8 April 2020, NIICE Commentary 3987
Kartik Bommakanti
The outbreak of an infectious disease such as COVID-19 raises important questions and brings to attention issues surrounding biosecurity that were hitherto either ignored or neglected or both. There are known and unknown biological agents. Planning for both place steep strains on the state and national health care systems. India can only plan for a very limited range of biological threats and health-related contingencies. Indeed, biological threats whether they involve the deliberate use of biological weapons or unexpected pandemic outbreaks are harder to plan for than against the potential use of nuclear weapons.
Responses to both require hard choices. With the difficult decisions are harder than the former to the extent that some biological threats can be prepared for and others cannot because they are so distinct and represent black swan outbreaks as is the case with COVID-19, which is Zoonotic disease spreading from bats and wildlife markets from Wuhan in China. Biosecurity by definition means the protection of populations against biological agents which could include viruses, pathogens, bacteria, fungi, yeasts, micro-organisms, etc. There are some key elements undergirding biosecurity. The first being the security of the physical laboratory infrastructure that plays host to various viral cultures, pathogens and biological specimens for testing and lab-based experimentation. This includes the safety and security of the personnel involved in laboratory activity, who could if infected by a dangerous pathogen become a source of transmission beyond the environs of the bio facility. A corollary to this aspect of biosecurity is the surveillance and regular monitoring of personnel involved in laboratory work. India as of today has National Disaster Management Agency (NDMA). It has roughly 2000 personnel dedicated to deal with Nuclear, Chemical and Biological attacks. However, New Delhi is yet to introduce specific legislation against bioterrorism. It has a nuclear doctrine that stipulates the use of nuclear weapons against use of all Weapons of Mass Destruction (WMD) including biological weapons.
The second element of biosecurity are preventive measures taken to protect personnel, particularly first responders such as medical staff covering paramedics, Emergency Response (ER) teams to nurses and doctors who need to be inoculated against viral infections. In addition, police personnel, paramilitary units and soldiers who might be deployed if a pandemic spread to control movement of people and quarantine the infected.
However, against known biological threats all the essential personnel mentioned above will need and can be subjected to vaccination, remain healthy and perform effectively during a medical and health-related emergency. The known agents that pose virulent threats cover diseases such as anthrax, Small Pox, Plague, Tularemia, Botulism and so on. Nevertheless, whole populations cannot be subject to vaccinations against anthrax attacks. There are cogent reasons for it to be so. Firstly, even if there is a vaccine against Anthrax, vaccinating entire populations might not happen or be demonstrably undesirable due to a deliberate or inadvertent outbreak because the effects of the vaccine or drug may wear of over time. Secondly, it may generate undesirable health-related side effects on specific segments of vaccinated populations and finally there are limitations imposed by lack of mass production capacity or insufficient stockpiles. Indeed, the United States (US) has sought India’s assistance in the supply of Hydroxycloriquine (HCQ), the anti-malaria drug, is illustrative of the limits of stockpiling. Shortfalls in stockpiling this drug by the US is because Malaria infects and kills more Indians than it does Americans, because of which India maintains a very large and surplus HCQ stockpile. It is a matter of co-incidence and chance that India has such a large stockpile HCQ that can serve at least as a prophylactic against the COVID-19. Further, the drug is cheap to produce making its export easier.
All these factors constrain, if not out rightly fetter timely governmental responses to viral and contagious outbreaks. Indeed, the only segment that can, should and likely be subjected to vaccination before an outbreak for known bio threats are first responders, medical staff, police and military personnel. Thus, a health emergency affecting a large number of people even in the case of well-known bio threats prior to an outbreak will increase the general public’s receptivity to mass vaccination, but remains a challenge to safeguard whole populations before an outbreak.
The resistance and avoidance to vaccination against known bio threats prior to the rapid spread of the disease from the mass public as well as from officialdom is perhaps wise as it reduces the burden particularly for the latter to justify, even if it is based on expert medical advice. Further, health care systems like India’s are likely to incur a steep cost for a subsidized vaccination programme even when a bio threat is known such as anthrax. Finally, pre-attack vaccination might not be effective because the state including its intelligence apparatus cannot predict where and when an anthrax attack might occur. Indeed, as one American Center for Disease Control (CDC) study observed about an anthrax attack: “Because the location and timing of a bioterrorism attack cannot be predicted, the risk-benefit profile for pre-event vaccination for the general public is low, and pre-event vaccination is not recommended. Preventing the morbidity and mortality associated with a deliberate release of B. anthracis [anthrax] depends on public vigilance, early detection and diagnosis, appropriate treatment, and rapid administration of PEP.” Early detection also enables the administration of drugs and vaccines against the most virulent biological agents such as Anthrax, Tularemia, Small Pox and Plague.
This challenge against known bio threats becomes harder for countries such as India as a sizeable proportion of its population is still indigent making vaccination more difficult particularly if the state is expected to subsidize the effort. Nevertheless, anticipating probable uses of known biological agents such as Anthrax by terrorists, rogue scientists or through accidental release, even if it initially claims some lives, is more straightforward due to the availability of vaccines and drugs. In the present case, there are no cures yet, although infected individuals have staged a recovery following stringent quarantine and carefully administered medical care, we are faced with a completely novel and unknown disease in the form of the COVID-19 and the knowledge we have about the latter is still limited and evolving. The preventive measures used in the present pandemic do share commonalities with the prevention of bioterrorism in the form of early detection, diagnosis and isolation.
In the current pandemic, there are no known vaccines or cures, hence essential personnel are still marginally vulnerable to contracting the COVID-19 and transmitting it, despite Personnel Protection Equipment (PPE) and decontamination measures. Nevertheless, against infectious disease like the COVID-19, cures or vaccines will be found, but never immediately. As is the case with past infectious disease and pandemics such as small pox, relentless testing is the surest way to find a vaccine and cure. Testing is an activity India will have to pursue more vigorously beyond the preventive tight lockdown measures. Indeed, the headcount of fatalities due to the novel corona virus in India is likely well above what official estimates suggest.
In the coming months, the pandemic will hopefully abate, but the most crucial measures for India to put in place will be preventive and mitigatory such as encouraging better hygiene, sanitation, greater investment in anti-smoking campaigns, and encouraging consumption of immunity boosting food. In the long-term, significant investment will be necessary from the Indian state, in the biological sciences and medicine to prevent the outbreak of pandemics and developing the health infrastructure of the country.
