Swine Flu: A Challenge for Public Health

Death toll from Swine flu or H1N1 virus is on the increase in India, and the Indian Public Health system seems to have failed to respond to the threat from the H1N1 virus. Newsclick interviewed Dr. Satyajit Rath, National Institute of Immunology to understand the seriousness of issue. According to Dr. Rath there is very little data available with the public health system and government is not prepared to deal with such outbreaks. He thinks that government should stop portraying the current outbreak as a major crisis or epidemic. While taking care of those severely ill, government should learn from the episode, address the everyday health situations and how to handle such short term crisis.

Rough Transcript

D.Raghunandan (DR):Hello and welcome to Newsclick. Today we are discussing the swine flu outbreak which seems to be very persistent. To discuss this issue with us, we have Dr. Satyajit Rath, President of the Delhi Science Forum and a Senior Scientist at National Institute of Immunology. Welcome Satyajit. Why has this Swine flu strain remained apparently as persistent as it has recurring frequently with rather high incidence and should we be worried about it?

Satyajit Rath(SR):It's not very clear that it is more or less persistent than many other flu viruses. Flu viruses are very large shall we say family or clan. The exchange material between each other in various ways and they change to small extents. So long as the changes are small we still recognize the descendant viruses and the original viruses. If you think about this particular H1N1 virus flu, it's H1NI1 2009 swine flu virus. It is not called Swine flu virus because pigs transmit it, simply because it has some genetic signatures of pig influenza virus in it. It's not very long. It's 4 or 5 or 6 years since we first detected it. So it is not terribly surprising that it is still around. The real questions are two fold. Number 1 is how prominent is this particular influenza virus in comparison with many other influenza viruses what are commonly referred to as seasonal flu viruses. And the second question is, in answer to your second question is how much we should be worried. How dangerous is it? Now, if you look at Western data, if you look at American and European data, this virus in no more prominent than many other of its cousins in the influenza clan. Nor its severity and morbidity or the chances for dying from it is dramatically higher than other seasonal influenza viruses. There is an interesting difference there that we can talk about later. Broadly, this is true. But this is all about the West. In India, is this correct or is this not correct. Unfortunately, the short answer to that is we don't know. We don't know because we have a health system which neither delivers health reliably nor does it collect information reliably. As a result of that, we don't know what frequency to any reliable extent. We have individual people, epidemiologists struggling manfully or womenfully with this problem. But, the real difficulty is we don't have nationwide reliable rigorous estimate. We don't know how many people per thousand population per week let us say suffer from influenza like illness. Of influenza like illnesses, what proportion are influenza viruses. Of those what proportion are H1N1. And have those numbers shifted dramatically. Now, if we don't know the original numbers, there are no ways to make us guesses about it.

DR: In fact, Satyajit, that was going to be my next question, related to what is the state of preparedness in India and I believe very similar if not slightly more serious incidences are taking place across the border in Pakistan. Is this a South Asian problem more acutely than in other regions. And is that due as much to the state of preparedness of the public health system in this region as to the virus itself.

SR: One of the pre-requisites of dealing with infectious disease has health crisis of this kind is to have information. Clearly, while we have anecdotal small study information have been from variety of places. We don't have rigorous information because we don't have disease surveillance of a quality that would provide these numbers reliably. Secondly, if we don't have that clearly that is one part of general difficulty we have about delivering health care. If we can't deliver health care for influenza like illnesses. For example, if you are suffering from cold, fever, this that and... the other what the newspapers and the others in public domain has been said. If you have fever for 102 degrees for more than two days, you should worry about this. The reality is how many people can worry about it, how many people can afford to worry about it and how many people if they do worry about it, can get timely, effective and efficient medical health, the answer to all of these is very few. Under those circumstance, what happens to that small groups so far it seems, small group of people who suffer from these kinds of viruses but who suffers very severe illness. And clearly, if we can't deal with ordinary illnesses. The likelihood of we deal effectively with good preparedness, with the more severe variety of illnesses is going to be very low and that really is the case. So let me just give an example, that's out there in public domain. People have actually said this that if you count that number of cases over say a fortnight or a month in these past few days that have tested to be flu virus positive by a genetic test for a flu viruses in Delhi versus Rajasthan. And then, if you count the number of these people, who have died in Delhi versus Rajasthan, now remember these numbers don't really tell us what the public health impact of the disease is. But, it does tell us what proportion in people on whom you are detecting the virus are dying and between Delhi and Rajasthan, those numbers are different. Many more people among the detected infected have died apparently if numbers are to be believed in Rajasthan compared to Delhi. Unsurprisingly, what this is underlining is the state of preparedness of our health-care delivery system for dealing with severe disease.

