How Could We Have Got It So Wrong?

Have you ever heard of these hot zones? What you didn8217;t know about isn8217;t on the television screens. What you did know about, doesn8217;t really seem to matter.

That8217;s how it works in India, always has. When the world sneezes, we get ready to catch the flu. But if we get the flu ourselves, life goes on.

And so India knows every dramatic step of Hong Kong resident Bhaskar Murthy8217;s journey from Mumbai to Delhi the day he tested positive for SARS. The day Union Health Minister Sushma Swaraj told the world India was off the WHO8217;s list of SARS-reporting countries, a nurse at Kingsway Camp8217;s Maharishi Valmiki Infectious Diseases Hospital 8212; swathed in a disposable surgical gown, N-95 mask, head cap, goggles, a cap hanging around the neck and a shoe guard covering her sandals 8212; was ready to serve breakfast to Murthy.

Twenty Indians have tested SARS positive at last count. Fatalities: Zero. Full-blown SARS: None.

India8217;s collective immune system, studded with a combative history of battling a mix of tropical viral fevers, clearly seems to have staved off a virulent strain of SARS that laid our eastern neighbours low.

Darkness on the edge of town

On the edge of Mumbai, in his modest brick home on a narrow lane in the township of Ambernath, Stanley D8217;Silva is lounging in denim and khaki shorts. Only last week, he was the face of the supposed Indian outbreak of SARS, a forlorn figure, hunched on a bed in an isolation ward in Pune.

No one saw his face actually. In his shiny green and white quarantine overalls, face mask and goggles, he looked like some captured alien.

He may have later strummed through his eight isolated hospital days in Pune with his guitar for company, but he will not easily forget his sister8217;s missed wedding. Health authorities huddled his family into quarantine after his discharge from hospital, after his fever had ebbed.

8216;8216;I still do not believe that I had SARS, I felt feverish when I returned from Indonesia but I had no difficulty breathing. Neither me, my family nor the doctors at the Naidu Hospital at Pune have seen the report that claims we tested positive for SARS,8217;8217; D8217;Silva told The Sunday Express. Isolation? D8217;Silva says he ordered take-away from the ward.

In Ambernath, the D8217;Silvas neighbours are wary. Doctors have goofed badly and blatantly through the quarantine and discharge dates, struggling to make up their minds on diagnosis, and Health Ministers have spouted discordant damage control from Panaji to Pune to Kolkata.

In the City of Joy, a mass hysteria led to an unseemly demonstration by hospital staff, demanding the expulsion of Asitabha Purakayastha, a suspected SARS patient.

It8217;s true that SARS is a new disease. It8217;s equally true that India8217;s creaky health infrastructure tried its best 8212; in its own sporadic, knee-jerk way 8212; to cope. The health system struggles to cope even with known diseases, so to expect miracles when the rest of the world was in shock is simply expecting the moon.

But it isn8217;t too much to tell the people what exactly is going on. And this is where the system failed.

8216;8216;Just tell the people that we are handling the virus safely and that all the protocols are being followed,8217;8217; Dr A K Mishra, the director of India8217;s premier SARS-testing centre, the National Institute of Virology NIV told The Sunday Express when he was asked to explain how exactly SARS testing was done. 8216;8216;The test and the analysis of data is too scientifically complex and complicated to explain to people.8217;8217;

That we-know-it-all attitude also overshadowed the fact that testing positive for the SARS 8216;8216;killer virus8217;8217; is not a fatal diagnosis for India. SARS in India is not the virulent strain of Beijing, Hong Kong, or Singapore 8212; where the only Indian victim, a taxi driver 8212; died last week. The nine medical staff in Pune8217;s Siddharth Hospital who tested positive for the coronavirus last week have all been declared symptom-free.

8216;8216;SARS is not as easily transmitted as many of us believe. The coronavirus cannot live for more than six hours average three hours outside the human body. It is not air-bone transmission like influenza,8217;8217; says Dr N Kumara Rai, director Department of Communicable Diseases, WHO South East Asia Region.

So many coronaviruses, which is which?

THE SARS story swirls around a crown of thorns, well, almost. Coronaviruses are named after their corona crown or halo of club-shaped spikes that show up under an electron microscope.

These viruses are irregularly shaped and infinitesimally small 8212; imagine 60 to 220 nanometres in diameter, less than a million times finer than a strand of human hair. Their spikes help them bind to host cells and sneak right inside, to release genetic material of the virus into the host cell. The newborn coronas collect in membrane-bound sacs and are eventually released by the cell itself.

And hold your breath. Second only to the notorious rhinoviruses that cause common cold, these viruses are everywhere and can enter from anywhere. Your eyes, nose, mouth and, invitingly, your hands.

Long before WHO declared India SARS-free, men of medicine and science had started asking nosy questions nobody wanted to answer. 8216;8216;They are fumbling in the dark. There are hundreds of coronaviruses already in circulation in India. The brothers and sisters of the coronaviruses in China might already be in circulation here, because of which we might have developed partial protection against this new strain,8217;8217; says retired epidemiologist N S Deodhar.

