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21 January 2008

Headless Chickens

Government is once again displaying its shocking lack of preparedness to prevent bird flu from entering the country and containing its spread among poultry thereafter. If people have not been infected so far, thank luck, not authority

As this article is being written, an Associated Press report filed at 5.30 pm, Saturday, January 19, informs that Government officials in West Bengal, despite accepting that the disease they are trying to fight and control is avian influenza, are "still waiting for test results to determine whether it is the H5N1 strain of the virus, which has been blamed for the deaths of 217 people worldwide since 2003". This shocking laggardness of the health department, which could -- let's pray it does not happen -- lead to the deadly virus crossing the species barrier to infect human beings, is unpardonable.
"If some initial sign, initial indication a pandemic happens, we have to immediately pick up, detect this initial sign or signals and implement all the necessary measures," said WHO regional director for the Western Pacific, Shigeru Omi, whose reference this writer had collected on December 3, from a journalists' workshop on bird flu conducted in New Delhi by the US Embassy. It was represented by the Government of India, too. The Government representative had, in a clear bid to hide the authorities' incompetence, lauded the effort by journalists to sensitise people of bird flu during its outbreak in Manipur early last year.
No scribe in that workshop would have braced for a utility of the knowledge gathered from there so soon. But that was in store not as a stroke of destiny but for sheer negligence of the Government -- and more so, the bureaucracy. Once again this year, as the babus of Birbhum district slept on the file for full 24 hours after the West Bengal Government issued a timely alert, it was a few journalists who, while trying to investigate the reason behind more than 10,000 chickens dying in the district, rushed to stop the villagers when they found them feasting of the dead poultry stock, thinking the birds died of Ranikhet. One wishes they cooked the meat really well; that kills even H5N1 virus.
As if this callousness were not enough, next it was found that the health workers did not have the adequate protective gears needed while disposing of dead, infected chickens. It's sheer chance that now as the health workers are going door to door in the area in search of people with fever, they have so far not come across anyone with bird flu symptoms.
The aforementioned report further states that last Thursday, "nearly 3,000 chickens were found dead in a previously unaffected district near the outbreak's epicentre... Officials have yet to announce whether those deaths were from bird flu". What the hell is happening?
At the workshop it was heartening for the Indian journalists to know that at least one institution equipped with world-class facilities to detect the H5N1 virus was located in this very country: National Institute of Virology in Pune. Last week, the name of High Security Animal Disease Laboratory in Bhopal figured in newspaper reports as another credible test centre. It is all too fine to counsel against 'alarmism', but if these eulogised institutions take a week to confirm what the causative agent of the disease outbreak in West Bengal is, it is time to stop celebrating them and hold them accountable. How long are the people to bear with Government statements like "these are preliminary reports", "the virus is yet to be confirmed by HSADL" and "the situation is under control"? The nation cannot afford to have scientists as laidback as clerks. Let the people not remain in the dark anymore and know what experiments need to be conducted that are taking the scientists so long.
In the required study -- here the method employed by the Centers for Disease Control and Prevention, US, is being cited as the one used by the Indian HSADL is not shared with the public -- a multiplex real-time assay specifically targets two different regions of the H5 gene. It is specific for H5 sub-type and capable of detecting and quantifying H5 RNA in clinical samples from patients obtained during different outbreaks of bird flu in 1997, 2003, and 2004 in three different parts of the world.

This technique not only reduces the risk of contamination but also the turnaround time to between one and two hours - three times faster than the conventional method. It is rapid, specific and relatively sensitive for directly detecting influenza A subtype H5 virus and is useful in routine diagnostic testing. The time required to detect the virus employing this method should not vary much whether the patient is a human being or a dead bird. So, why are we still waiting for confirmation from those who rule the ivory towers of HSADL, Bhopal, or NIV, Pune?
This censure does not mean that the Government can pass the buck to lax bureaucrats and scientists. Its bird flu containment policy, too, must be questioned. What was all the hype by the Health Ministry about the preparedness to, first, not let the virus enter the country's territories and, second, if it did, to contain it immediately?
Let's also study the efficacy of having a stockpile of Tamiflu, touted as a panacea. True, two drugs (in the neuraminidase inhibitors class), oseltamivir (trade named Tamiflu) and zanamivir (commercially known as Relenza) can reduce the severity and duration of illness caused by seasonal influenza. But the efficacy of the neuraminidase inhibitors depends, among other factors, on their early administration (within 48 hours after symptom onset). Going by the pace at which our system works -- where it takes more than a week to confirm a virus -- administering the drug within two days would be expecting too much.
For cases of human infection with H5N1, the drugs may improve prospects of survival, if administered early, but clinical data are limited. The H5N1 virus is expected to be susceptible to the neuraminidase inhibitors. Antiviral resistance to neuraminidase inhibitors has been clinically negligible so far but is likely to be detected during widespread use during a pandemic.
For the neuraminidase inhibitors, the main constraints, which are substantial, involve limited production capacity and a price that is prohibitively high. At present manufacturing capacity, which has recently been quadrupled, it will take a decade to produce enough oseltamivir to treat 20 per cent of the world's population. The manufacturing process for oseltamivir is complex and time-consuming, and is not easily transferred to other facilities. This demand-and-supply factor coupled with manufacturing complexities make it evident how high the price is, and it's anybody's guess that when our Government panicked to stock Tamiflu, the owners of Roche Laboratories Inc, the drug's manufacturer and marketer, must have laughed its way to the bank (the medicine was originally developed by Gilead Sciences Inc).
But there is an alibi ready for the Government. It might say WHO had prodded it to keep a stock of Tamiflu. After all, the UN agency's documents say that though "so far, most fatal pneumonia seen in cases of H5N1 infection has resulted from the effects of the virus, and cannot be treated with antibiotics... since influenza is often complicated by secondary bacterial infection of the lungs... WHO regards it as prudent for countries to ensure adequate supplies of antibiotics in advance".
Finally, chances are slim that any Government functionary or official can be proven guilty by law either for not screening poultry import from affected regions of the world, or for not letting the people know of the fatal virus H5N1 in time, or for exposing health personnel to the disease, or worse -- that we pray shouldn't happen -- the virus affecting the people. The workshops journalists are sent to, to let them know how to spread the right information, are either glorified junkets or are, at best, people's first line of defence -- in Maharashtra, in Manipur, in West Bengal. The Government, like the police in Bollywood films, always arrives late. Is the delay deliberate?
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Surajit Dasgupta treats no individual, organisation or institution as a holy cow.