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Panic pandemic

The media and the government health services have unwittingly collaborated to create and escalate public alarm over the H1N1 influenza outbreak in India. Sandhya Srinivasan points out what their response to this public health crisis should have been

As the pandemic influenza disperses throughout India, the media and the government health services have unwittingly collaborated to create and escalate public alarm. The beneficiaries will be private doctors and hospitals, which are known for irrational and profit-driven practices.

Virologists and epidemiologists have repeatedly emphasised that the H1N1/09 influenza virus causes a mild infection in the vast majority of people whom it infects, just like the seasonal influenza. The symptoms are the same. Also like seasonal influenza, the standard treatment is isolation, rest, lots of liquids, and medication for pain and fever if necessary. A small percentage of patients have complications such as pneumonia that require hospitalisation and, possibly, intensive care.

The overall case fatality rate from H1N1/09 is believed to be about 0.5%, about the same as that for the seasonal influenza virus. In Mexico, where the new virus was first noticed, and where the outbreak was severe, about 2% of all reported cases died.

Though seasonal influenza is not generally viewed with apprehension, it causes severe illness in 3 million to 5 million people every year worldwide. 250,000 to 500,000 die from complications of influenza – about 33,000 of these in the US. In temperate regions, epidemics of this influenza occur in the winter; in India the virus is most active during the monsoons.

While everyone is at risk of seasonal influenza (the virus keeps mutating so no one is completely immune to it), the very young, the elderly and those with chronic conditions that compromise their immunity are more likely to suffer severe illness. In the case of H1N1/09, the majority of people who have fallen severely ill are between the ages of 5 and 59. Older people may be protected because they were exposed to a similar virus in their childhood. Other groups at risk of flu complications are pregnant women and people with underlying health conditions such as asthma and diabetes.

The difference between seasonal influenza and H1N1/09 is that the new virus is much more infectious. “So the absolute number of people who get infected – and the number who die – will be much higher,” says Dr S Sridhar, Vadodara-based paediatrician and public health expert and member of the Medico Friend Circle, a group of health activists and analysts. Crowded living conditions and low immunity because of malnutrition are likely to add to the problem.

Further, the virus has most likely been dispersing in India for some time and the current figures (about 1,000 cases and 17 deaths as of August 12) are likely to be gross under-estimates. “Many people will have had H1N1/09 flu in the last few months,” says Dr Sridhar. “It’s just that many people will not seek treatment because the symptoms are mild or because they do not have access to care. Even if patients do seek treatment, doctors may not suspect H1N1/09 unless there are complications. And many deaths will not be recorded as influenza deaths.” These deaths become part of the routine background of illness and death in India, accepted because no one is too alarmed when poor people fall ill and die.

Of course, there are many unknowns. Will the virus mutate to become more severe?  Will the impact in India be milder or more severe than it has been elsewhere? Why are there clusters of severely ill people? For now such speculations should be put aside to focus on the job at hand.

A vaccine may prevent infection and lessen the severity of infection when it occurs – just like the seasonal flu vaccine that is manufactured every year for use in the West before the winter flu season. But there is no H1N1/09 vaccine at present, and the task of the moment is to tell people how to protect themselves from infection and provide supportive treatment in those who do become infected. Those with complications of influenza will need more intensive care, for which there should be facilities. The health system should ensure that those needing treatment are directed to the appropriate facility and receive rational treatment.

The job of the media is to enable the public to take intelligent decisions. In times of a health crisis, they must give people useful information on how to avoid falling ill, when to approach a doctor, and what to expect from the health services. The media should give information on exactly how serious the problem is, after checking their facts with those who know the subject. Differences in opinion should also be reported but with the aim of helping readers make informed choices.  The media should also identify the challenges that need to be addressed at the larger level by the government.

Instead, some sections of the media have shouted “fire” in a crowded auditorium and reported on the ensuing stampede.

