Deadly outbreak of swine flu in India may be due to a mutated strain

AHMEDABAD, India — Dr. Dinesh Joshi puts on an N95 medical mask and opens the door to the swine-flu ward at Civil Hospital in India’s western state of Gujarat. With 5,000 beds, it is one of the largest hospitals in Asia. The swine-flu ward is at the end of a long corridor, its walls lined with drawings made by schoolchildren on the importance of washing one’s hands after using the toilet, of eating a diet rich in protein and of avoiding public gatherings — all actions that Joshi believes will prevent a worse outbreak of the virus that is currently sweeping the country. 

Inside the ward for swine flu ward, labeled by its official medical name, H1N1, 6-year-old Purvi sits on a bed with an IV tube in her nose. Her chances of survival, like those of the 15 or so other patients in the room, are uncertain. In the corner, medical assistants enter details of swine-flu cases into the state and central government database. Across the hall is another room, with the word “Suspect” written on the door in Gujarati, reserved for those who may have the virus.

“The suspect room is empty,” Joshi says, beaming. 

Since the outbreak of H1N1 earlier this year, there have been 32,233 cases across India and 1,911 deaths. Gujarat is the worst-hit state, with 410 deaths, of which more than 175 have occurred at Civil Hospital. A few weeks ago, Joshi was working 16-hour days, sometimes admitting as many as 70 new swine-flu patients each day in five wards set up to combat the virus. Today, two remain reserved for H1N1, and Joshi estimates there are fewer than 50 cases at his hospital. 

With temperatures rising — Ahmedabad is expected to hit 107 degrees Fahrenheit this week — Joshi and his staff are confident that India’s swine-flu problem is on the wane, given that the flu virus thrives in cold temperatures. But MIT researchers Ram Sasisekharan and Kannan Tharakaraman stress the need for caution. 

In a March 11 report based on their analysis of two strains of the virus, the pair observed that it may have mutated into something distinct from and more virulent than the strain that caused the 2009 outbreak, which resulted in the death of 284,000 people across 74 countries, including India. A deadlier strain may infect human cells more efficiently, even in the summer heat. 

“The point we’re trying to make is that there is a real need for aggressive surveillance,” Sasisekharan said in an interview with Time magazine.  

Indian medical professionals are skeptical; representatives from the National Institute of Virology and National Center for Disease Control, who declined to be interviewed for this story, have repeatedly insisted that the swine flu seen in India shows no mutation from the 2009 virus. 

But medical corruption, including bribing doctors, fudging statistics and failing to crack down on malpractice, is commonplace in the country. In 2012, a popular Indian talk show called Satyamev Jayate, which stars the Bollywood actor Aamir Khan, raised awareness of this issue when it documented abuses in India’s public-health system. 

Mohamed Baloch, a surgeon in Ahmedabad who used to work at an Indian government-funded hospital, has seen several swine flu patients who were in need of surgery. He says he would not be surprised to hear that the scale of the swine-flu problem is bigger than the Indian government is admitting. He cites the outbreak of dengue fever in India, which involved almost 300 times as many cases from 2006 to 2012 as the Indian government acknowledged. 

“Yes, this playing of the numbers happens,” says Baloch, who now works in a private practice. “I know this because in government hospitals I have been asked to write these reports, and at times I have fabricated the numbers. What other choice did I have?”

Swine flu gets its name from a similar virus that is also found in the respiratory tracts of pigs. Symptoms include fever, cough, nasal secretions, fatigue and headache. This makes it difficult to detect because it mirrors a common household flu. It can be cured if treated early, especially by vaccination and antibiotics, but too often patients wait to visit a doctor. 

The first case of swine flu, according to a U.S. government website that tracks viruses, was recorded in central Mexico in March 2009 and then quickly spread to California and other parts of the world. By 2010, it was largely under control. The World Health Organization initially said that 18,500 people had died, but a 2012 study by the London-based journal Lancet Infectious Diseases said that the number of casualties was actually 12 times that figure. 

In 2010, 1,763 Indians died of swine flu, but the virus was largely contained thereafter. Last year, for example, there were only 238 deaths. Doctors are still unsure why there has been a spike in recent months. 

“Most likely there is probably a new strain that is operational,” says Dr. Om Shrivastav, who runs a swine-flu isolation ward at Jaslok Hospital in Mumbai, in an interview with the Rediff website. “In India, with one plus billion people, any amount of overcrowding is actually going to make the progression of the virus significantly higher.” 

Amit Varshney, a doctor in the rural town of Kanwat in Rajasthan, another Indian state hit hard by swine flu, points out that some of his patients do not have a strong enough immune system to fight diarrhea, let alone swine flu, a virus that can only be detected by a costly lab test and often leads to debilitating respiratory problems.