All suspect cases showed mild clinical symptoms. Their X-Rays did not reveal pneumonia. As India edged toward a 20-case mark, WHO said that India8217;s SARS cases perfectly fit WHO8217;s definition of 8216;8216;suspect8217;8217; cases rather than 8216;8216;probable8217;8217; cases. 8216;8216;The SARS virus may have mutated once it entered India and become less virulent,8217;8217; says Rai. Then on May Day WHO suddenly changed track to say India was SARS-free.

So is merely testing positive for the coronavirus an indication for SARS? 8216;8216;The coronavirus implicated as the cause of the disease is certainly around but is unlikely to be the causative agent of SARS. In fact, the proportion of samples from Canadian SARS patients that show the coronavirus is going down. The case definition of SARS is still very loose,8217;8217; Frank Plummer, Director of the National Microbiology Laboratory NML, in Winnipeg, Canada, told The Scientist on April 11. The NML is one of 11 collaborating laboratories world-wide working on SARS.

The Canadians have classified their patients according to severity of symptoms and need for hospitalisation and isolation. They classify people who test positive for the virus but have no potent travel history or symptoms as Persons Under Investigation, not suspect cases.

8216;8216;The PCR test for SARS is a highly sensitive test but I would be extremely sceptical about its specificity in detecting the strain. The test could come up positive for a related strain and not necessarily the one in China and hence its infectious nature is a big question mark unless we start studying it properly,8217;8217; says Deodhar.

8216;8216;We should have acquired samples from Hong Kong and China to compare and validate our test results,8217;8217; says Dr Mahesh Patil, head of research, anti-infective unit, Wockhardt.

The NIV admits that it is not doing any cell cultures of our desi strain, no animal experiments. 8216;8216;So what are they doing?8217;8217; asks Deodhar.

One WHO hypothesis points to the possibility of cross immunity existing between the new corona virus ie SARS virus with the already circulating corona virus that causes common cold in humans and diseases in pigs, chicken and birds.

The vaccine to prevent small-pox is manufactured using a different virus from the one that causes small-pox. Small-pox vaccine contains live vaccinia virus that causes cow-pox in cow, while small-pox is caused by variola virus. Immunity to vaccinia also confers immunity to variola, that is cross-immunity.

In viral infections, it is generally true that when the disease starts as a new epidemic, the affected persons gets a more severe form of the disease. In subsequent transmission waves it becomes less severe, until it becomes a very mild illness. This is one possible explanation for the mild SARS virus in India.

8216;8216;The virus may be different. And the people are different. So what their interaction leads to is something our health authorities and scientists have no idea about,8217;8217; says Deodhar.

The only diagnostic parameter we seem to be following is the result of the RT-PCR Reverse Transcriptase Polymerase Chain Reaction that gives a Yes or No answer for the new coronavirus. But does its presence really mean that it will lead to the deadly respiratory disease?

The great shroud of immunity

Why are children not affected? Most patients are adults 30-plus.

8216;8216;Children catch flu at the drop of a hat. Yet they are strangely immune to this virus. Why?8217;8217; asks Kalyan Banerjee, former NIV director.

On Washala8217;s mystery fever, district health officer B R Gholap says, 8216;8216;Such illnesses are common during this time of the year when the mercury reaches its peak. We have noticed that the affected are the ones who have to be out in the hot sun while the fever has not touched small children who remain in the house.8217;8217;

A study released in Hong Kong on Tuesday by Professor Tai Fai Fok of the Department of Paediatrics of Hong Kong University concurs. They found that among children who tested positive, teenagers exhibited more symptoms than young children. The younger the patient, the less infectious he was found to be.

8216;8216;With a new disease, following generalised rules is dangerous. Common sense and creativity which is in such scarce supply has to kick in. We are not Canada, USA or even China. We must constantly predict Indian problems and manifestations using our resources optimally,8217;8217; says Banerjee.

Statistically speaking, we have a greater chance of dying from infectious tuberculosis than SARS. TB kills an Indian adult every minute.

How Goa Bumbled with SARS Number 1

From the silver sands that flashed news of India8217;s first SARS case at the Goa Medical College Hospital, Chief Minister Manohar Parrikar once said it was a 8216;8216;false alarm.8217;8217; Then he said the patient was neither a 8216;8216;spreader nor a super spreader.8217;8217;

Meanwhile, Singapore-returned Prasheel Varde had wandered around the Hospital, trying to locate the isolation ward. Mid-way, Varde had stopped by the hospital8217;s canteen for a tuck-in.

Prasheel was discharged from the hospital only to be summoned back hastily four days later 8212; from a party, no less 8212; once the doctors discovered belatedly, that they had let go of a SARS-positive. 8216;8216;The purpose of an isolation ward defeated the way the GMC authorities handled the case in a most negligent manner,8217;8217; blusters his doctor Pradip Pai Dhungat.

By the evening of May 1, Varde was the only 8216;8216;SARS probable8217;8217; in India8217;s high-pitched search for SARS. The hysteria is now slipping away, we know a little more about the rogue virus than the day a lonely groom attended his wedding in Pune. Typical to India8217;s SARS story, Maharashtra 8212; the state with the maximum suspects 8212; is now boasting it has finally procured 800 masks. We don8217;t know 8212; yet 8212; if they will be used.

with N Ganesh in Mumbai and Raju Nayak in Panaji