APRIL 13, 2020

By Naresh Minocha, Consulting Editor

"FOLLOWING every widespread epidemic or pandemic of influenza, the contemporary literature becomes virtually flooded with reports of scientific studies on the etiology and the epidemiology of the disease. By the time that recrudescences have ceased, interest has usually lagged and eventually research in this subject has practically ceased, only to be revived with the development of the next extensive epidemic".

Dr. Warren T. Vaughan made this observation way back in September 1920 in preface to a Monograph captioned 'Influenza - An Epidemiologic Study'.

This classical study traces history of influenza right from BC era to the 1918 one - a fact that might be disliked by climate change theorists. The 1918 infection is commonly referred to as Spanish flu - the most disastrous one in modern history. This flu wiped out 2% of British India's population. Monograph notes that first "true pandemic" happened in 1580.

Dr. Vaughan observed: "To one who has had occasion to review the extensive literature of the last pandemic, it becomes apparent that many of the recent writers are uninformed, or at best only partially informed, regarding the rather extensive information accumulated during the 1889 epidemic. The longer one studies the observations made in 1889-93 the more firmly convinced one becomes that the recent pandemic was identical with the former in practically all of its manifestations".

He added: "It is desirable that, following each epidemic prevalence some individual or individuals review the literature of the preceding epidemics, acquaint himself with what has been written regarding influenza in the intervening time up to the epidemic prevalence and correlate the work done in these two periods with the various reports regarding the latest epidemic".

Dr. Vaughan's observations are extremely relevant to Covid-19 pandemic from the standpoint of governance. The unfolding disaster reflects the same mistakes that the regimes & the public repeated in the past till a flu outbreak turned into pandemic.

After exhaustive review of pandemics from 1918 Spanish Flu onwards, anyone would conclude that majority of the Governments including Indian Government are responsible for the unfolding crisis.

Let us not blame novel Corona virus, China or World Health Organization (WHO). Let each Government make itself accountable for its inaction or delayed initiatives.

A search through WHO's website show how indifferent most of the regimes are when it comes to updating Pandemic Influenza Preparedness Framework (PIPF) and implementing it effectively and on time.

Of the 194 countries studied, 99 have either not published or not made public their respective National Plans for Pandemic Preparedness and Risk Management (NPPP&RP).

As many as 63 countries published NPPP&RP before 2009 with 15 others publishing or revising plans during next four years to 2013. The remaining 17 nations published or revised their plans in 2014 and after.

As put by Global Preparedness Monitoring Board (GPMB), "For too long, we have allowed a cycle of panic and neglect when it comes to pandemics: we ramp up efforts when there is a serious threat, then quickly forget about them when the threat subsides. It is well past time to act".

GPMP is an independent board of eminent professionals. It was co-convened/constituted by WHO and WB in 2018. In its 2019 annual report captioned 'World at risk: annual report on global preparedness for health emergencies', GPMP reviewed the status of implementation of recommendations made by WHO's high-level committees since the outbreak of 2009 swine flu.

The Report concludes: "Many of the recommendations reviewed were poorly implemented, or not implemented at all, and serious gaps persist".

It notes: "The world is at risk. But, collectively, we already have the tools to save ourselves and our economies. What we need is leadership and the willingness to act forcefully and effectively".

It is indeed shocking that most Governments are penny wise and pound foolish when it comes to spending time and money on prevention as compared to effort & resources exhausting in coping with impact of pandemic including lockouts. Prevention includes timely roll-out of mandatory quarantine by Governments on all persons arriving in their respective countries. Prevention requires regular public awareness campaigns on risks of influenza, both seasonal & pandemic. It requires repeated hammering down of virtues of hand-washing & social distancing in mind of public, particularly when infections hit headlines.

"The cost of financing pandemic preparedness has been estimated at US$ 4.5 billion per year, or less than US$ 1 per person per year, which is less than 1% of the cost estimates for responding to a moderately severe to severe pandemic", says WHO's Report 'Global Influenza Strategy 2019–2030 Prevent. Control. Prepare'.

Compare this with global economic stimulus whose total cost might ultimately touch $ 8 trillion. The US has already unveiled $ 2 trillion stimulus. Similarly, Japan has announced trillion stimulus. Several other nations too have unveiled substantial packages. International Monetary Fund (IMF) has created a special facility to lend $ 100 billion to member countries.

Turn now to WHO's 'Review Committee on the Functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1) 2009'. It is commonly known as swine flu pandemic.

In its report, presented to World Health Assembly in 2011, the Committee concluded: "The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency. Beyond implementation of core public-health capacities called for in the IHR, global preparedness can be advanced through research, reliance on a multisectoral approach, strengthened health-care delivery systems, economic development in low and middle-income countries and improved health status".