Since the first H1N1/09 death in India on August 3, the newspapers have carried four-column and six-column front-page spreads in addition to many inside pages on H1N1/09, much of this of the “Panic Flu” variety. They advised that people with “symptoms of swine flu” get tested, and gave the names and numbers of the testing service. But there are no symptoms specific to swine flu – and the media did not tell us what we should watch out for. Of course, the government didn’t bother to tell us either.

The death of Reeda Sheikh could not on its own have got people lining up outside hospitals. The newspapers and televisions channels started the panic.

Of course useful information appears periodically, hidden in this incendiary reporting. For example, newspapers have reported that US, UK and WHO guidelines advised home treatment for flu unless complications develop. Likewise they have reported that guidelines on shutting schools have varied from country to country. One paper carried the Indian Association of Paediatrics’ advice to parents. But only on August 12 were the warning signs of severe flu published prominently, and this flu put in the context of deaths from other diseases. This was also when an article noted that government health spending in India is among the lowest in the world – a critical factor in the government’s ability to respond to any public health crisis.

We’ve seen extensive reports on the pros and cons of various masks for public use. But masks may need to be used by certain groups of people only. Because all papers and TV stations seemed to have carried sloppy reporting on this subject, people have wasted money, and panic buying has encouraged hoarding and profiteering, possibly depriving those who actually need the special masks.

Dr Anant Phadke of the Pune-based Jan Arogya Abhiyan says that people with proven or suspected flu, and their caregivers, may need to wear the cheap surgical masks – but only to shield others from the droplets thrown out by their sneezes and coughs. In a severe outbreak such as in Pune, others whose work puts them in contact with many people, such as bus conductors and shopkeepers, may also use this mask which may be washed and reused. The sophisticated and expensive N95 mask is useful only for healthcare workers. In the US, which might be viewed as extra-cautious on such matters, the Centers for Disease Control advocate the N95 mask, also called a “respirator”, only for healthcare workers.

The increased impact of television compared to the print media is further magnified as channels jostle with each other to create “new news” and grab viewers. So the news channels continuously replay footage of frantic crowds outside hospitals and people on the streets with faces covered by masks or scarves. Flashy graphics with repeated “updates” of the numbers of confirmed cases and deaths heighten the sense of urgency.  Anchors introduce their Pune correspondent (masked, of course) as reporting from “ground zero”. They refer to the outbreak of a “deadly virus”, to the “terror of swine flu”, “the spreading tentacles of swine flu”, “terror unmasked” and “clear and present danger”.

Caught between this media-generated panic and a government that has largely remained silent, the public is desperate for information. TV channels’ helplines have been besieged by viewers with simple questions whose answers should have been widely publicised by now: How “at risk” are pregnant women? How safe and effective are the drugs?  Should I let my child go to school?

This media coverage also feeds off the panic that it has generated. When the central reserve police force is called out to control crowds outside the Ram Manohar Lohia hospital in Delhi, the television cameras are ready to roll. They are ready when the Maharashtra Navnirman Sena and Shiv Sena seize the political opportunity to forcibly shut down schools in Mumbai. When the Pune airport and station are filled with people looking for a ticket out of town, a reporter is at hand to stick a mike in students’ faces and ask if they’re desperate to get out because they feel unsafe in the city.

It is only since August 11 that the media started toning down its shrillness, and even now it is clearly torn between the need to sell papers – or grab viewership – and help the public make intelligent decisions.

Government “action”

The government, in turn, has woken up very late, and its pathetic response stokes the fire as people have no idea what to be worried about and where to get treatment.

Four months after H1N1/09 was identified as a new influenza virus, and two months after the WHO declared it a pandemic that would circle the globe and infect up to one-third of the world’s population, the Indian government’s department of health did not bother to prepare for the virus’ arrival in India – the need to keep the public informed, spell out screening and treatment protocols and ensure adequate treatment facilities. Its vague declarations on how it is handling the situation do not inspire confidence. Now, it has started talking about setting up more testing centres and isolation wards in collaboration with private hospitals.

