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India on alert: Implications of the avian influenza outbreak

By Sandhya Srinivasan

The outbreak of bird flu in Nandurbar district, Maharashtra, is particularly worrisome for a country like India, which has a weak public health system and an annual per capita public health expenditure of just Rs 200

"Several countries with outbreaks in poultry have weak health infrastructures, with weak capacity for the detection of cases, particularly in rural areas where the majority of domestic birds are raised. Capacity to diagnose a difficult disease such as H5N1 is also weak. Moreover... the full clinical spectrum of H5N1 illness is unknown. Milder cases of illness could be occurring, yet fail to reach the attention of health care staff."

These comments from the website of the World Health Organisation are of particular concern in India today.

On February 18, 2006, the High Security Animal Disease Laboratory in Bhopal, central India, confirmed that the H5N1 virus was found in samples from birds following mass poultry deaths starting in late-January. The virus causes 'highly pathogenic avian influenza', more commonly known as bird flu. This is the latest in the series of outbreaks caused by the H5N1 virus all over Asia and more recently in eastern Europe and Africa. These outbreaks have resulted in the death of more than 1.5 million farm birds, through disease or through culling for outbreak control.

By the time the government made the announcement, press reports indicate, up to 40,000 chickens had already died on poultry farms in Nawapur taluka, Nandurbar district, a tribal area in Maharashtra 460 km from Mumbai.

The state government immediately announced plans to slaughter all poultry in the 'alert zone' 3 km around the affected farms and to vaccinate all poultry in farms within the 'surveillance zone' of 10 km radius.

The poultry industry has contested the laboratory findings and demanded repeat testing though there seems to be no doubt about the diagnosis. Further, the compensation of between Rs 10 and Rs 40 per bird is seen by farmers as extremely inadequate. Government teams in some places have been met by belligerent farmers angry at the prospect of losing their livelihoods overnight. Small poultry farmers have refused to permit what they see as pointless destruction of healthy chickens and without just compensation. There are reports of distress and covert sale of healthy-looking chickens.

Press reports also indicate that the WHO guidelines for slaughter and disposal of potentially infected poultry are not being followed uniformly. Some affected poultry farms seem to be exempt. Reporters have seen birds being slaughtered and disposed of without protection to workers or the environment. Newspaper photographs show government health workers in 'space suits' alongside farm workers handling birds with no protective gear.

India is the second largest egg producer and the fifth largest broiler producer in the world, according to the National Egg Coordination Committee. It employs more than 3 million people in rural areas. Poultry farm owners in the region face losses that could wipe them out. And thousands of workers are being rendered jobless as farms are shut down. Finally, in a country like India, and particularly in a poor region like Nandurbar, many people would prefer the unknown risk of an unknown illness to the certainty of hunger.

The feelings of small poultry farmers are understandable since government inaction has encouraged poultry farming without ensuring hygienic breeding conditions. Poultry in India is often handled in conditions which provide the perfect breeding ground for disease outbreaks. Birds are packed tightly into pens encouraging the quick spread of any infection, they are transported to the market in cages covered with excrement, and markets are strewn with feathers and unwanted body parts of slaughtered birds.

Without becoming an agent of vegetarian fascism, it must be noted that livestock breeding worldwide is rife with malpractices such as pumping animals with steroids and antibiotics to increase their size, feeding herbivores animal waste to reduce the cost of feed, and slaughtering methods that allow infected meat to contaminate uninfected meat. The last is illustrated by the story of mad cow disease and its move from cows to human beings.

Indeed, while both migratory birds and smuggled birds have been suspected as the cause of the spread of the H5N1 virus, many feel that the most likely route is through the international commerce in chickens for the poultry industry. The government banned the import of chicks in February 2004.

Bird to human H5N1 infection

When humans have been infected by H5N1 through close contact with poultry, they have suffered an aggressive illness, damaging the lungs and often resulting in multi-organ failure. There is no vaccine for humans and while an antiviral drug has been developed, treatment has often necessitated ventilator support as well.

As of February 20, 2006, the World Health Organisation recorded 170 laboratory-confirmed cases of human infection, and 92 deaths - a case fatality rate of more than 50%. They have occurred in Cambodia, China, Indonesia, Iraq, Thailand, Turkey and Vietnam. The most recent death was of an egg-seller in Indonesia on February 10, 2006.

(The WHO documents only laboratory-confirmed cases. More people may have had bird flu but did not get tested properly or tested at all. Also, people who might have suffered milder infections may not have even been suspected of having the bird flu.)

The poultry workers in Nandurbar are likely to be poor tribals whose malnourished condition increases their risk of infection and the severity of illness. Human exposure also increases in poor regions where the birds are part of households. Forty per cent of the 490 million birds in the country are reared on backyard farms.

"This is a huge epidemic in birds," says Dr Jacob John, referring to the outbreak in Indian poultry. "The amount of virus in the environment would be so high that most likely several people will be infected."

The prospects of human to human infection

All documented instances of H5N1 infection in humans so far have been traced to contact with infected birds. There has been no proven human to human infection of bird flu. But the H5N1 virus is constantly mutating, and it is feared that it will eventually mutate into one that moves from human to human.

