BMJ 2015;350:h2286 doi: 10.1136/bmj.h2286 (Published 29 April 2015)
Page 1 of 3
Feature
FEATURE PUBLIC HEALTH
Swine flu: how well did India respond? Some media reports criticised the response, suggesting the recent outbreak of swine flu had led to panic. Jeetha D’Silva reports on India’s increasing preparedness and where more needs to be done to reduce morbidity and mortality Jeetha D’Silva journalist, Mumbai, India The current outbreak of swine influenza A H1N1 virus sweeping across India is one of the worst flu outbreaks the country has seen in recent years, with over 35 000 people infected1 and 2335 deaths from 1 January to 21 April.2 In the last major outbreak, which followed the global flu pandemic of 2009, India saw 47 840 cases and 2744 deaths during May 2009 to December 2010.3 In the current outbreak, although rapid transmission is a worry, it is the high mortality that has been most alarming. In Jaipur, where the infection broke out in late December, swine flu caused three deaths in the first week of January.4 At the last count, the state had had 429 deaths from swine flu, with 6671 people infected. Rajasthan’s neighbouring state, Gujarat, has had 6561 cases of swine flu since January and a death toll of 439.1 Dinkar Raval, deputy director of epidemics, Gujarat, told The BMJ that the high death rate of 6.63% was “baffling and worrisome.” In comparison, global mortality during the 2009 flu pandemic was 1 in 5000 (0.02% of those infected).5
Better prepared Doctors who are directly involved in managing swine flu cases also reported an improvement in response compared with the last outbreak. Om Shrivastav, director of the infectious disease clinic at Jaslok Hospital, a private hospital in Mumbai, said that management of flu outbreaks has improved in the state: “In 2009, we did not know how to deal with the outbreak. At one point, we were screening almost 1000 patients a day. At the peak of this outbreak, our teams were better prepared and were screening about 200 people each day.” Shrivastav, who also heads the infectious disease unit at Mumbai’s civic run Kasturba Hospital, said that this time the medical teams were better trained and the facilities were better equipped. For instance, there were adequate stocks of oseltamivir, protective gear, and ventilators.
Improvements over 2009
Mandatory notification
Despite the high incidence and mortality, health system officials claim that the health ministries at central and state levels have been building competency to deal with influenza outbreaks since the 2009-10 epidemic. Pradip Awate, state surveillance officer for Maharashtra’s integrated disease surveillance programme, told The BMJ, “Between 2009 and now, we have improved our diagnostic facilities and treatment facilities.” Since the previous outbreak, he said, the state had formulated guidelines for managing influenza cases, trained doctors, and created facilities to manage patients with flu.
Nilesh Shah, group president, scientific services and operations, at Metropolis Laboratories, a diagnostic and pathology testing company with a pan-India presence, said that the government clamped down on indiscriminate testing by mandating that tests can be conducted only after a referral from a doctor.
Maharashtra had only one diagnostic facility in 2009, and now it has eight sites that can test for swine flu: four government centres and four authorised private providers. This has improved diagnosis and monitoring of incidence, said Awate. In addition, 128 hospitals were ready to deal with the outbreak.
“The government also made it mandatory to notify it of the results of all tests,” Shah said. The government provided regular updates on the number of patients screened, tested, and admitted to hospital—as well as deaths.6 Many people were treated earlier and hence the statistics were marginally better than in 2009-10, when 6118 cases were reported in the state, with a death toll of 669.7 This year, Maharashtra has reported 422 deaths, with 4670 people infected.
Gujarat too claimed that a lot of effort had gone into dealing with the outbreak. “We provided free testing to all patients. Free medicines were provided to all patients, irrespective of whether they were admitted to government or private hospitals. We even provided free vaccination to all healthcare workers, including drivers of ambulances,” Raval said.
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BMJ 2015;350:h2286 doi: 10.1136/bmj.h2286 (Published 29 April 2015)
Page 2 of 3
FEATURE
“The state ensured that there was adequate stock of vaccines, diagnostic kits, medication, and masks,” he said. The Gujarat health department also launched an awareness campaign, employing more than 100 000 community workers, who went door to door to educate people about the infection.
“Despite all our efforts, the numbers continued to rise,” admitted Raval, indicating the relentless pressure on the state’s health infrastructure.