More testing centres are not needed. On August 11, the National Institute of Virology announced that it had discontinued testing except for monitoring purposes. But the government has not conveyed to the public that there is no point testing every suspected H1N1/09 case when the virus is dispersed in the community.

The government has called on private hospitals to provide isolation and intensive care facilities for flu patients. But such facilities are necessary for many conditions, and they were needed even before this new influenza.

The government seems to be responding to the media’s needs rather than those of the public. It has announced its plans at press conferences but until a couple of days ago, it had not provided any information to the public through announcements, and had given confused instructions to private doctors.

The initial panic in Pune started after the first death was reported. The patient did not fit the criteria given to private doctors for when to suspect H1N1/09 and refer the patient to the government testing centre. She had flu symptoms but had neither travelled abroad nor had contact with a known flu patient. The criteria should immediately have been revised to include symptoms of flu complications, says Dr Anant Phadke of Jan Aarogya Abhiyan. But they were not revised, and after the media reports, anyone who had a cough or sniffle ran to a private doctor. Private doctors played it safe by referring all patients with flu symptoms to the government’s Naidu hospital. So the government issued a directive to private doctors to treat patients “properly” or face punishment – without explaining what “proper” treatment is.

Concerned about this situation, the Jan Aarogya Abhiyan, Jan Swasthya Abhiyan, Janwadi Mahila Sanghatana, the Pune Municipal Kamgar Union, Prabuddha Medical Forum,  Lok Vidnyan Sanghatana, the National Alliance for People’s Movements, and a Pune municipal corporator, Siddhartha Dhende, have called on health authorities to give the public essential information, revise guidelines for testing and treatment, provide masks and drug prophylaxis to healthcare providers, prevent profiteering, and include health organisations and private doctors when developing a strategy to tackle the flu.

On August 11, this group proposed a specific set of criteria for suspecting H1N1 flu: a fever of at least 100° F and a cough/sore throat, and one or more of the following: A history of travel to a state or country where there are one or more confirmed or probable cases; OR close contact with a confirmed case within the last eight days; OR if the fever does not come down within three days despite routine treatment for fever.

What the public needs to know

Treatment of H1N1/09 is no different from other influenzas. Stay at home so that you don’t infect others (for at least a week, and 24 hours after symptoms disappear, whichever is longer), rest, drink lots of fluids and take paracetamol for the fever or body pain. Any other medication should be prescribed by a doctor.

Seek urgent medical care if there are any serious symptoms such as breathlessness, chest or abdominal pain, dehydration, persistent diarrhoea or vomiting, coughing blood, unresponsiveness, dizziness or confusion. See a doctor if the fever remains high for more than three days.

Whether or not you have flu symptoms, cover your face when you cough or sneeze, avoid touching your face, and wash your hands – when you return from outside, before and after preparing food, and before and after taking care of a sick person.

Panic-driven business

Pharmacists’ shelves were emptied of antibiotics after the plague scare in 1994 and the leptospirosis in 2005. Private doctors made money on dengue and chikungunya. That’s already happened with masks in August 2009, and it’s sure to happen with antiviral drugs if they become available in private pharmacies.

The Centre for Social Medicine and Community Health at Jawaharlal Nehru University in Delhi has condemned the government’s “knee-jerk” response to a media-generated panic about a relatively mild virus. By involving the private sector without regulating its practice, the government has issued a licence to make money.

Indeed, the health minister has stated that private hospitals conducting tests would be allowed to fix their own rates – business as usual.

On August 11, the National Institute of Virology acknowledged that there was no longer any point in routine testing for H1N1/09. Testing thousands of samples overloads the system (it also costs up to Rs 10,000 per person tested), it doesn’t affect treatment, and we know the virus is established in the community.

That may not prevent many private doctors from ordering these tests – whether because their patients demand it or for other reasons. It happens routinely with other drugs, tests, procedures. Will it be any different for this flu? The media-generated panic will certainly help some unscrupulous doctors order all sorts of expensive and unnecessary treatments.

