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Flu: India safe but ill-equipped on epidemic drugs

By Rrishi Raote in New Delhi
May 04, 2009 09:52 IST
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Swine flu was first reported in Mexico, SARS and bird flu in China, but India surprisingly escaped being ground zero for any.

China: SARS in 2002-2003 and bird flu in 1996, both in the southern provinces. Malaysia: the Nipah virus in 1998 -- encephalitis in humans via pigs, from fruit bats. Probably Mexico: swine flu or Mexican flu this year, a hybrid of human, swine and avian viruses which the WHO politely rechristened Influenza A(H1N1), using the technical terminology, a few days ago.

Pair up these widely feared pandemics -- there have been many others in history -- with their supposed places of origin and one fact is prominent for its absence: India. Doesn't India incubate any such dangerous viruses?

To start with, the reason these viruses are such a threat is that they are totally new in humans, and therefore we have no immunity to them. Since the body has no defence, even a relatively mild pathogen can become a severe hazard, even a killer.

The reason such viruses are new is that they evolved at first in animals other than humans, typically vertebrates like pigs, birds, cats, dogs, horses.

Each of these species, like humans, is a reservoir of hundreds of specific pathogens which are perfectly adapted to them. The animal, or the human, does not even need to be apparently sick to be harbouring, or indeed spreading or "shedding" the pathogens.

Clearly these are animals with which people live and work. In poorer parts of the world, humans may even share living space with some of these animals.

Such extended proximity explains why what starts out as an animal virus can eventually evolve enough to make the jump from one species to another -- to humans. In the case of the ongoing influenza, which probably originated in pigs (physiologically not dissimilar to humans), scientists think that the pigs were a mixing bowl in which avian and human respiratory viruses came together with a swine virus, to make a hybrid virus which could attack human cells and, thanks to the avian element, could reproduce speedily.

Such a virus can be a quick learner and a quick adapter -- and therefore more virulent. The human-to-human transmission of Influenza A(H1N1) comes from such adaptability, and this is what has health professionals so worried now.

So why has this not happened in India? After all, the conditions that made a cross-species jump possible in south China or Malaysia are not so different from conditions in parts of India.

"It's the heat that has killed the virus," speculates medical historian Mridula Ramanna, who has closely studied the Indian career of the 1918-19 pandemic of 'Spanish flu', which is estimated to have killed between 35 and 100 million people worldwide in the immediate aftermath of World War I.

"The number of deaths was almost 17 million in India in 1918," says Ramanna. "The colonial power attributed [the flu] to India, but it appears to have come from outside by ship." Many epidemiologists (experts on the transmission and control of disease) and historians think the 1918 influenza started in southern China and probably, like the ongoing 'swine' flu, combined avian and swine with human traits -- although at a much higher level of virulence. (Even so, only a small proportion of those who contracted it actually died.)

Spanish flu is the spectre in the minds of modern epidemiologists.

The unseasonal April heat in India is one reason medical opinion cites, because the influenza virus does not last long in hot weather outside the host's body; but it is not always hot here. Peak influenza season (when people have coughs and colds), moreover, is cool weather, yet no outbreak of an emerging virus has started in India even in winter.

Not surprisingly, medical professionals are extremely wary of speaking about the influenza situation in India.

"We don't know that they don't occur in India. They probably do, and we don't know." say Kalpana Swaminathan and Ishrat Syed, authors of a substantial new book on mass disease and history, and both paediatricians.

"If 10 people die one after another in a jhuggi cluster, who notices? Next time you're travelling across the city, look and you will see lots of swine and humans around living in close proximity, living together in some cases."

And it's a misconception, they point out, that doctors always know what they are treating: "Most of these new emerging diseases which are viral or present mainly as fevers -- all you can do is make sure the person stays alive until his own body can overcome the pathogen. These diseases are killers because we don't know anything about them."

Given the constraints they are so familiar with, these doctor-authors are full of praise for China during SARS, once the government realised that concealment was counterproductive: "China is like us -- sprawling -- so when you look at what China did to control SARS, it's really marvellous. Would we be able to do it?"

For the moment, Influenza A(H1N1) appears to be less potent than doctors originally feared. The number of confirmed fatalities, while tragic, is not large. Yet such viruses don't vanish -- they continue to exist in various reservoirs, and may come into play again in cooler weather.

The more widely they spread, the greater the risk they pose. It's just possible that India has not given the world such a virus -- yet -- but the future is wide open.

India yet to wake up to epidemic drugs

Although the Influenza A (H1N1) virus (swine flu), has so far killed 16 people (in Mexico only) and infected 615 people in 15 countries (the World Health Organisation (WHO) figures) as of Sunday, and caused a global panic and media attention, statistics reveal that hundreds of people died and millions were infected in India since 2000 with epidemics such as Chikungunya, Japanese Encephalitis (JE), Meningococcal disease, Dengue fever, Plague and Cholera.

However, most of these outbreaks in India have not attracted the same level of interest in the global healthcare industry. Pharma companies are yet to even develop drugs for diseases such as chikungunya and JE, note industry experts.