Management criticised Not surprisingly, management of the outbreak has been criticised. The leadership of state health systems has been put on the back foot by the fact that increased efforts have not improved the numbers.
Media reports blamed lack of awareness, infrastructure, and resources for the inability to tackle the epidemic at various levels. One report in The Tribune said that the outbreak “has raised many questions about the country’s capacity to regularly monitor respiratory infections.”8 Another on the BBC’s website indicates that India is “struggling” with the outbreak.9 The outbreak has also led to some activism against the government. A few public interest litigations have been filed in the Gujarat High Court and the Bombay High Court, reflecting public angst.10 11
What really went wrong? One explanation for the high mortality is comorbidity. “In Maharashtra, we saw that 68% of those who died had comorbid conditions,” said Awate. Manish Kakkar, senior public health specialist, communicable diseases and adjunct associate professor at the Public Health Foundation of India, a New Delhi based public-private venture, said that a large scale outbreak that spreads rapidly would probably have taken most countries by surprise.
Recent outbreaks in Europe show that even countries with well established influenza monitoring and management programmes have struggled to cope. France reported a flu epidemic earlier this year with more than 2.5 million cases. It also saw record death rates earlier this year—a 19% increase above the average for the period—mostly the result of influenza.12 In England and Wales, mortality rose by almost a third this January because of vaccine resistant flu and the cold weather. Almost 28 000 people died in the fortnight before 23 January, about 7000 above the five year average.13 Kakkar thinks that India is increasingly well prepared for outbreaks of infectious diseases. “Systems have been put in place, diagnostic and critical care facilities have been set up, and there has been a fair amount of training and retraining that has been conducted on a regular basis,” he said.
Kakkar described one of the gaps in the government’s response: “Risk communication has to be timely and effective.” Misinformation among doctors at the start of the outbreak could have been avoided by advance training, he said. “There is always scope for improvement of surveillance: it has to be more comprehensive and in real time. Currently many of the smaller surveillance centres update periodically, adding to the risk of under-reporting. And we need to have in place well trained rapid response teams of doctors who can deal with such a crisis swiftly and efficiently.”
Preparing for next time As swine flu cases subside with rising temperatures, health officials in several states acknowledge that the outbreak presented the government with a challenge.
“We are now working towards a more robust and responsive system,” said Raval. The Gujarat health department is testing new surveillance software that will enable reporting in real time.
“We are also developing new manuals, especially for community health workers. In addition, we will ensure that every doctor in the state is trained on a regular basis through continuing medical education programmes. These measures will make the state more vigilant and better prepared to deal with future outbreaks,” he said. In Maharashtra, a technical committee is being set up to review the outbreak. “We know that there are lacunae: we need to identify them and plug the gaps in our surveillance, preparedness, and response,” said Awate. “We are also considering an immunisation policy, especially for those with conditions that make them at high risk of complications. Hopefully, by the next cycle, which is expected after the monsoons, we should be better prepared.” Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6 7
Scope for improvement
8
Notwithstanding some appreciation of the current efforts, the consensus is that India still has a lot of scope for improvement. Nata Menabde, WHO representative to India, told The BMJ that the WHO Country Office for India has been advising the Health Ministry about preparedness and response for seasonal influenza outbreaks. It has been continuously advocating for augmenting influenza surveillance, outbreak preparedness, and response, as well as recommending influenza vaccination for high risk groups.
