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[NEW DELHI] As severe acute respiratory syndrome (SARS) cases begin to surface in India, public health experts are raising doubts about whether the country’s disease surveillance system, in shambles when plague broke out in 1994, has been sufficiently improved to prevent a major disease outbreak.

Nine cases of SARS have been confirmed in India, three of whom were individuals who had recently visited Southeast Asia. No one in India has yet died from the infection.
But experts agree that that does not leave room for complacency.

“This is a new disease without a curative drug or vaccine; it is bound to spread with time, and an infectious pool may build up gradually,” warns Kamal Krishna Datta, former director of the Delhi-based National Institute of Communicable Diseases (NICD), which tackled the Indian plague outbreak.

Memories of plague are still fresh in the minds of most Indians, many of whom feel that the country is no better equipped to deal with major disease outbreaks. “The level of public health hygiene in Indians has not improved,” says Mira Shiva, deputy director at the Voluntary Health Association of India. "Cough and fever are common ailments. So many people do not take care while coughing or spitting."

The plague outbreak claimed 46 lives and cost the Indian economy US$7 billion due to the cancellation of airline and hotel bookings and the banning by several countries of flights originating from India. The World Health Organisation's South East Asia Region Office (SEARO) has since said that the losses outweighed the actual plague problem.
After the outbreak, Datta recommended setting up disease surveillance networks in 600 districts in a pilot project. The project was started in 1996, but so far only 100 districts have been covered.

The large number of travellers arriving from Southeast Asia, and a poor public health system, are additional risk factors for the spread of SARS in India. For example, it is still unclear whether India has invested enough in diagnostic equipment to handle a major outbreak.

India has only two testing centres for SARS — the National Institute of Virology in Pune and the NICD in Delhi. Health authorities on Monday announced four more centres would be equipped for testing — the National Institute of Cholera and Enteric Diseases (NICED) in Kolkatta, Tuberculosis Research Centre (TRC) in Chennai, National AIDS Research Institute (NARI) in Pune, and Enterovirus Research Centre (ERC) in Mumbai.
More than 70 per cent of India’s health care is private, and there has been little briefing of private doctors on guidelines for screening, testing and treatment.

To streamline and tighten monitoring and prevention procedures, health minister Sushma Swaraj last week ordered the compulsory screening of all travellers arriving on international flights, and the provision of masks for protection of all employees at international airports and hospitals.

Indian states have also been instructed not to discharge suspected SARS cases from hospital until reports of all tests carried out on such patients have been received, and to ensure that cases that test positive but do not show clinical symptoms are quarantined at home for 10 days.

The government has formed a committee to contain the spread of SARS, made up of senior health ministry officials, directors of Indian Council of Medical research (ICMR) and the NICD, and representatives of five states where most international flights land. But it has not yet listed SARS as a notifiable disease.

Datta, however, points out that “quarantine and isolation alone should not play the major role in any public health management system”. Epidemiological surveillance should take precedence, he says. Also, treatment and management should be offered in all hospitals, rather than just in infectious disease hospitals as is currently the case in India.

Uton Muchtar Rafei, director of SEARO, however, was more optimistic and told journalists earlier this month that India has learnt two lessons from the plague outbreak: it has improved its disease surveillance system and it has not fuelled panic by exaggerating reports of suspected cases.

Meanwhile, a team of scientists from Council of Scientific and Industrial Research (CSIR) and Indian Council of Medical research (ICMR) are conducting laboratory tests on the potential use of an anti-viral extract from the green mussel, Perna viridi, in treating SARS symptoms. The extract was isolated by the National Institute of Oceanography in Goa, a laboratory under CSIR, and has shown a range of anti-viral properties, especially against those causing upper respiratory tract infections, according to CSIR director general Raghunath Mashelkar.

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