in Tamil Nadu in 1992-93, Dr P. Kuganantham, then Director of the Communicable Diseases Hospital in Tondiarpet, Chennai, with the backing of officials of Chennai Corporation, made suggestions to the government of Tamil Nadu that seemed to be draconian. Most of these suggestions—cutting down on the length of hospital stays by using a never-before-tested protocol, insisting on increasing the chlorine content in drinking water to incredibly high levels, and making sure that everyone afflicted was isolated and moved to a treatment facility—worked to ensure that the number of deaths from the affliction was kept low. He went on to become one of the most proactive Health Officers of Chennai Corporation and is a sought-after public health expert in India today. Excerpts from an interview he gave Frontline on the coronavirus infection and its implications:
What has been India’s record in controlling infectious diseases since many such diseases are endemic to the country?
We have had many epidemic outbreaks in India: small pox in the 1920s and the 1960s, plague and swine flu [Spanish flu] in 1918. [At one time] there used to be cholera outbreaks almost once in five years. More than five lakh people died in the Madras presidency in the swine flu outbreak [in 1918]. The last major epidemic which spread to many parts of the world was the cholera outbreak of 1992-93. The strains of this cholera outbreak were new and named O-139. The first strain was discovered in Chennai by my team, and then we had to develop a new protocol for the management of cases. We treated at least 75,000 cases in the Communicable Diseases Hospital.
In the case of H1N1 [the swine flu pandemic in 2009-10], we identified all the cases. The epicentre was Mexico. From there it spread to California, Hong Kong, Indonesia, and so on. We decided that all those who had a travel history to these places needed to be tested. We intercepted all passengers from these destinations and took those who had symptoms to the Communicable Diseases Hospital in Tondiarpet. Over a period of time, we treated about 3,500 patients. All the patients were kept under observation during the incubation period of between 7 and 14 days. The source of infection is from the throat, nostrils. The infection gets into the throat or nostrils and gets into the lungs and multiplies there.
What we thought was this: a patient who has sufficient exposure needs to be admitted in the hospital and given a mouthwash. This is done in a slightly peculiar manner. You raise your head to the roof and keep the salt water or the antiseptic solution in touch with the throat for a minute. The virus is killed because of this action. This is actually like washing the throat frequently to remove the virus, which will be a source of infection to the neighbourhood. Through the period of the epidemic, we managed to ensure that no patient died.
There are also epidemics that occur after a disaster. I have seen such epidemics after the Gujarat earthquake, after the tsunami [in Nagapattinam], and in Odisha [after the supercyclone in 1999]. In all these places, we have had a small outbreak of diseases after the event.
What is the way to contain, mitigate and manage the spread of an epidemic?
The best public health approach to control an epidemic starts with identifying all cases in a given geography. They should then be treated or isolated. There should be no delay in treatment. There is no time to sit around and discuss in an epidemic setting. In the case of H1N1, apart from the throat wash and checks for lung infection, we made sure that the virus didn’t cause inflammation of the tissue. This is critical because the virus lodges itself in the cell and infects it. If this happens, then opportunistic infections will affect the patient. We gave them prophylactic vitamin A, some antibiotics like amoxicillin. With this we managed to isolate the virus. For mucus secretions to be removed, we gave them mucolytes, and bronchodilators for five days.
Along with effective treatment, which is not [to be] delayed for any reason, it is important to undertake a massive awareness drive in society. At a clinical level, all effort should be simultaneously made to identify the organism, and a protocol for management and treatment should be developed. There should be no panic, and there should be no political obsession about hiding the number of cases. If you start hiding them, the cases, which are like an iceberg in the community, will flare up. People will die as a result.
I see the swine flu epidemic of 2009 and this epidemic (COVID-19) in the same way. Both of these are, in some ways, like common cold infection. Even a common cold can sometimes become very virulent because of the mutation of the virus. For example, a swine flu virus is found in wild animals, pigs, birds and human beings. The viruses in these different hosts sometimes get together and mutate and develop as a new virus. This process is termed a novel virus. This is called the reassortment of a virus. H1N1 was called a novel virus. Coronavirus is also being called a novel virus.