9
For personal use only: See rights and reprints http://www.bmj.com/permissions
10 11 12 13
Six more swine flu deaths, toll touches 2159. Economic Times 2015 Apr 6. http://articles. economictimes.indiatimes.com/2015-04-09/news/60979442_1_swine-flu-h1n1-virus-tolltouches. Swine flu claims 2335 lives in India. DNA 2015 Apr 28, http://www.dnaindia.com/india/ report-swine-flu-claims-2335-lives-in-india-2081453. Ministry of Health and Family Welfare. Cases of influenza A H1N1 (swine flu)–state/UT-wise, year-wise for 2009, 2010, 2011 and 2012. http://mohfw.nic.in/showfile. php?lid=2121. Swine flu claims 3 lives in Rajasthan in 6 days, NDTV 2015 Jan 6. www.ndtv.com/indianews/swine-flu-claims-3-lives-in-rajasthan-in-6-days-723336. Roos R. Study puts global 2009 pandemic H1N1 infection rate at 24%. 2013.www.cidrap. umn.edu/news-perspective/2013/01/study-puts-global-2009-pandemic-h1n1-infectionrate-24. Status of influenza A (H1N1) in the state of Maharashtra, 29.03.2015. https://arogya. maharashtra.gov.in/Site/Uploads/Category/H1N1_State_Report_Date_29.03.15.pdf. Pal S. 100 deaths per month, still doctors say swine flu nothing to worry. DNA 2015 Mar 18. www.dnaindia.com/mumbai/report-100-deaths-per-month-still-doctors-say-swine-flunothing-to-worry-2069704. Tandon A. Why swine flu has country holding breath. Tribune 2015 Mar 8. www. tribuneindia.com/news/sunday-special/kaleidoscope/why-swine-flu-has-country-holdingbreath/50701.html. India struggles with deadly swine flu outbreak, BBC 2015 Feb 20. www.bbc.com/news/ world-asia-india-31547455. Gujarat High Court PIL seeks compensation for families of swine flu victims. IBN Live 2015 Mar 5. http://ibnlive.in.com/news/gujarat-high-court-pil-seeks-compensation-forfamilies-of-swine-flu-victims/532261-17.html. Deshpande V. PIL filed in HC against rising swine flu cases in Maharashtra. The Hindu 2015 Mar 10. www.thehindu.com/news/cities/mumbai/pil-filed-in-bombay-hc-against-risingswine-flu-cases-in-maharashtra/article6978142.ece. Record winter mortality rate in France blamed on flu; RFI 2015 Mar 12. www.english.rfi. fr/france/20150312-winter-high-mortality-rate-france-influenza-blame. NHS Choices. Flu and freezing weather may be driving up winter death rates, 4 Feb 2015. www.nhs.uk/news/2015/02february/pages/flu-and-freezing-weather-may-be-driving-upwinter-death-rates.aspx.
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2286 doi: 10.1136/bmj.h2286 (Published 29 April 2015)
Page 3 of 3
FEATURE
Cite this as: BMJ 2014;349:h2286
For personal use only: See rights and reprints http://www.bmj.com/permissions
© BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Feature
FEATURE PUBLIC HEALTH
Swine flu: how well did India respond? Some media reports criticised the response, suggesting the recent outbreak of swine flu had led to panic. Jeetha D’Silva reports on India’s increasing preparedness and where more needs to be done to reduce morbidity and mortality Jeetha D’Silva journalist, Mumbai, India The current outbreak of swine influenza A H1N1 virus sweeping across India is one of the worst flu outbreaks the country has seen in recent years, with over 35 000 people infected1 and 2335 deaths from 1 January to 21 April.2 In the last major outbreak, which followed the global flu pandemic of 2009, India saw 47 840 cases and 2744 deaths during May 2009 to December 2010.3 In the current outbreak, although rapid transmission is a worry, it is the high mortality that has been most alarming. In Jaipur, where the infection broke out in late December, swine flu caused three deaths in the first week of January.4 At the last count, the state had had 429 deaths from swine flu, with 6671 people infected. Rajasthan’s neighbouring state, Gujarat, has had 6561 cases of swine flu since January and a death toll of 439.1 Dinkar Raval, deputy director of epidemics, Gujarat, told The BMJ that the high death rate of 6.63% was “baffling and worrisome.” In comparison, global mortality during the 2009 flu pandemic was 1 in 5000 (0.02% of those infected).5
Better prepared Doctors who are directly involved in managing swine flu cases also reported an improvement in response compared with the last outbreak. Om Shrivastav, director of the infectious disease clinic at Jaslok Hospital, a private hospital in Mumbai, said that management of flu outbreaks has improved in the state: “In 2009, we did not know how to deal with the outbreak. At one point, we were screening almost 1000 patients a day. At the peak of this outbreak, our teams were better prepared and were screening about 200 people each day.” Shrivastav, who also heads the infectious disease unit at Mumbai’s civic run Kasturba Hospital, said that this time the medical teams were better trained and the facilities were better equipped. For instance, there were adequate stocks of oseltamivir, protective gear, and ventilators.