According to WHO's India statistics, 151 districts in 9 states of Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra, Gujarat, Madhya Pradesh, Kerala, Delhi and Andhra Pradesh were affected by chikungunya and dengue fever, spread by Aedes albopictus mosquitos in 2006. More than 1.25 million suspected cases were reported from the country from February to October 2006.

Neither the multinational drug companies, nor any of the Indian drug companies are yet to develop an effective drug for this disease. During the outbreak, doctors had to prescribe  paracetamol and other antibiotics to check the viral infection.

Nicholas Piramal India, which planned to form a joint venture drug discovery research programme with the French pharmaceutical company, Laboratories Pierre Fabre backed out from the project due to procedural delays. 

"We dropped the drug research plans for chikungunya, since the drug controller general of India (DCGI) delayed to sanction the project. It is almost six months' since we applied," Swati Piramal, director- strategic alliances, NPIL, told Business Standard in November, last year.

Pierre Fabre had developed effective medicines to prevent the disease outbreak which happened in Re-Union islands, a French colony, about three years ago and in some other tropical countries.

In July -August period of 2005, 1,145 cases of Japanese Encephalitis(JE) or brain fever cases were reported from 14 districts of Uttar Pradesh.  Of this, one fourth or 296 people had died. Another 90 cases were reported from Bihar.

The disease was caused by Culex tritaeniorhynchus and Culex vishnui group of mosquitos, the vectors of JE. Only two months ago the U.S. Food and Drug Administration approved Ixiaro, a new generation vaccine manufactured by a UK based biotech company Intercell, that can effectively prevent this disease. 

Another fatal disease that infect India repeatedly is the meningococcal disease. In 2005, about 405 cases were reported in Delhi and suburbs and of this, 48 had died.  Meningococcal disease is endemic in Delhi and outbreaks of Meningococcal Meningitis in and around Delhi were reported in 1966 and 1985. During 1966, 616 cases of meningitis were reported with case-fatality rate of 20.9 per cent.

The outbreak in 1985 was bigger in magnitude, both in terms of cases and the geographical area affected, with 6133 cases with 799 deaths.

Vaccines are currently available against four of the five strains of this disease, and a vaccine against the B strain is in development.

Menactra, Menomune of Sanofi-Aventis, Mencevax of GlaxoSmithKline and NmVac of JN-International Medical Corporation are commonly used vaccines. Indian companies such as Serum Institute are also developing vaccines for this disease.

Antibiotics such as ciprofloxacin is normally used by doctors to prevent the disease. P B Jayakumar, Business Standard

Swine Flu epidemic plays out in cyberspace

Scammers - netizens who spam with the intention of cheating -- are cashing-in on the H1N1 influenza (swine flu) scare. With email messages that include subject lines like 'Salma Hayek caught swine flu!', "Madonna caught swine flu!", 'US Swine Flu Statistics', and "Swine flu in Hollywood", they are (mis)leading gullible users to online pharmacies.

Online security company McAfee Avert Labs has noted that such emails now account for 2 per cent of all spam messages. Some e-mails contain malware too.

One such email which references a vaccine for swine flu reportedly includes a link to a malicious file on a Mexican website that is designed to steal bank login information, according to security firm SonicWall.

Simultaneously, F-Secure Corp, another online security company, said that over 250 websites with the term "swine flu" were registered within the first few days following the announcement of the outbreak. Sites like these which include, and claim to have cures for the influenza.

Noswineflu, for instance, claims to have a concoction of special Chinese and a Western herb which can "crush almost any flu symptom, sometimes overnight." Pigflufighter, on its part, lists all swine flu infections by country and cajoles visitors to buy eight boxes of 'pig flu' masks (160 pieces for $190 plus free shipping).

Even the US Food and Drug Administration has alerted the public to be wary of internet sites selling products that claim to prevent, treat or cure the  H1N1 flu virus, and has informed offending websites that they must take prompt action to correct and/or remove promotions of these fraudulent products or face immediate enforcement action.

The Better Business Bureau too has warned consumers to be on the lookout for fraudulent emails and websites trying to take advantage of the current flu outbreak. The operators of these websites, according to USFDA, take advantage of the public's concerns about H1N1 influenza and their desire to protect themselves and their families.

However, the internet is also helping hundreds of thousands of users in getting relevant information on the flu. Wikipedia's page on the flu, according to Nielsen Online, was updated literally hundreds of times this week (119 times as of early on May 1).

There were around 100 Facebook groups dedicated to the flu till early May 1, and more than 500 other groups (the three largest groups have a combined total of over 10,000 members), according to Nielsen. And despite the flutter it caused with its earlier tweets last week, Twitter too churned out flu tweets at a rate of more than 10,000 per hour earlier in the week.

Even the Centre for Disease Control (CDC) is leveraging several different online channels to provide a "voice of reason in the fury of discussion around the flu -- and in the process is setting a roadmap for those wondering how social media can be used for crisis communication", according to Nielsen.

CDC has a few Twitter accounts and over 65,000 followers (users who follow the tweets) -- up 86 per cent since Nielsen began tracking it. It also has set up a dedicated page about flu on its site, which according to Nielsen estimates, has seen a nearly 100 per cent increase in unique visitors. -- Leslie D'Monte, Business Standard

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Rrishi Raote in New Delhi
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