Buried in the report is an invaluable advice titled 'Rapid containment: stopping an emerging pandemi'. The Report says: "Rapid containment (RC) is considered an extraordinary public-health action that goes beyond routine outbreak response and disease control measures. It is intended to stop the spread of an incipient pandemic at its initial source".

RC could have prevented Covid-19 from becoming a pandemic, had it been followed swiftly by countries that are facing brunt of Corona Virus. It would have obviated the need for 35-days nationwide lockdown in India. RC idea has been taking shape for 15 years. It got a shot in arm from two mathematical modelling studies published in 2005.

The models stipulated that detection, investigation and reporting of the first cases, followed by largescale deployment of antiviral drugs and public-health measures to block transmission, such as isolation, quarantine and border controls, would need to be enacted rapidly in the affected area. The window of opportunity to enact these extraordinary measures was estimated to be three weeks at most.

WHO's International health Regulations (IHR) 2005 categorically provide for quarantine of travellers and cargo when defined "public health risk" arises from an infection. The time-frame for present pandemic from discovery of infection by a novel virus is almost same (two months) as was it in case of Swine flu.

Two months should be taken a thumb-rule for global spread of influenza caused by an unknown virus. This is crucial to emphasize the urgency to tap 3-week window to frustrate virus's determination to emerge as pandemic.

RC strategy should have thus been followed by different regimes after release of WHO's first daily situation report dated 21 st January 2020. It showed that novel corona virus had reached three countries -Thailand, Japan and South Korea.

A key component of RC is rollout of quarantine by countries for persons arriving by air, sea or road into their territories. RC has to be applied first and fast for air travellers. Most countries notified/revised quarantine regulations of varying duration & mode after WHO notified Covid infections as a pandemic on 11th March 2020.

India initially opted for home quarantine of air travellers returning home from abroad. Home quarantine puts a family at risk. It is often breached. It is India's laxity that let the genie out of bottle as in case of other countries such as the United States, Italy, Iran, etc.

Several countries have provisions for introducing timely quarantine regulations in their respective NPPP&RP. The USA's 2006 National Strategy for Pandemic Influenza (NSPI) - implementation plan, for instance, says: "The Federal Government will develop criteria and protocols for isolation and quarantine of travellers early in a pandemic, prior to significant spread of the virus in the United States".

NSPI explains: "Quarantine is a contact management strategy that separates individuals who have been exposed to infection but are not yet ill from others who have not been exposed to the transmissible infection; quarantine may be voluntary or mandatory".

NSPI describes 300 critical actions to prevent pandemic influenza. It was signed by President George W. Bush. He wrote: "Our Nation will face this global threat united in purpose and united in action in order to protect our families, our communities, our Nation, and our world from the threat of pandemic influenza".

It is ironic that this vision did not translate into effective action in preventing a wave of Covid pandemic sweeping across the US.

Consider now Japan's Report of the Review Meeting on Measures against Pandemic Influenza (A/H1N1) prepared in 2010.

As for quarantine policy, the Report recommended: "Prior to any outbreak, it is necessary to examine what kind of measures should be taken at the point of entry against infectious diseases including a pandemic influenza and to practice the measures on a regular/preparatory basis".

It appears that most countries took lightly the severity and rapidity of Covid pandemic. Several countries have in recent days put in place mandatory 14-days quarantine for anyone returning to their territory.

New Zealand, for instance, revised on 9th April its quarantine rules for those arriving in its territory. Under updated rules, "all arrivals will now have to remain in either managed isolation or quarantine for 14 days before they can continue to their destination".

This is a belated step keeping in view that the fact that New Zealand Influenza Pandemic Plan provides for such regulation. Issued in August 2017, the Plan calls for "warning travellers to New Zealand prior to departure that should it be deemed necessary they may be placed in quarantine on arrival for a specified period".

In fact, all countries should have standing rules on paid quarantine to be borne by foreign travellers in case of flu caused by a novel virus or any other novel infection that spreads like wildfire. The provision for paid quarantine would act as deterrent for tourists and restrict foreign travel to urgent work.

RC can thus slow, if not check, spread of virulent microbe till medical researchers unmask its novelty & work out some means to control it.

If we study origin and spread of flu epidemics and pandemics since 1918, we find that virus was brought in by persons travelling from one country to another by sea, air or road routes. In each case, RC was not tried or was tried half-heartedly and belatedly.

Covid-19 disaster should unite the world into unveiling a new influenza risks prevention framework. Its first and foremost objective should be to banish the word 'pandemic' once for all. And a key component of it should be liberal funding of research and development of universal flu vaccine.

At least two UFVs should be developed through different techniques and their technology transferred to all leading vaccine makers under a global agreement.

Reining in influenza viruses from acquiring pandemic dimensions is key to putting the world economy on sustainable growth path. The time-tested wisdom 'Prevention is better than cure' should be etched on the cover page of Statute Book of all countries.