more studies to know how long this virus can remain in solid surfaces. Again it depends on humidity and various other environmental conditions and then when people touch on these contaminated surfaces and then they touch their face or nose or your eyes etc. The disease can get transmitted. So, at the moment what we know is that we did a close contact with a patient or exposure to droplets within 1 to 2 meters or by touching surface which is contaminated with the droplets coming from infected people.

There seems to be only very few reports of children becoming infected like most of the stories that are coming out from mainland China or other countries where the virus has taken hold is mainly attracting older people but not really children. Is this normal for viruses? Why could this be happening?

Here, we should be looking at this a little differently because data is coming out from China. Most of the data coming out is from severe cases, severe hospitalized cases because in any of these types of outbreaks initially, this particular outbreak was detected because there was an increase in pneumonia. Pneumonia cases are already in the hospital, so there was an increase in the admission of pneumonia and therefore investigated and they found that there was a new virus. So as of today most of these laboratories confirmed cases or in the literature or clinical features or you know the incidences of this disease is hospitalized cases most probably and these are also said that these hospitalized cases vast majority of proportion is adults. So, that may be the reason that we are not seeing many children. That is where you need more data coming out in a more detailed study looking at a full spectrum of the disease. What is the proportion of this disease causing symptoms or whether children are infected, and if they are infected whether they are transmitting , whether people are able to transmit, you know all sorts of epidemiology and transmission dynamics are yet to be studied. You can understand that when this scale of an outbreak is happening so the countries will be more focused on responding. So, but you also need to conduct studies to understand that China is already doing many of the studies that WHO is also working with China and several information is coming out but most of their information out is based on hospitalized severe cases and the other countries who are the people who got infected, so these are the people who travel to China and when they come back they infect some of their family members or some of the other contacts. So, again this naturally will predominantly adults but there were reports of children getting infected as in 30 days old child also getting infected, so there are reports but we need more data and ask about the epidemic and I think we will get a clear picture.

Dr Arun, you were also a part of the whole Nipah virus outbreak that took place in Kerala and right now Kerala has few cases of coronavirus. What learning from the Nipah virus outbreak that you as a virologist takeaway and what learning do you think is applied with Kerala you know how it is tackling these cases of coronavirus right now.

In the public health system, the ability or the sensitivity of your surveillance system to detect any change is the most important. Only if the surveillance system detects some change that cases will come to a laboratory for confirmation. So, the Nipah virus time what happened was an alert clinician saw that a cluster of encephalitis reported to him and says that one of the person have died 12 days before because of similar illness, so that made him to contact the laboratory and sample came to laboratory because it is a family cluster encephalitis, then the only encialaphilitis that clusters as family is Nipah, so it was tested for Nipah and we found it. So, then after that immediately the public health response was that containment contained the disease there itself and find out that other diseases are there activated or enhanced surveillance and containment response, so that was actually learning experience for Kerala also. So, because we were able to detect several other cases which were not directly connected to this family but later we found that all the transmission, now from the original prospects, so that definitely helped in that scenario also. Here, we really know that this originated in China and people are going to bring the disease to other countries through travel by traveling and Kerala particularly has a number of people studying, number of medical students in China particularly in Wuhan. On, 17th of january, the system was activated. It is already known that there will be people coming to Kerala from china. So,airport screening etc are part of the national plan, it was already put up and kerala implemented it quite meticulously they are tracking the cases and isolating the symptomatic and home quarantining the other people. So that really helped to pick up the cases and subsequently testing these cases.

Do you think our all states health surveillance systems are actually on par with Kerala? Is e there some special formula that Kerala has or is it just a good old fully functional public health system in action because it seems to be that Kerala you know always passes with flying colors when it comes to what could be potentially serious outbreaks like this.

Kerala has been known for their public healthcare or the primary healthcare models for long times, they have very good primary level healthcare systems and systems when you know this type of situations come, they use a central command and put the complete system for this, so that is how with leadership or the leadership from the ministers onwards they put up a central controlled room and monitor and provide protocol and things like that, that’s how they are able to do it but again the problem there is that the whole system is responding like a firefighting sort of thing and then your several other regular programs get affected. So, the other states, we are not very sure how efficient the system is because manpower is one of the major problems because the entire India we have every district has integrated surveillance programs doing this type of activity what we saw in Kerala. But i think most of these primary health centers and many of these post public health response system, people are there you know whereas many other states most of these vacancies may not be filled or availability of manpower maybe an issue, so those type of things because a number of people have come from China, and the people under observation are something around less than 12000 people, so we should have expected much more people to be under observation.