‘Disease outbreaks often happen in the forest’
What is the source of these frequent virus epidemics in the global context?
One thing we forget is that disease outbreaks often happen in the forest. When there is a human invasion into the forest and a disturbance of the ecosystem in the forest, the infection will end up in the places where human beings are settled. This was evident in the plague in Surat in 1996. In Surat, wild rats in the forest moved to the human habitation areas because of some disturbance in the forest. These rats infected domestic rats in the town. This was the beginning of the plague.
When the British ruled India, we had surveillance outposts in major forests. For instance, in the Kyasanur forest near Mysore there was a surveillance centre. This is the reason why a vector control centre was set up in Hosur. Unfortunately, all the surveillance centres were later closed by the Indian government.
What have you learnt about the coronavirus and the COVID-19 infection?
Coronavirus is a weak virus. It’s a novel virus and its behaviour cannot be quantified. Here, planners have to understand that it affects a larger population when people live in densely populated settings. In spite of infecting a large number of people, the deaths are low. This is exactly what we saw in H1N1: the infection rate was very high but the number of deaths was low.
It’s also not necessary that all those infected suffer from the disease. There is a parallel with TB here. In most thickly populated cities in India, almost everyone harbours TB infection in their lungs. But they do not suffer from TB disease. They are infected, but it is not flaring up as a disease. It will flare up only when their immunity comes down.
In any case, the question now is this: Has this novel virus invaded our population significantly? From news reports, we know that this is prevalent in many places mainly because of the travel history of individuals. But this could be stopped if all these people are identified and isolated. For that, we need to insist that people are tested. At least, this should be done for those who have come in contact with a COVID-19 patient, who have a travel history, who are in an immunocompromised state and who have exhibited symptoms.
Testing the whole population is difficult because this can lead to panic and, also, we may not have enough facilities. The private sector should be part of this effort to control the spread of the disease. Restricting testing to a few places is not right. You have to rope in the private sector. Only then the asymptomatic cases can be identified and treated. Otherwise, though these people will not suffer any problem, they will pass on the infection to others.
Unfortunately, our governments are taking a very strange decision of restrictions in testing. If a person wants to get tested today, there is no provision for it. Many are telling people that if they want to get tested, they need to get admitted in the hospital, etc., just to discourage them.
Are private hospitals equipped to treat such patients? In fact, are government hospitals equipped to handle these patients?
Many private hospitals do not have infectious diseases wards. In the past, infectious diseases hospitals were located outside cities. Now, in the Western world, this treatment is highly technical, and they maintain the isolation wards in a general hospital itself but maintain the room in which an infectious patient is kept under negative pressure. There are not many hospitals in the private sector with negative pressure rooms.
How do you view the restrictions imposed in China on its citizens following the outbreak of COVID-19?
Never in the history of public health has any country done what China is doing now. It is difficult to imagine the same happening in India, the U.S. and in most other places. If such a disease had occurred in any of these countries [before it occurred in China], we would have seen devastation similar to that seen along the path of a hurricane.
Without bothering about criticism from outside, they went about their job of isolating, tracking travel history of people, creating awareness in schools, employment of drones, building hospitals in just a few days, and imposing movement restrictions. It worked. With our limited experience with this pandemic, we can see that this approach has saved lives.
In the event of an epidemic, does Chennai have the adequate capacity to treat everyone who may need treatment?
For a city the size of Chennai, we need about 5,000 beds. We don’t have that many beds for infectious diseases. We have general beds which will amount to much more than that number. We have only one Communicable Diseases Hospital, which has 500 beds. All the other hospitals should have isolation wards. If you want to handle such pandemics in the future, there is no way but to set up a 5,000-bed hospital outside the city.
What are the lessons that were learnt from the handling of the cholera epidemic in 1992-93?