DR: Or with any form of outbreak taking place. Just a brief question since the media has been full of this. There are many commentators in the media who used the term epidemic to describe what is happening. Do you think the term is appropriate?

SR: Well, an epidemic is a very very large outbreak. One can debate actually what the numerical cut off is, very very large outbreak located, localised in time and space. Since I said, we don't know what the earlier situation was is very hard to characterise this as an epidemic. If you were not testing at the same level for it earlier, the fact that we are detecting more cases now than we were earlier, doesn't necessarily mean anything at all. So it is a little uncertain about whether we should be calling it epidemic or not.

DR: At least, in common perception it would look as if the world over we are facing increased incidences of such outbreaks. It was a SARS virus earlier, H1NI1, now Avian flu and then the more virulent HIV AIDS and recently the ebola outbreak. It looks as if we are encountering large outbreaks may be even call them pandemics. Is this the reality or is this the result of the greater knowledge that we have today, what does it tell us about the outbreaks of such diseases and the responses of the public health system the world over.

SR: So clearly, we are in the public domain encountering these events more and more no question. But is this really the consequence of many more infectious viruses out there, I don't think. An epidemial sort of demographic perspective on this would be have life expectancy decline measurably over the period, the answer seems to be no. Yet, is there something real under this perception and I would argue that the three realities under this perception. One is, as a species there are many more of us today than there were ten years. There were twenty years ago and there were thirty years ago. And the more crowded the species is, the easier it is for transmissible infection to spread. Beyond a point, this is almost a truce.

DR: There is also greater communication, people traveling…

SR: and added to that is the increasing human glottalization. Added to this is the fact, that despite everything our levels of inequality between different communities, between different groups has apparently over the last three decades certainly, rather than declining there seems to have been an increase.  Therefore, if inequality has been increased consequence of increase in inequality is likely to be an extremely desperate and increasingly unequal access for the inputs required for the health. Good nutrition, good health-care and all the associated issue and therefore, we may actually be creating the consequence, some categories of people who are particularly susceptible. And it is not surprising that the Ebola epidemic has taken the toll that it has taken in West Africa that Swine flu behaves very differently in the Global North compared to the Global South.

DR: Another question which certainly people of Delhi are asking other parts of the country as well, there is apparently a vaccine available for H1NI. Yet, health-care practitioners do not seem to be advocating it's use in the general population. Could you tell our viewers something about this.

SR: You see, flu vaccines are something of an oddity because flu vaccines provide protection against flu virus strains that are currently circulating. Even in West every year, new cocktails of vaccines are made. So every year, you have to take a vaccine shot. It's not clear to me that we know what flu virus train cocktails are circulating amongst us today for us to say, take this cocktail. Under those circumstances, the reason we seem worrying about taking a flu vaccine appears to be this H1N1 Flu. But this H1N1 flu in fact that turn out to be a small minority of overall flu. We don't know. If it turns out to be that then we have even less reason to worry about it as a vaccine target. In other word, what we began this conversation with is where we come back. The lack of information we have that is connected with the lack of public health delivery and disease surveillance means that there is not really good rational basis on which one can make recommendations about taking vaccines for a disease like flu that are very intimately dependent on what the current situation is.

DR: My last question is, are there any particular measures that you think the government at the centre and the states should take in response to the outbreak of H1N1?

SR: It's very tempting to refer to the H1N1 Swine flu as a crisis. I suggest once again that we don't have information needed to call it a crisis. And yet for governments it's equal tempting to treat it as a crisis and to mobilise itself, mobilise government “war footing” to deal with short term crisis after which everything can go back to what it was earlier. I would argue that it would be an inappropriate response. Certainly, government needs to deal with those who are severely ill. But it is not clear to me the numbers of those are such today as to constitute a crisis. Instead, what government needs to do is to see these outbreaks as those swallows that together makes a summer. They are telling us something about our state of preparedness not to deal with crisis real or imagined, they are telling us something about our lack of preparedness in dealing with the everyday health situations of all our people. If we those take those lessons to heart, and if we don't respond to those by a systematic increase in investment, increase in efficiency increase in capacity and manpower building, then we are not learning the lesson. That's Swine flu is teaching us.

DR: Thank you Satyajit.

SR: Thank you.