How Could We Have Got It So Wrong?
What’s a little SARS when we battle horrors like TB and malaria every day? RANJANI RAMASWAMY and TOUFIQ RASHID investigated the isolation wards, the hi-security labs, and the mass hysteria, to find that the SARS virus either reached India in a milder form, or failed to overwhelm our desi immune system. Or maybe both
THE day the World Health Organisation (WHO) declared India SARS-free, a dot of a sun-baked village 70 kms from Thane in Mumbai’s backyard, was waking up to a mystery viral fever. Three people had died around Washala village, where 35 tribals were fretting about fever and respiratory complaints.
The very week SARS was storming through TV channels and bumbling through local hospitals, Murshidabad in West Bengal was quietly grappling with a fever that has claimed two lives and affected 96 at last count.
In October 2002, seven succumbed to a mystery fever in the coastal village of Kharekuran near Palghar. None of the patients responded to conventional treatment, some showed signs of acute pneumonia at the last stage.
Have you ever heard of these hot zones? What you didn’t know about isn’t on the television screens. What you did know about, doesn’t really seem to matter.
That’s how it works in India, always has. When the world sneezes, we get ready to catch the flu. But if we get the flu ourselves, life goes on.
And so India knows every dramatic step of Hong Kong resident Bhaskar Murthy’s journey from Mumbai to Delhi the day he tested positive for SARS. The day Union Health Minister Sushma Swaraj told the world India was off the WHO’s list of SARS-reporting countries, a nurse at Kingsway Camp’s Maharishi Valmiki Infectious Diseases Hospital — swathed in a disposable surgical gown, N-95 mask, head cap, goggles, a cap hanging around the neck and a shoe guard covering her sandals — was ready to serve breakfast to Murthy.
A SHOT IN THE DARK
India’s only SARS test is a fortune cookie
There are hundreds of coronavirus varieties. There is no sure-shot test. The test used by the National Institute of Virology, Pune, simply detects the presence of a broad variety of coronaviruses in blood, sputum or urine samples. Here’s how it’s done and how it can go wrong.
1 Blood samples are drawn and transported unsupervised. Scientists extract the virus
WHAT CAN GO WRONG
If the blood isn’t drawn or transported properly, it can be contaminated and skew the test. Even a cough from a scientist can seed it with other bugs
2A segment of the virus’ DNA is extracted in a vial. NIV scientists add pieces of synthetic DNA, or primers, (imported from Germany). More genetic material, available from the market, is added, based on information from the Internet
WHAT CAN GO WRONG
If the virus in the sample is a mutant—as the Indian SARS is suspected to be—the test could be useless.
3The mixture is heated and cooled to let the concoction create copies: in three hours, one million copies. All to confirm the virus’ presence—and its virulence.
WHAT COULD GO WRONG
If the sample was in any way contaminated, or had a mutant strain, the wrong coronaviruses could be amplified a million fold.
If the test confirms the SARS virus—after all these ifs—there is no way to compare the results with the virulent strain ravaging the Far East. The sample is not retested by a global authority. And a patient whose fever has subsided in the 18 to 20 hours it takes for this test, won’t hang around for a re-test.
Twenty Indians have tested SARS positive at last count. Fatalities: Zero. Full-blown SARS: None.
India’s collective immune system, studded with a combative history of battling a mix of tropical viral fevers, clearly seems to have staved off a virulent strain of SARS that laid our eastern neighbours low.
Darkness on the edge of town
On the edge of Mumbai, in his modest brick home on a narrow lane in the township of Ambernath, Stanley D’Silva is lounging in denim and khaki shorts. Only last week, he was the face of the supposed Indian outbreak of SARS, a forlorn figure, hunched on a bed in an isolation ward in Pune.
No one saw his face actually. In his shiny green and white quarantine overalls, face mask and goggles, he looked like some captured alien.
He may have later strummed through his eight isolated hospital days in Pune with his guitar for company, but he will not easily forget his sister’s missed wedding. Health authorities huddled his family into quarantine after his discharge from hospital, after his fever had ebbed.
