Should India take SARS more seriously?

‘Rebuild immunity, health will be restored’

Dr Viraj Suvarna

Severe acute respiratory syndrome (SARS), for want of a better name, has come in a big way and has apparently come to stay. In India one is generally exposed to an environment conducive to infectious diseases acquisition. Our woeful personal and environmental hygiene standards coupled with a burgeoning population, overcrowding and inadequate health infrastructure has on the one hand contributed to high morbidity and mortality rates due to infectious disease but has also provided us with the ammunition to make Darwin proud of our resilience.

‘Survival of the fittest’ is apt to most Indians as we are repeatedly put to the ‘test’ and survive fitter than before. Our children are reportedly less susceptible to asthma as compared to their Western counterparts since they are more frequently exposed to viral upper respiratory tract infections that confer protection against hypersensitive bronchospastic attacks.

Although it is now six months since the first SARS case was reported in China, India has yet not recorded a single case of SARS death. Neither have the majority of the so-called “confirmed” SARS cases in the country demonstrated the virulent clinical symptoms of the disease, as seen in other SARS-affected countries.

In Hong Kong and China, patients developed acute respiratory distress and inflammation of the lungs within five days. But a majority of the SARS suspects in India have not demonstrated such acute deterioration. So, why are SARS-affected persons in India not deteriorating like those patients in Hong Kong, Singapore or China?

Kumara Rai, World Health Organisation’s director of the department of communicable diseases for South-East Asia if of the opinion that there could be a possibility of a cross-immunity existing between the SARS virus with the already circulating corona virus in India. When a disease starts as a new epidemic, the affected persons get a more severe form of the disease. In the subsequent waves of transmission, the disease becomes less severe, till it becomes a very mild illness.

James da Costa, a pathologist who has been studying falciparum malaria for the past nine years, believes exposure to the disease could be giving Indians some protection against the virulent manifestation of SARS. He also wonders whether other infections, with symptoms similar to SARS, are being missed. In the past five months he has seen 17 cases of atypical pneumonia and other respiratory disorders, all of which have symptoms similar to SARS.

All these patients tested negative for falciparum malaria in routine tests, but the special enzyme linked immuno-sorbent assay (ELISA) antibody test found them positive for falciparum malaria. The April 17, 2003 issue of Indian Pediatrics reports co-existing Parvovirus B19 infection in a child with Plasmodium falciparum malaria. According to Da Costa, the mere presence of the virus does not mean that the person has SARS. “Development of the disease would depend on how your immune system responds to the microbe.”

The writer is Medical Advisor, Medical and Research Division, Pfizer Ltd, Mumbai. E-mail: Viraj.Suvarna@Pfizer.com

‘There is no room for complacence’

Dr R S Shetty

“India has no cases that fit the SARS definition”, Dr H J Habayeb, the WHO representative of India told a news conference recently. This was followed by the comments of Union Health Minister, Ms Sushma Swaraj ‘‘The Government had been very very cautious and today the WHO is giving us a certificate.’’ There is no doubt that the Indian government has done an excellent job in taking appropriate measures to prevent, detect and to control SARS. But the effort should continue in the same intensity and definitely there is no room for complacence - given our huge population, congested living condition, rampant malnutrition and overburdened health services.

We should definitely learn a lesson from Aids epidemic which none of us thought would make India ‘No. 1 Aids’ country in the world by the year, 2005. This has been predicted by none other than WHO who had certified India, ‘SARS free’ today. This happened only because of our ignorance of the disease and its consequences and the inadequate measures adopted by the Government to check the disease before it became an epidemic.

We may recollect the Dengue fever epidemic in Delhi and the plague tragedy in Surat which more than proved that we are ill-equipped to face the challenges of unexpected epidemics. Let us not repeat the same mistake again with SARS; the consequences could be more dangerous. The following facts about SARS and the recent unexpected developments should make us more vigilant about the disease:

• The infection is highly contagious - has been amply proved in other countries.
• The SARS virus can remain viable for more than 3-4 hours in the outside environment.
• The virus has been detected in urine, stools for months even after the patient has recovered and discharged from the hospital.
• At the moment, laboratory tests for diagnosing of SARS are highly sophisticated, not easily available and costly and needs repetition to confirm the diagnosis.
• Laboratory diagnosis of SARS even according to WHO is not fully reliable. Hence dependency is more on clinical and epidemiological grounds; this may lead to “missing of positive cases”.
• Mutation of SARS virus has been reported in Hong Kong. This will make the diagnosis, treatment and development of any vaccine (which would be a better bet) very difficult.
• There are reports of relapses in many patients who are earlier certified to be free from the disease. This is a dangerous trend.
• Microbiologists at the Chinese University reported 4 more strains of SARS and there is an apprehension that this may lead to change of symptoms. Higher portion of Hong Kong patients with SARS have been suffering from diarrhoea compared with earlier victims (is there change of symptoms?)
• Mortality rate in countries like Hong Kong has risen to 10.6 per cent from five per cent two weeks ago and 2.5 per cent in late March, 2003.

Dr Shetty is the Medical Advisor, FDC Ltd, Mumbai. E-mail: fdcmed@vsnl.net