Improvements over 2009
Mandatory notification
Despite the high incidence and mortality, health system officials claim that the health ministries at central and state levels have been building competency to deal with influenza outbreaks since the 2009-10 epidemic. Pradip Awate, state surveillance officer for Maharashtra’s integrated disease surveillance programme, told The BMJ, “Between 2009 and now, we have improved our diagnostic facilities and treatment facilities.” Since the previous outbreak, he said, the state had formulated guidelines for managing influenza cases, trained doctors, and created facilities to manage patients with flu.
Nilesh Shah, group president, scientific services and operations, at Metropolis Laboratories, a diagnostic and pathology testing company with a pan-India presence, said that the government clamped down on indiscriminate testing by mandating that tests can be conducted only after a referral from a doctor.
Maharashtra had only one diagnostic facility in 2009, and now it has eight sites that can test for swine flu: four government centres and four authorised private providers. This has improved diagnosis and monitoring of incidence, said Awate. In addition, 128 hospitals were ready to deal with the outbreak.
“The government also made it mandatory to notify it of the results of all tests,” Shah said. The government provided regular updates on the number of patients screened, tested, and admitted to hospital—as well as deaths.6 Many people were treated earlier and hence the statistics were marginally better than in 2009-10, when 6118 cases were reported in the state, with a death toll of 669.7 This year, Maharashtra has reported 422 deaths, with 4670 people infected.
Gujarat too claimed that a lot of effort had gone into dealing with the outbreak. “We provided free testing to all patients. Free medicines were provided to all patients, irrespective of whether they were admitted to government or private hospitals. We even provided free vaccination to all healthcare workers, including drivers of ambulances,” Raval said.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2286 doi: 10.1136/bmj.h2286 (Published 29 April 2015)
Page 2 of 3
FEATURE
“The state ensured that there was adequate stock of vaccines, diagnostic kits, medication, and masks,” he said. The Gujarat health department also launched an awareness campaign, employing more than 100 000 community workers, who went door to door to educate people about the infection.
“Despite all our efforts, the numbers continued to rise,” admitted Raval, indicating the relentless pressure on the state’s health infrastructure.
Management criticised Not surprisingly, management of the outbreak has been criticised. The leadership of state health systems has been put on the back foot by the fact that increased efforts have not improved the numbers.
Media reports blamed lack of awareness, infrastructure, and resources for the inability to tackle the epidemic at various levels. One report in The Tribune said that the outbreak “has raised many questions about the country’s capacity to regularly monitor respiratory infections.”8 Another on the BBC’s website indicates that India is “struggling” with the outbreak.9 The outbreak has also led to some activism against the government. A few public interest litigations have been filed in the Gujarat High Court and the Bombay High Court, reflecting public angst.10 11
What really went wrong? One explanation for the high mortality is comorbidity. “In Maharashtra, we saw that 68% of those who died had comorbid conditions,” said Awate. Manish Kakkar, senior public health specialist, communicable diseases and adjunct associate professor at the Public Health Foundation of India, a New Delhi based public-private venture, said that a large scale outbreak that spreads rapidly would probably have taken most countries by surprise.
Recent outbreaks in Europe show that even countries with well established influenza monitoring and management programmes have struggled to cope. France reported a flu epidemic earlier this year with more than 2.5 million cases. It also saw record death rates earlier this year—a 19% increase above the average for the period—mostly the result of influenza.12 In England and Wales, mortality rose by almost a third this January because of vaccine resistant flu and the cold weather. Almost 28 000 people died in the fortnight before 23 January, about 7000 above the five year average.13 Kakkar thinks that India is increasingly well prepared for outbreaks of infectious diseases. “Systems have been put in place, diagnostic and critical care facilities have been set up, and there has been a fair amount of training and retraining that has been conducted on a regular basis,” he said.
Kakkar described one of the gaps in the government’s response: “Risk communication has to be timely and effective.” Misinformation among doctors at the start of the outbreak could have been avoided by advance training, he said. “There is always scope for improvement of surveillance: it has to be more comprehensive and in real time. Currently many of the smaller surveillance centres update periodically, adding to the risk of under-reporting. And we need to have in place well trained rapid response teams of doctors who can deal with such a crisis swiftly and efficiently.”
Preparing for next time As swine flu cases subside with rising temperatures, health officials in several states acknowledge that the outbreak presented the government with a challenge.