‘‘I still do not believe that I had SARS, I felt feverish when I returned from Indonesia but I had no difficulty breathing. Neither me, my family nor the doctors at the Naidu Hospital at Pune have seen the report that claims we tested positive for SARS,’’ D’Silva told The Sunday Express. Isolation? D’Silva says he ordered take-away from the ward.
In Ambernath, the D’Silvas neighbours are wary. Doctors have goofed badly and blatantly through the quarantine and discharge dates, struggling to make up their minds on diagnosis, and Health Ministers have spouted discordant damage control from Panaji to Pune to Kolkata.
In the City of Joy, a mass hysteria led to an unseemly demonstration by hospital staff, demanding the expulsion of Asitabha Purakayastha, a suspected SARS patient.
It’s true that SARS is a new disease. It’s equally true that India’s creaky health infrastructure tried its best — in its own sporadic, knee-jerk way — to cope. The health system struggles to cope even with known diseases, so to expect miracles when the rest of the world was in shock is simply expecting the moon.
But it isn’t too much to tell the people what exactly is going on. And this is where the system failed.
‘‘Just tell the people that we are handling the virus safely and that all the protocols are being followed,’’ Dr A K Mishra, the director of India’s premier SARS-testing centre, the National Institute of Virology (NIV) told The Sunday Express when he was asked to explain how exactly SARS testing was done. ‘‘The test and the analysis of data is too scientifically complex and complicated to explain to people.’’
That we-know-it-all attitude also overshadowed the fact that testing positive for the SARS ‘‘killer virus’’ is not a fatal diagnosis for India. SARS in India is not the virulent strain of Beijing, Hong Kong, or Singapore — where the only Indian victim, a taxi driver — died last week. The nine medical staff in Pune’s Siddharth Hospital who tested positive for the coronavirus last week have all been declared symptom-free.
‘‘SARS is not as easily transmitted as many of us believe. The coronavirus cannot live for more than six hours (average three hours) outside the human body. It is not air-bone transmission like influenza,’’ says Dr N Kumara Rai, director Department of Communicable Diseases, WHO South East Asia Region.
So many coronaviruses, which is which?
THE SARS story swirls around a crown of thorns, well, almost. Coronaviruses are named after their corona (crown) or halo of club-shaped spikes that show up under an electron microscope.
These viruses are irregularly shaped and infinitesimally small — imagine 60 to 220 nanometres in diameter, less than a million times finer than a strand of human hair. Their spikes help them bind to host cells and sneak right inside, to release genetic material of the virus into the host cell. The newborn coronas collect in membrane-bound sacs and are eventually released by the cell itself.
And hold your breath. Second only to the notorious rhinoviruses that cause common cold, these viruses are everywhere and can enter from anywhere. Your eyes, nose, mouth and, invitingly, your hands.
Long before WHO declared India SARS-free, men of medicine and science had started asking nosy questions nobody wanted to answer. ‘‘They are fumbling in the dark. There are hundreds of coronaviruses already in circulation in India. The brothers and sisters of the coronaviruses in China might already be in circulation here, because of which we might have developed partial protection against this new strain,’’ says retired epidemiologist N S Deodhar.
All suspect cases showed mild clinical symptoms. Their X-Rays did not reveal pneumonia. As India edged toward a 20-case mark, WHO said that India’s SARS cases perfectly fit WHO’s definition of ‘‘suspect’’ cases rather than ‘‘probable’’ cases. ‘‘The SARS virus may have mutated once it entered India and become less virulent,’’ says Rai. Then on May Day WHO suddenly changed track to say India was SARS-free.
So is merely testing positive for the coronavirus an indication for SARS? ‘‘The coronavirus implicated as the cause of the disease is certainly around but is unlikely to be the causative agent of SARS. In fact, the proportion of samples from Canadian SARS patients that show the coronavirus is going down. The case definition of SARS is still very loose,’’ Frank Plummer, Director of the National Microbiology Laboratory (NML), in Winnipeg, Canada, told The Scientist on April 11. The NML is one of 11 collaborating laboratories world-wide working on SARS.
The Canadians have classified their patients according to severity of symptoms and need for hospitalisation and isolation. They classify people who test positive for the virus but have no potent travel history or symptoms as Persons Under Investigation, not suspect cases.