You think India has adequate epidemiological surveillance of you know zoonotic pathogens and by that i mean also is there enough in terms of research and surveillance that’s actually taking place with regards to interaction pathogens with human population because Nipah and Coronavirus are just like you said earlier are just probably a handful of these viruses which are there in animals and which have potential to jump over to a different species. Is there enough being done in terms of surveillance and research in India?

Not enough, of course India has identified a potential threat and also promoting the idea of one health where the human health as well as the animal health system you know coming together and acting and identifying and responding to them but we have not progressed much. We need to do a lot in that area on disease systematic laboratory suppported disease surveillance and cutting across these sectors like one health approach and data sharing and data integration between these various departments both at national level and state level and even upto the village level, we should have this type of approach, So we do have a system is an integrated surveillance program but that has to be strengthened, strengthened with a more manpower, trained manpower and laboratories and data collection and data analysis, data has to be regularly analyzed and it is not only the active or passive disease surveillance but also like to identify the risk areas like looking for these type of viruses for example Nipah, which all places in india has a higher risk of Nipah transmission, we dont have much information but what about coronavirus we know that bats harbour a lot of Coronaviruses and various other viruses and there are several other animals. So, it may not be like China but we also have a lots of animal human interfaces at various levels so these are all areas where we need to be concerned and should be taken on priority basis and also needs a lots of investment because traditionally India’s investment in health is more for curative,so we need more investment in public health. We need more investment and we need to use advanced technologies including artificial intelligence for early detection and prediction because we see this you know like this type of an event affects the country’s economy, it really shakes their economy. If a similar situation happens in India, are we prepared, we have to be prepared for these types of events because it can happen anywhere anytime in the world.

As with the Ebola breakout that took place in 2014–15 we feel like science is not well yet coordinated on this and then coupled with this again there is a massive problem pseudo science being peddled. As someone working in this field, how can we tackle this? Also, we have had our own health ministry tweeting out like saying you know that this part is in unani, this in homeopathy could tackle coronavirus. So, how do we navigate this space of this information when it comes to these kinds of outbreaks?

So, of course, from last 2 years or the Ebola time we have really moved forward because this is one particular outbreak which has seen a lot of scientific information coming out so quickly because the genome of the virus was available and virus was identified in a very very fast manner and it was shared genome or the whole genome and several of the clinical features have been shared but however, we need to develop more trust between countries between people and some of these situations, the public health action, the information sharing for public health action should be priority than publications. Of course publications are important so countries and our WHO like organisations should ensure that the information generated or countries that generate information gets the credit and also intellectual property rights, protection etc. You know this has to be done more transparently and we need to develop more trust between countries, so this is a difficult process but some way has to be worked out because a simple thing i tell you that genome of the virus is released and someone is developing a test and then the test is readily available for country which really needs it and then you know cost is involved, intellectual property rights etc. so these has to be addressed on a more global platform so then only we can bring out this information, then only we can beat the misinformation campaign because the governments and the people who are acting on public health respond should have the right information and also the countries should have good risk communication strategies as well as mitigation plans what to tell, what service to use it, what place is appropriate usage of services, so, we need to have plans we need to use the entire plan in an appropriate manner.

There is a lot of talk that this outbreak could soon be qualified as a pandemic and also I have seen many people comparing it with Spanish Flu from many centuries ago. Could you tell us what pandemic means and when is something classified as pandemic?

When the disease is spreading in an epidemic form in more than one continent, one or more than two continents, it is referred to as a Pandemic. For example, right now most of these transmissions are happening in China, so it is only in one continent. So, even though it has exported to many countries no other countries having huge level of human to human transmission at this moment expect Singapore and you know there are some of the other asian countries whereas outside asian continent we have not yet seen an increased level of transmission at this point but there are indications that in the coming days there is a very high chance that such a transmission will be seen, so if such a transmission is seen then it becomes pandemic, it will be referred as a pandemic. But we should understand that this disease is able to transmit even when the person is mildly ill compared to the nipah, nipah patient will transmit or MERS corona patient will transmit only when the patient is sick or hospitalized or that scenario otherwise they don’t transmit whereas this disease can be transmitted even when they are mild of you really don’t know how many symptomatic people are able to transmit, this is kore looking like a influenza in terms of its transmissibility that how influenza H1N1 came to India in 2009, so we had contained the disease for several months, but ultimately that disease was caught into community because of the nature of the transmission and then we have the virus here, so we should compare this virus in its transmissibility with influenza virus. That’s why many experts feel that there is a high possibility that this will become a will come to many countries and other experts feel that this is an opportunity for other countries to prepare.

