Ebola in India: How Prepared are We?

Anoop Amrith Lala

a. Department of Community Medicine, ESIC Medical College, Parippally, Kerala

The deadly Ebola virus has finally arrived India. As of the writing of this editorial, only one convalescent case of Ebola, in quarantine at the international airport at New Delhi is reported from the country.1 Nonetheless, this brings to realisation the warnings issued by the WHO as well as by Peter Piot (one of the discoverers of the Ebola virus) about India being one of the countries to which the disease could easily spread, given the more than 45,000 Indian population residing in the affected West African countries. These observations were also corroborated by a paper published in the Lancet, which listed India among the top countries to which Ebola could spread.2 This was on the assumption that on an average more than 600 people travel every month from the affected countries to India.

Figure 1. Ebola Virus Disease Outbreak, 2014 - Cases and Deaths by Countries

Figure 1. Ebola Virus Disease Outbreak, 2014 – Cases and Deaths by Countries

As per the latest available report by the WHO (14 November 2014), since the outbreak was identified in March this year, 14413 cases and 5177 deaths have been reported from 8 countries; most of them from the West African countries of Sierra Leone, Guinea and Liberia, but also from countries as far off as the USA and Spain (Figure 1).3 Also a WHO press release has predicted occurrence of up to 10000 cases per week by December if the situation goes unchecked. Given these circumstances, it was only a matter of time before Ebola showed up in India.4

Ebola Virus Disease (EVD), previously known as Ebola hemorrhagic fever, is a contagious disease of high mortality caused by infection with one of the Ebola virus strains. Ebola can cause disease in humans and nonhuman primates like monkeys, gorillas, and chimpanzees. The virus belongs to group V negative-sense single stranded RNA viruses. Even though five strains of the virus were previously identified, it was found that the virus causing the current epidemic has undergone more than 300 mutations.5

The virus is named after the Ebola River in the Democratic Republic of the Congo (formerly Zaire), where the first epidemics of the disease occurred in 1976. The virus replicates preferentially in monocytes and macrophages. Other cells are infected secondarily. Rapid viral growth occurs in hepatocytes, endothelial cells and epithelial tissues. There is a strong cytokine mediated inflammatory response which is responsible for the disease manifestations, including haemorrhage, DIC and multi-organ failure. Incubation period ranges from 2 to 21 days. Treatment is largely supportive and patients usually succumb to the disease in a week’s time. The case fatality rate in the current Ebola epidemic is estimated to be 71%.

Given the lack of effective treatment options and high mortality rates, efforts towards control of the disease are directed mainly at preventing its spread. Here again, there is much ambiguity regarding our understanding of the modes of transmission of the disease. Current evidence limit the modes of transmission of Ebola among human beings to direct contact with body fluids and contact with contaminated fomites6 but animal experiments suggest the involvement of aerosol mode as well.7,8 Even though transmission through the aerosol mode among humans is not well documented, actual experiences and recommended precautions suggest that droplet sprays reaching the mucosa directly may transmit the disease. Also the fact that the Ebola virus can survive outside the body for long periods of time adds to the communicability of the disease.

India’s preparedness to combat against a possible Ebola epidemic can be evaluated on the basis of the three pronged strategy that need to be in place for any country to defend itself against Ebola:

  1. Screening and quarantine at ports of entry of travellers originating from affected countries,
  2. Standard, Contact and Droplet Precaution facilities at health care facilities treating Ebola patients, and
  3. Maintaining health system preparedness in case there is an outbreak in the community.

Even though all affected countries have been given directives to carry out universal exit screening to prevent infected individuals from travelling out, this something that cannot be relied upon.9 Since there are no direct flights connecting any of the affected West African countries to India, the number of incoming flights that needs to be screened is considerably large.  In this situation, self-declaration by passengers about their travel history over the previous 21 days is the only method available for screening. For this purpose, airlines are provided with declaration forms for onboard passengers before they disembark at Indian airports. An evaluation by an expert team appointed by the Union Ministry of Health found that this was not being followed by most of the airlines. Furthermore the team found that only 2 of the 14 identified airports in the country (Delhi and Mumbai) had the required man power and facilities for effective screening and quarantine.

The CDC10 as well as WHO11 recommends Standard, Contact and Droplet Precautions for the care of patients with known or suspected Ebola Virus Disease in healthcare settings. The implementation of these precautions require isolation rooms with negative airflow ventilation, availability of specialized Personal Protective Equipment (PPE) and hospital personnel who are specifically trained for this purpose. In India at present only one hospital, the Ram Manohar Lohia Hospital at New Delhi, reportedly has all these measures in place. And only two centers in the entire country – National Centre for Disease Control, New Delhi and National Institute of Virology, Pune – have the laboratory facilities for Ebola tests.