Tamiflu is no wonder drug

Oseltamivir or Tamiflu, the antiviral drug available in India, has limited value. For one, it is best taken within 48 hours of symptoms. Second, it only reduces the severity of infection which must in any case run its course. Third, it is known to have side-effects which may outweigh the benefits of routine use. Finally, resistance to the drug has already been documented, and this will certainly become more common in the near future. `

So the health minister’s announcement that another 2 crore tablets of oseltamivir had been bought was little more than a political gesture, says Dr Shahid Jameel, group leader, virology, at the International Centre for Genetic Engineering and Biotechnology in Delhi. The same is true for the announcement that the ICMR was working on an indigenous H1N1/09 test instead of the current WHO-accredited test that is priced at Rs 10,000 and is patented by a US company. Of course we should ask why the test should cost so much if it is of critical importance. But that is not the need of the moment.

“Fortunately, this flu has a relatively low complication and mortality rate, but that doesn’t mean it will stay like that,” says Dr Sridhar. “Also, it is not going to go away on its own. It’s going to keep coming back, because the population has not been exposed to it, especially the younger generation.” This virus has genetic material from earlier pandemic flu which older people may have encountered in their youth. “Most people will have mild infections, but some will have serious illness. There’s not much more we can do until we have a vaccine to prevent infection as well as reduce its severity.”

We can’t vaccinate everyone

A flu vaccine would prevent many infections, reduce the severity of infection and indirectly reduce the transmission of infection. Vaccines would be used in priority – those at high risk of severe infection and healthcare workers whose jobs expose them most to the flu.

The seasonal flu vaccine is made from a “seed” virus, which is isolated from the various samples made available to the WHO by countries across the world. This virus sample is selected because it represents the dominant strain of the virus in circulation. The same process is used for H1N1/09, says Dr Jameel.

The vaccine manufacture process is relatively straightforward and internationally manufacturers expect to have a vaccine ready by November. Three foreign companies should be out with vaccines by the end of this year, in time for the flu season in cold countries. But the bulk of this supply has been paid for in advance and “booked” by governments of developed countries.  In May there was a dispute between vaccine manufacturers and some developing countries on whether those who provided virus samples would be assured the vaccine and we do not know how this has been resolved.

But in any case, you can’t give the vaccine to everyone, says Dr Jameel. There is limited production capacity worldwide, and certainly in India. And while three Indian companies have also been given the seed virus and expect to have a vaccine out by the end of the year, the Indian government will have to place orders with these companies to be assured of vaccines for groups at high risk.

This flu has underlined the fact that we don’t have adequate vaccine manufacturing capacity, says Dr Amit Sengupta of the Delhi Science Forum. Even if this particular flu is not serious, we should be able to manufacture vaccines when we need them.

“Developing a vaccine should not be rocket science,” says S Srinivasan of LOCOST Pharmaceuticals, Vadodara. But it’s going to take time to take the vaccine through safety and efficacy trials and get regulatory approval.

Perhaps the most important question is whether the government has ensured that it has rights to the technologies developed with its support. Srinivasan notes that the department of biotechnology has called for applications for developing a testing kit and a vaccine. We can assume that the companies will have agreed to supply vaccines to the government. We cannot assume that the technology developed will be available in the public domain. “If the government has funded the technology, it is co-owner. Has it retained the right to manufacture the vaccine at its own production units?” he asks.

Will people benefit?

The H1N1/09 flu is treated much the same way other influenza is. The necessary healthcare infrastructure is the same as is needed for many other diseases – and should have been in place anyway. People should be assured appropriate and affordable treatment whether or not this influenza becomes a big deal. Unfortunately, these basic rights are not fulfilled in India. Those with the money buy expensive treatment that might be irrational and sometimes dangerous. Those without the money usually do without; some may be better off as a result, some may be worse. Will this change overnight? Not likely.

Infochange News & Features, August 2009