‘‘The PCR test for SARS is a highly sensitive test but I would be extremely sceptical about its specificity in detecting the strain. The test could come up positive for a related strain and not necessarily the one in China and hence its infectious nature is a big question mark unless we start studying it properly,’’ says Deodhar.
‘‘We should have acquired samples from Hong Kong and China to compare and validate our test results,’’ says Dr Mahesh Patil, head of research, anti-infective unit, Wockhardt.
The NIV admits that it is not doing any cell cultures of our desi strain, no animal experiments. ‘‘So what are they doing?’’ asks Deodhar.
One WHO hypothesis points to the possibility of cross immunity existing between the new corona virus (ie SARS virus) with the already circulating corona virus that causes common cold in humans and diseases in pigs, chicken and birds.
The vaccine to prevent small-pox is manufactured using a different virus from the one that causes small-pox. Small-pox vaccine contains live vaccinia virus that causes cow-pox in cow, while small-pox is caused by variola virus. Immunity to vaccinia also confers immunity to variola, that is cross-immunity.
In viral infections, it is generally true that when the disease starts as a new epidemic, the affected person(s) gets a more severe form of the disease. In subsequent transmission waves it becomes less severe, until it becomes a very mild illness. This is one possible explanation for the mild SARS virus in India.
‘‘The virus may be different. And the people are different. So what their interaction leads to is something our health authorities and scientists have no idea about,’’ says Deodhar.
The only diagnostic parameter we seem to be following is the result of the RT-PCR (Reverse Transcriptase Polymerase Chain Reaction) that gives a Yes or No answer for the new coronavirus. But does its presence really mean that it will lead to the deadly respiratory disease?
The great shroud of immunity
Why are children not affected? Most patients are adults 30-plus.
‘‘Children catch flu at the drop of a hat. Yet they are strangely immune to this virus. Why?’’ asks Kalyan Banerjee, former NIV director.
On Washala’s mystery fever, district health officer B R Gholap says, ‘‘Such illnesses are common during this time of the year when the mercury reaches its peak. We have noticed that the affected are the ones who have to be out in the hot sun while the fever has not touched small children who remain in the house.’’
A study released in Hong Kong on Tuesday by Professor Tai Fai Fok of the Department of Paediatrics of Hong Kong University concurs. They found that among children who tested positive, teenagers exhibited more symptoms than young children. The younger the patient, the less infectious he was found to be.
‘‘With a new disease, following generalised rules is dangerous. Common sense and creativity which is in such scarce supply has to kick in. We are not Canada, USA or even China. We must constantly predict Indian problems and manifestations using our resources optimally,’’ says Banerjee.
Statistically speaking, we have a greater chance of dying from infectious tuberculosis than SARS. TB kills an Indian adult every minute.
How Goa Bumbled with SARS Number 1
From the silver sands that flashed news of India’s first SARS case at the Goa Medical College Hospital, Chief Minister Manohar Parrikar once said it was a ‘‘false alarm.’’ Then he said the patient was neither a ‘‘spreader nor a super spreader.’’ P> Meanwhile, Singapore-returned Prasheel Varde had wandered around the Hospital, trying to locate the isolation ward. Mid-way, Varde had stopped by the hospital’s canteen for a tuck-in.
Prasheel was discharged from the hospital only to be summoned back hastily four days later — from a party, no less — once the doctors discovered belatedly, that they had let go of a SARS-positive. ‘‘The purpose of an isolation ward defeated the way the GMC authorities handled the case in a most negligent manner,’’ blusters his doctor Pradip Pai Dhungat.
By the evening of May 1, Varde was the only ‘‘SARS probable’’ in India’s high-pitched search for SARS. The hysteria is now slipping away, we know a little more about the rogue virus than the day a lonely groom attended his wedding in Pune. Typical to India’s SARS story, Maharashtra — the state with the maximum suspects — is now boasting it has finally procured 800 masks. We don’t know — yet — if they will be used.
http://www.indianexpress.com/full_story.php?content_id=23215
I still say if I got this disease I would have my wife hunt for a doctor that would give me GH until I reached the levels of a 3 year old!