Table 1. Top 20 final destination countries of individuals initiating air travel from within Guinea, Liberia, and Sierra Leone and corresponding indicators of health system capacity

Table 1. Top 20 final destination countries of individuals initiating air travel from within Guinea, Liberia, and Sierra Leone and corresponding indicators of health system capacity

Even though we have made giant strides in diverse fields of development, India still is a country where human life is expendable. Only a small minority of its 1.25 billion population has access to healthcare facilities that are standard in most developed countries. The Lancet article2 that lists countries that are susceptible to the spread of Ebola also describes health system indicators of these countries, as a measure of their preparedness to combat the disease (Table 1). The ranks of India among 191 countries for per-capita healthcare expenditure, physicians per 1000 people, nurses per 1000 people and hospital beds per 1000 people are 153, 102, 96 and 149 respectively.

Looking at these figures, we can comfortably conclude that we have a long ways to go not only in preparing ourselves for an impending deadly epidemic, but also in ensuring basic healthcare facilities to our people.  As for the Ebola threat, the government should ensure that the following measures are in place on an immediate basis:

  1. Cataloging of all Indian citizens residing in Ebola affected countries and monitoring their movements to the extent possible.
  2. Issuing stringent guidelines to airlines and identified airports to collect travel declarations from passengers arriving by specified flights and implementing quarantine measures whenever necessary.
  3. Selecting hospitals in the vicinity of the identified airports and strengthening their Ebola case handling capacities, including facilities for testing, isolation, personal protection and training of personnel.
  4. Alerting the healthcare system in the country such that cases that may slip through the screening system may be traced in time.

These are all but preliminary steps to prevent outbreaks in the community, in the unfortunate events of which, a range of measures on a wholly different scale will be needed. Keywords: , ,

References

  1. Malhotra A. India Quarantines Man Previously Treated for Ebola in Liberia. Wall Street Journal [Internet]. 2014 Nov 18 [cited 2014 Nov 19]; Available from: http://online.wsj.com/articles/india-quarantines-man-previously-treated-for-ebola-in-liberia-1416333296
  2. Bogoch II, Creatore MI, Cetron MS, Brownstein JS, Pesik N, Miniota J, et al. Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak. The Lancet [Internet]. 2014 Oct [cited 2014 Nov 19]; Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61828-6/abstract
  3. WHO | Ebola response roadmap – Situation report [Internet]. WHO. [cited 2014 Nov 19]. Available from: http://www.who.int/csr/disease/ebola/situation-reports/en/
  4. World Health Organization. WHO Virtual Press Conference on Ebola response [Internet]. WHO Media Centre; 2014 Oct, 14. Available from: http://www.who.int/mediacentre/multimedia/vpc-14-october-2014.pdf
  5. Gire SK, Goba A, Andersen KG, Sealfon RSG, Park DJ, Kanneh L, et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science. 2014 Sep 12;345(6202):1369–72.
  6. Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A, et al. Assessment of the Risk of Ebola Virus Transmission from Bodily Fluids and Fomites. The Journal of Infectious Diseases. 2007 Nov 15;196(s2):S142–S147.
  7. Johnson E, Jaax N, White J, Jahrling P. Lethal experimental infections of rhesus monkeys by aerosolized Ebola virus. Int J Exp Pathol. 1995 Aug;76(4):227–36.
  8. Reed DS, Lackemeyer MG, Garza NL, Sullivan LJ, Nichols DK. Aerosol exposure to Zaire ebola virus in three nonhuman primate species: differences in disease course and clinical pathology. Microbes Infect. 2011 Oct;13(11):930–6.
  9. WHO | Statement on travel and transport in relation to Ebola virus disease outbreak [Internet]. WHO. [cited 2014 Nov 20]. Available from: http://www.who.int/mediacentre/news/statements/2014/ebola-travel-trasport/en/
  10. Center for Disease Control and Prevention. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals [Internet]. 2014. Available from: http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html
  11. WHO | Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola [Internet]. WHO. [cited 2014 Nov 20]. Available from: http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/

Author Information Anoop Amrith Lal, Associate Professor of Community Medicine, ESIC Medical College, Parippally, Kerala. Email: anooplal@gmail.com, Phone: +91 94 95 97 9000 Conflict of Interest: None declared

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