He also bemoans the fact that some are trying to profit from the outbreak. Varshney observes that swine-flu prevention kits are selling for as much as 10,000 rupees, or around $160. (The annual median per capita income in India is 74,920 rupees.) Many of the items included in the kits do not even ward off the virus, he adds. One apartment building, in an effort to lure buyers nervous about contracting the illness, even billed itself as “India’s first swine flu free homes.” 

Now there is concern that the disease could spread to other parts of the world. Some flights in and out of India are being monitored for swine flu, as they have been for Ebola, and the Indian government is taking precautions by limiting large public gatherings. 

But Dr. Veena Iyer, an assistant professor at the Public Health Foundation of India in Ahmedabad, a public-private initiative set up in 2006, believes awareness of the virus is still lacking. “I still do not see any outcry about this, nor do I see any calls to reform India’s health-care system,” Iyer says. Like many other physicians, she points out that the country spends just 1.2 percent of its GDP on health care, placing its expenditure on public health lower than Gabon’s, Haiti’s, Sudan’s and Afghanistan’s.

Dr. Syed Shahid Abbas, a doctoral student at the University of Sussex in England, has spent the past five years working at the Delhi office of the Public Health Foundation of India and is currently studying the swine-flu outbreak. While Abbas agrees with Iyer that India should spend more on its health-care system, he believes the solution is more complex. 

“Almost every population in the world believes that their government should spend more on health care,” Abbas says. “But in India, if you add more money, it will not automatically improve the health infrastructure, especially if it is not added to the right area.” 

During a two-week visit to India, he attended a meeting of experts on swine flu in Gujarat, an experience that left him dismayed. “What often happens in discussions on health care in India is that political forces take over and health-care professionals are marginalized. So either we have politicians interpreting what the country should do on swine flu or health-care professionals who cannot speak freely because of political pressure.” 

This means that the swine-flu crisis in India may be bigger than the government has acknowledged, because the real statistics are not being reported. Dr. Gulrez Shah Azhar Shah made news last year while he was a professor at the Indian Institute of Public Health and discovered that more people were dying of heatstroke than the government was revealing. 

“The problem is not that there is some person sitting in a room at the top telling people to fabricate their numbers. The issue is at the local level,” says Shah, who is now a doctoral student at the Rand Corp. in Los Angeles. “If a doctor accurately reports the level of a virus, he may be reprimanded by his superiors because they believe it is in the interest of all to show lower numbers.” He notes that Gujarat data may show a higher number of swine flu cases than other states because Gujarat is a relatively wealthy state with better reporting mechanisms. “It could be much higher in other states, but we just do not know.” 

JP Gupta, the top government health official for the city of Ahmedabad, dismissed the MIT study: “Their research sample was too small.” According to Gupta, “What we know about swine flu is that this is the same swine flu we saw earlier in 2009.” 

But the MIT report’s authors point out that international scientists are able to study swine flu primarily by using a public database built by countries where cases are found. And that even though India has the highest number of swine flu cases in the world, it has contributed less than 1.5 percent of genetic sequences to the public swine-flu-virus database. That means that, largely because of India, the available sample for researchers to analyze is limited. (In comparison, the United States, with significantly fewer swine flu cases, has contributed more than 38 percent of the database's influenza sequences.) 

Samar Halarnkar, the editor of the data-journalism site IndiaSpend, has written a series of articles on swine flu in the country, and adds that the swine-flu samples the researcher duo analyzed came from India’s own National Institute of Virology. “This report did not come from a roadside clinic. It was published in a peer-reviewed journal published by MIT scientists. If India’s critique is that the MIT scientists should have analyzed more data, then we should ask, ‘Why is India not contributing more swine-flu sequences to the public database?’” The problem, he says, is that the Indian government becomes prickly when its health practices are criticized. “Too often in India we close our shutters and become defensive instead of examining what these reports tell us about conditions in our country.”  

Gupta disagrees, saying that the government has done what it can to stop the spread of this virus, including working with outsiders. He also firmly rejects the idea that there is underreporting of swine-flu statistics: “We have it in our interest to prevent this from spreading, and we are handing out masks and information kits each day for free to combat this.” 

However, in a hospital across town, another doctor, who asked to remain anonymous for fear of reprisal, says that the government is being lackadaisical in its response. He spent more than 30 years working in an Ahmedabad health department within the central government and now works at an elite private hospital with just 50 beds. He lifts up a stack of files from his desk with one hand, the other covering the patients’ names to protect their privacy.

“All these are new swine-flu patients,” he says. “The summer has already started and we are still seeing cases. It may be less, but it has not gone away. We should just accept that we do not know what is happening.”