If that happens, highly pathogenic avian influenza will spread like wildfire. The flu virus spreads through droplets in the air, from coughing or sneezing, and infection is almost impossible to contain.

While influenza sweeps the world every winter, it is usually relatively mild except in the elderly and otherwise immuno-compromised. But if a human H5N1 develops, WHO's conservative estimates are between 2 and 7.4 million deaths.

With the virus' potential to adapt to human hosts, a human epidemic can
develop," writes Jacob John in a November 2005 commentary in the Economic
and Political Weekly
on the public health implications for India of the
bird flu.

"The risk may be very small but the consequences could be unimaginably severe... If the mortality trend continues we will have an infrastructural breakdown affecting all societal activities - hospitals may not have enough personnel, schools, cinema halls and offices may have to be shut down and all forms of transportation may come to a standstill... Countries with robust public health systems are gearing up to face a H5N1 global epidemic (pandemic). In this context, India's weakness in public health is a cause for worry " wrote Dr John in the EPW commentary.

Need for a disease surveillance system

"Many diseases, even outbreaks, are not diagnosed by cause, for want of sufficient laboratory support services; and there is no functional disease and death surveillance system. Thus information generation and gathering are both primitive and inadequate," wrote Jacob John in an editorial for the Economic and Political Weekly in November 2005 on the public health implications for India of the bird flu.

As a result, he pointed out, the country has seen repeated outbreaks of Japanese encephalitis, dengue haemorrhagic fever, leptospirosis, cholera, and typhoid. The government's vertical disease control programme addresses only TB, malaria, HIV/STDs, filariasis and a selection of childhood diseases. So we are mute witnesses to regular outbreaks such as when at least 1.5 million children in Eastern Uttar Pradesh were infected by Japanese encephalitis between August and October 2005. Over the years, dengue and JE outbreaks have become regular occurrences in India, and have extended their coverage in the country.

The need for accurate routine disease surveillance was obvious following the deluge Mumbai experienced in July 2005. Leptospirosis is transmitted through skin contact with animal urine - possible in Mumbai's annual floods and even more so when the flood waters were 10 feet high in some areas. Cholera, typhoid and some variants of hepatitis are transmitted by faecal contamination of drinking water and food. All three are known to occur regularly in Mumbai, with a peak during the rainy seasons.

But the public records of such diseases are highly inaccurate. The surveillance system is based solely on information from public hospitals and clinics, though private services see the vast majority of people seeking care. Private hospitals and clinics do not follow the law on notifiable diseases, apparently in order to avoid the associated red tape.

With such scanty information, the authorities were in no position to deny - or assert - the existence of any epidemic. Pressed to declare whether there was an epidemic of these diseases in Mumbai, a reluctant health department did a number of flip-flops on the subject. Some officials argued that there had actually been a decline in such diseases compared to previous years. And in one hospital, pathology reports confirming cholera were reportedly falsified because the health department did not want to acknowledge the existence of this serious disease.

Public health systems

If H5N1 ever starts spreading from human to human the burden on our public health system is hard to imagine. We might learn some lessons from the July 2005 Mumbai floods. Over-worked staff in public hospitals were soon overwhelmed by the crowds of patients. Many ill people were forced to go to private hospitals, paying for treatment from their own pockets. Voluntary organisations struggled to provide services in the slums and other less accessible areas where government staff apparently did not turn up.

This was inevitable given the consistent manner in which the government has withdrawn from health services over the years, particularly after the Structural Adjustment Programme after 1991. Public hospitals are being turned over to private parties to run on a 'for-profit' basis. The top government hospitals in Mumbai are witnessing an exodus of medical professionals - they're going into private practice either for better prospects or because they find the working conditions in government hospitals intolerable.

We have not invested much in the public sector," says Dr John in an interview. . "The government's vertical programmes do not provide space to respond to new diseases. The public health system must be such that it is always prepared for any disease."

Drugs

More difficulties are highlighted when one considers the availability of life-saving drugs. The current outbreak may be an opportunity to challenge the patent on the antiviral drug oseltamivir. The patent-holder Roche has licensed manufacture to a local company, Hetero. But in November 2005 Cipla declared its intention to challenge the patent. Roche's patent application is in the patent mailbox in India. Yusuf Hamied, chairperson and managing director of Cipla, has been quoted as saying that there is no clarity over the patent on this drug. Since India has not yet granted a patent to the drug, Cipla and other companies seem confident of manufacturing the drug without serious legal opposition.

The drug is to be given only to people with symptoms of the infection or with exposure to the virus. "Drug use must be carefully controlled in such situations," notes Jacob John. "They must be prescribed by competent people, on the basis of need, and distributed equitably, not hoarded by those with money." Misuse of the drugs will quickly create resistant strains.

The demand will be greater in the event of a human-to-human H5N1 flu pandemic However, a single course of oseltamivir costs Rs 650 at the current wholesale rate. According to the National Health Policy 2002, the annual per capita public health expenditure is no more than Rs 200.

InfoChange News & Features, February 2006