When cholera broke out in 1992-93, the Communicable Diseases Hospital had only 300 beds, and we added sheds across the entire campus to handle the additional patients coming in. We created about 1,500 beds in all.
Daily admission was over 1,500 patients. Because of the epidemic, government hospitals refused to take patients. That is the time I was forced to think: should I keep the inpatients for a week as was conventional? If I keep a patient for a week and if I have daily admissions of 1,500, just imagine what will be the bed load. We employed about 700 professionals, including about 150 doctors and 300 nurses. It was a war.
So I was forced to take a decision to cut down hospital stay from one week to 48 hours. This was our research point based on data and the clinical symptoms. As a result of this research we identified a new strain of cholera, and it was named the Madras strain. The treatment we simplified using antibiotics like 300 mg of doxycycline and five pints of ringer’s lactate, and the patients were much better in 48 hours. Every authority, including the WHO [World Health Organisation], was astonished at our management. The management was based on our understanding of the bacterium, how it manifests, how it spreads and how it can be controlled.
For a cholera infection, which can be cured and the cure rate was 100 per cent, we had so many facilities. Just imagine the scale of what you require now for a pandemic that is capable of spreading everywhere, and the treatment is highly problematic because a patient’s cure rate depends on his or her health status. Fortunately, we haven’t yet seen a massive upswing in infections.
What went right? How did those in authority at Chennai Corporation and the Tamil Nadu government react?
The Chennai Corporation gave me the full freedom to function: recruit, bring patients to the hospital in a fleet of over 100 ambulances and implement innovative treatment protocols that we developed for that particular situation. Remember that the cases were coming in from all over: from neighbouring States and even faraway districts.
It was fortunate for this city that Mr R. Poornalingam, IAS, was the special officer; he quickly understood the gravity of the situation. The then Chief Minister, Jayalalithaa, too supported our efforts because we treated two Ministers and about half a dozen IAS officers. One of the things I forced the government to act on was to increase the level of chlorine in the drinking water system. This was a big struggle because there was a major difference of opinion on my suggestion to increase the chlorine content. But since I had an army of staff helping me, we mapped the chlorine content in water in public fountains in all the wards of the Corporation. The correlation was hard to miss: wherever the chlorine level was nil, we saw a spike in cholera cases.
There were also many press articles at that time supporting my view or the contrary view. At a meeting with the Chief Secretary, I showed him historical evidence of how cholera was controlled and suggested we do the same here, that the culprit was water. Deaths in cities outside Chennai, such as Madurai, were increasing. The Chief Secretary empowered me to take a decision on the chlorine content in the water supply system.
My instruction was to increase the chlorine content to 10 ppm. The WHO’s recommendation is 0.2 ppm. When we checked in some of the tail-end points, we found that even after an increase of 10 ppm at the waterworks points, the tail-end areas had barely 0.2 ppm. This is because a lot of the pipelines were laid many decades ago. In just a week after we increased the chlorine level, the cases in the worst affected areas came down from 1,000 to 50-60.
After so many epidemics, does India have a national approach to such diseases?
There is an Epidemic Task Force in all local bodies. All States have a State Epidemic Task Force. All the experts and administrators discuss and decide on approaches to an epidemic. But what is happening now is haphazard statements from different quarters. They have to develop an agenda for it. They have to plan a strategic road map to handle the situation.
The U.S. has an organisation called the Epidemic Intelligence Services [EIS]. They are the first people to gather information on any disease outbreak anywhere. The same system was copied and started in Delhi in 2012. It is responsible for monitoring the country.
After the Surat plague outbreak here, the U.S. sent massive shipments of PPE [personal protective equipment] to India. At that time, India had not even declared that there was an outbreak of plague. Also, there is a National Institute of Communicable Diseases in New Delhi [now called National Centre for Disease Control]. It too has not been talking. The disease surveillance units across the country should function properly. There are vacancies across States, from what I hear. These units have to monitor even the smallest outbreak of disease. They should conduct epidemiological research on that. They should identify the hotspots and stamp it out as soon as possible.