“We are now working towards a more robust and responsive system,” said Raval. The Gujarat health department is testing new surveillance software that will enable reporting in real time.
“We are also developing new manuals, especially for community health workers. In addition, we will ensure that every doctor in the state is trained on a regular basis through continuing medical education programmes. These measures will make the state more vigilant and better prepared to deal with future outbreaks,” he said. In Maharashtra, a technical committee is being set up to review the outbreak. “We know that there are lacunae: we need to identify them and plug the gaps in our surveillance, preparedness, and response,” said Awate. “We are also considering an immunisation policy, especially for those with conditions that make them at high risk of complications. Hopefully, by the next cycle, which is expected after the monsoons, we should be better prepared.” Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6 7
Scope for improvement
8
Notwithstanding some appreciation of the current efforts, the consensus is that India still has a lot of scope for improvement. Nata Menabde, WHO representative to India, told The BMJ that the WHO Country Office for India has been advising the Health Ministry about preparedness and response for seasonal influenza outbreaks. It has been continuously advocating for augmenting influenza surveillance, outbreak preparedness, and response, as well as recommending influenza vaccination for high risk groups.
9
For personal use only: See rights and reprints http://www.bmj.com/permissions
10 11 12 13
Six more swine flu deaths, toll touches 2159. Economic Times 2015 Apr 6. http://articles. economictimes.indiatimes.com/2015-04-09/news/60979442_1_swine-flu-h1n1-virus-tolltouches. Swine flu claims 2335 lives in India. DNA 2015 Apr 28, http://www.dnaindia.com/india/ report-swine-flu-claims-2335-lives-in-india-2081453. Ministry of Health and Family Welfare. Cases of influenza A H1N1 (swine flu)–state/UT-wise, year-wise for 2009, 2010, 2011 and 2012. http://mohfw.nic.in/showfile. php?lid=2121. Swine flu claims 3 lives in Rajasthan in 6 days, NDTV 2015 Jan 6. www.ndtv.com/indianews/swine-flu-claims-3-lives-in-rajasthan-in-6-days-723336. Roos R. Study puts global 2009 pandemic H1N1 infection rate at 24%. 2013.www.cidrap. umn.edu/news-perspective/2013/01/study-puts-global-2009-pandemic-h1n1-infectionrate-24. Status of influenza A (H1N1) in the state of Maharashtra, 29.03.2015. https://arogya. maharashtra.gov.in/Site/Uploads/Category/H1N1_State_Report_Date_29.03.15.pdf. Pal S. 100 deaths per month, still doctors say swine flu nothing to worry. DNA 2015 Mar 18. www.dnaindia.com/mumbai/report-100-deaths-per-month-still-doctors-say-swine-flunothing-to-worry-2069704. Tandon A. Why swine flu has country holding breath. Tribune 2015 Mar 8. www. tribuneindia.com/news/sunday-special/kaleidoscope/why-swine-flu-has-country-holdingbreath/50701.html. India struggles with deadly swine flu outbreak, BBC 2015 Feb 20. www.bbc.com/news/ world-asia-india-31547455. Gujarat High Court PIL seeks compensation for families of swine flu victims. IBN Live 2015 Mar 5. http://ibnlive.in.com/news/gujarat-high-court-pil-seeks-compensation-forfamilies-of-swine-flu-victims/532261-17.html. Deshpande V. PIL filed in HC against rising swine flu cases in Maharashtra. The Hindu 2015 Mar 10. www.thehindu.com/news/cities/mumbai/pil-filed-in-bombay-hc-against-risingswine-flu-cases-in-maharashtra/article6978142.ece. Record winter mortality rate in France blamed on flu; RFI 2015 Mar 12. www.english.rfi. fr/france/20150312-winter-high-mortality-rate-france-influenza-blame. NHS Choices. Flu and freezing weather may be driving up winter death rates, 4 Feb 2015. www.nhs.uk/news/2015/02february/pages/flu-and-freezing-weather-may-be-driving-upwinter-death-rates.aspx.
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2286 doi: 10.1136/bmj.h2286 (Published 29 April 2015)
Page 3 of 3
FEATURE
Cite this as: BMJ 2014;349:h2286
For personal use only: See rights and reprints http://www.bmj.com/permissions
© BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