What goes into fast tracking research and developing a vaccine and do you know of any indian scientists or research centres or labs which are also doing their own research into this?

In particular, the Coronavirus in India, the designated laboratory in India is the National Institute of Virology, Pune. They might have started some work but i don’t know anything in particular, because at the moment no other organisation in India is authorised to work with coronavirus, this novel coronavirus. But all over the world there are several organisations that are working on vaccines because these are the times when people are talking about platforms for vaccines because people have already started working on vaccines against MERS coronavirus because the people working on MERS coronavirus the same system can be easily adapted for developing a vaccine into novel coronavirus or COVID-19 causing SARS-coronavirus 2, they could quickly make that. So, India also should be working on such labs. Already I think the Department of Biotechnology under the bio programme they are encouraging several other vaccines, so i am sure they are all looking for this type technology where if one is readily available, so it can be immediately passed onto other virus or you know it can be used in other scenarios, so that type of preparedness is really required.

How do you think this might all end? Is there usually like a point in these outbreaks where all might taper out?

Yes, yes whether it is pandemic or an epidemic or an outbreak, you know it will taper out but the question is how long will it take. For example- Ebola, we never thought Ebola will cause an year long outbreak, Ebola was reported from Central Africa and it used to affect less than 300 people because the infection used to come in a small community, remote communities and it all ends there but when the Ebola got introduced into the urban slums of West african countries, so an year long outbreak causing a large number of people, now congo is fighting for how many months more than an year, so it depends on that, we won’t be able to predict at this moment , how long this will take but definitely we have this, indications coming from china, in Wuhan it started, it has not seen the peak, cases are increasing, so we don’t know what will happen in other parts of china, whether the epidemic is or whether it is going to be increased or whether they are going to taper down, so, it is too early to say that when it will end, definitely it will end at sometime and during that time how much damage it does, cause the information coming from China as soon as other countries like Hong Kong or Singapore, 15% of the cases needs hospitalization, severe cases, 15% of the cases needs hospitalization for a disease which has capability to sustain transmission in the community, it’s a big burden on hospital, it’s a big burden on our system. So even though the mortality rate can be very low,if the person is in the hospital for a longer period of time, it adds to the stress and this is what China is currently facing.

If you look at Indian government hospitals, they usually convert like one ward to quarantine ward, and during the Ebola outbreak which happened in 2014–15, there was a scare in India, one of the things many articles reported that not many people are trained to use the PPE suits, they are not readily available, have those gaps been filled in the last few years or are these concerns still legitimate?

We have lots of gaps because whenever something comes we just act immediately do something, we stock something. If you go to a hospital like you know during the bigger outbreak, okay everyone wearing pp’s something and all but you know in the end everything fades away, it is not getting into our culture, our regular hospital culture, we will be definitely faced with one or the other outbreaks, here and there, so there hospital person had to be prepared, on dealing with such things and that should be done on continuous basis not on a firefighting mode. Major things happen we may have to additionally reinforce but there should be a functioning regular system, if hospital infection is a major major concern in indian hospitals, the lot of things have been done but that’s not enough. That needs a lot of investments, that needs a lot of training, that needs a lot of manpower, so you need a very different approach and you need a long term investment, a long term plan for dealing with these types of things. But the message is that whatever disease comes, we should be in a position to deal with it and the understanding of public cooperation is very very important, India is at the stage of containment at this moment because we don’t have wide scale transmission of this disease, we have only a few cases and we should do everything to contain the disease and buy as much time as possible. So, the message to the public is that travel to the infected areas and also keep regularly washing your hands and dont touch face frequently without washing your hands because most of the time infection comes through that way and also keep away from sick people or a coughing person at least keep 1 to 2 metres distance and the mask use is only required for a person who is coughing or people who are working in close proximity to the hospital, hospital people or the healthcare workers or the family members who the person infected. Only these people require masks, there is no point in using masks in public space but handwashing with soap and water or alcohol based handrub is the most important.

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