A sneeze, a global cold and testing times for China

Published in The Hindu on 1st February, 2020

The Year of the Rat has begun on an inauspicious note for China. A new virus belonging to the Coronavirus family (now named 2019-nCoV) has claimed over 100 casualties and numbers infected has crossed 4500. On 25 January, President Xi Jinping convened a meeting of the top leadership to underline the seriousness of the outbreak which has assumed epidemic proportions in China. Chinese authorities have been directed to take whatever steps are needed on emergency footing to deal with “a grave public health crisis”. However, for President Xi, it is more than a public health crisis, it is a credibility challenge, with both domestic and global dimensions.

Wuhan – the epicentre
Ironically, the epicentre of the outbreak is the bustling town of Wuhan which also hosts a number of biotech enterprises. The virus is believed to have originated in the ‘wet market’ in Wuhan where dead and live animals including seafood are stocked in close proximity. The genome of the new virus has been compared to more than 200 coronaviruses which normally affect animals revealing that this possibly originated in a certain species of local snakes. The virus underwent a change and, in the process, developed a capability that enables it to bind to human cells.

Normally, coronaviruses is a large family of viruses that are often the source of respiratory infections, including the common cold. Majority of the viruses are common among animals and only a small number infect humans. Sometimes, an animal-based coronavirus mutates and successfully finds a human host. Rapid urbanisation forcing animals and humans into closer proximity (as in the ‘wet market’) creates a perfect petri dish from where such zoonotic outbreaks can originate.

The first official acknowledgement of a new virus outbreak in Wuhan came on 31 December after the first casualty was confirmed. During the past four weeks, the number of those infected and fatal casualties has climbed rapidly. Cases have been reported from different parts of China as well as Hong Kong; nearly fifty cases are reported from Thailand, Japan, South Korea, Taiwan, Australia, USA, France, Austria, Germany, Cambodia, Vietnam, Malaysia and Singapore, though no casualties yet. However, about 4000 Chinese from Wuhan are reported to be still abroad. For India, the most critical is cases being reported in Nepal since India and Nepal share an open border though so far, all tests undertaken in India have been negative. WHO has called it a health
emergency in China and refrained from describing it as a pandemic. The Director General of WHO Dr Ghebreyesus is in Beijing for talks to review the Chinese response to date.

Decoding the new virus
Initially, there was uncertainty about the mode of transmission but now it is clear that 2019-nCoV virus is passed from human to human via – air through coughing or sneezing, personal touching or contact, and also, contact with an object that may be hosting viral particles (such as a door handle) and transferring it ones nose or mouth. More significant is the new understanding that the virus is contagious even during incubation, that is even before a patient exhibits any symptoms. The incubation period can last up to a fortnight. This characteristic amplifies the transmissibility factor. It also explains the travel bans across China, and the literal isolation of Wuhan, a city of 11 million and Hubei province with a population of nearly 60 million.

For China, the timing of the outbreak could not be worse. The Chinese Lunar New Year began on 24 January and normally, it marks a week long holiday, marked by feasting and travel by large numbers to join their families for the celebrations. Undoubtedly, this movement contributed to the rapid transmission of the disease across China and to many countries before the Chinese authorities cracked down hard.

Holidays across the country have been extended by three days till 2nd February in an effort to stagger the returns. Starbucks and McDonalds have shut down their outlets in Hubei; in Shanghai, Disneyland and in Beijing, the Forbidden City is closed, and a number of temple celebrations have been called off to prevent large scale gatherings. In Shanghai, businesses have extended the holiday period till 10 February, except for supermarkets, medical suppliers and public utilities. Hong Kong has drastically cut travel between mainland and the city.

Can China cope?
Comparisons are being drawn SARS (Severe Acute Respiratory Syndrome) outbreak in 2002-03 which infected 8000 patients and claimed nearly 800 casualties. SARS is also a zoonotic case, part of the coronavirus family that jumped to humans from horseshoe bats. The first incidents were reported in Guangdong province in November 2002 but WHO was officially informed only after three months though mysterious flu outbreaks were being widely reported. It quickly became more than public health issue and later, the Chinese health authorities issued a public apology. It was the first case of a coronavirus family virus develop lethal pathogenicity together with high transmission. The global economic loss was estimated at between $30-100 billion.

This time, the Chinese government has been more open but the question being asked is, has it been open enough? The response mechanisms, especially in the early days evidently fell short, reflective the top down bureaucratic approach of the Chinese system. The system has kicked in now with the all-of-government approach which characterises the China model. This is embarrassing for ‘core leader’ President Xi, the author of ‘China’s rejuvenation’ who replaced Deng Xiaoping’s advice of ‘keep head down, hide your capability, bide your time’ with the mantra ‘demonstrate capability, assume responsibility and claim rightful place’ implying that China’s time has come. How China manages this challenge will be a test – demonstrating that the Chinese model can deliver when it comes to a crunch and that it is a responsible global player, no longer hesitant about engaging with the WHO. For SARS, it took 20 months from the genome sequencing to the first human trials; for 2019-nCoV, US authorities are working on a deadline of 90 days.

Learning right lessons
It provides an interesting contrast with how the Kerala government dealt with Nipah outbreak in May 2018. Nipah is also zoonotic and made the jump from fruit bats to humans. Though there were 17 deaths in May, effective quarantine measures by local authorities prevented the spread. It helped that health is a state subject. The local doctor took the initiative to contact the Manipal Centre for Viral Research which had worked in the northeast (where Nipah is more prevalent and a 2001 outbreak in Siliguri had claimed 49 lives) and had the diagnostic tools to identify the virus. The state heath machinery responded with alacrity. More than 2500 persons were put under observation. No new case was reported after 1 June and a month later Kerala was declared Nipah-free and travel restrictions were removed. Had the district and state authorities not taken the initiative and only reported matters to Delhi and awaited instructions while Delhi sent teams to prepare plans, the outbreak would have taken a higher toll.

Kerala managed to curtail the Nipah outbreak with few casualties. However, infectious diseases including of the zoonotic variety are on the rise in India. In addition, regions in India suffer from seasonal outbreaks of dengue, malaria and influenza strains. The nation-wide disease surveillance programme needs to be strengthened. There is an acute shortage of epidemiologists, microbiologists and entomologists which translates into wasteful delays in diagnostics. Given the growth potential of India’s biotech sector, it is time to put in place a robust public-private partnership model that can transform the health services sector in the country, covering disease surveillance, diagnostic kit availability and accelerated vaccine development.

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