Clinicians and microbiologists constantly speak to each other. Anyone hearing these conversations a couple of months ago would have realised that the human metapneumoviruses, or HMPV, and influenza were being detected in a significant proportion of those tested for an acute respiratory infection.
Earlier in January, one would have heard our concerns that mycoplasma pneumoniae appeared to be sounding an alarm about an epidemic and the possibility that some strains might not be responding clinically to macrolides, such as azithromycin and clarithromycin – we have no way to confirm this. What is worrisome is the direction of the flow of information. Surveillance systems need to warn clinicians about what is impending, rather than the other way around.
What began as reports about a cluster of infections in China with human metapneumovirus has led to widespread panic in India, with “breaking news” of “first cases” being reported. A dashboard of surveillance data would have reassured citizens that these were unlikely to be “first cases” and data on trends would have calmed anxieties by revealing that the virus has always been around, with numbers waxing and waning with seasons.
Respiratory multiplex molecular tests targeting at least 15 respiratory viruses and four to five bacteria are performed on swabbed pharyngeal secretions. These tests are expensive – as much as Rs 15,000 or more – and therefore those tested tend to be a select few: hospitalised patients with severe illness, affluent people with no financial constraints who pay out-of-pocket, or immunocompromised patients who need to get tested. Despite these limitations, if data across the country was pooled, one could possibly detect trends from these tests resulting in preemptive action.
Data from our institution alone suggests that close to 10% of our samples tested over the past three months detected mycoplasma pneumoniae while HMPV was found in 2%. In the preceding three months, the corresponding figures were less than 1% for mycoplasma pneumoniae, and 17% for HMPV – influenza figures were 13% and 17% during the same periods, respectively. These figures validate what clinicians have been reporting on the ground.
What are the impediments in making this data available to the public in real-time?
First, except for influenza and Covid-19, the other viruses detected are not notifiable and therefore laboratories testing for various respiratory viruses are not mandated to collect or report such data. Second, in the absence of mandatory notification, the reporting of data with patient identifiers has ethical implications for confidentiality. Will patients with transmissible diseases be stigmatised? How will the data be used to inform public health? Third, how can testing be made universal and representative, if the tests are prohibitively expensive for a majority? This is where surveillance needs to play a role, offering testing at subsidised rates for sampling, even if this is on a limited scale and as part of research.
Improving transparency with access to such data is key. The data already exists in private laboratories and hospitals to some extent – what is needed is a dashboard that collates this information, nationally, in an ethical and confidential manner. Just as air quality index data is getting more granular and universally accessible, transmissible diseases also need real-time data for proactive decisions.
Equally important is communicating this data. Advisories tend to either be paternalistic – “we have no cause for concern and are monitoring the situation closely” – or alarmist: “we recommend mandatory isolation and universal precautions for anyone reporting symptoms”. There is an urgent need to communicate and quantify risk better. In an age when diagnostic tests are getting better and media coverage is reminiscent of the Covid-19 pandemic years, there is a need to strike a balance.
The current media sensationalism risks creating a boy-crying-wolf situation, numbing citizens to future advisories. Conversely, repeatedly stating that only the elderly and the vulnerable need to be worried leaves a significant proportion of the population in a constant state of anxiety and helplessness. There is a need for tools to empower the elderly and immunocompromised to grade their risk – and this has to be done in a scientific manner.
Could this be the start of a new pandemic?
If the strain circulating in China is a novel one, with high transmissibility, there is a possibility. Without whole genome sequencing and clinical data suggesting increased virulence or transmissibility, there is no way to know yet. Periodic and seasonal surges in viral infections are not a new phenomenon, and preventing fearmongering every time this happens requires robust surveillance systems and clear, unambiguous communication, even when there is uncertainty. Those of us reading this have survived one pandemic, should not have to constantly live in the fear of the next.
Dr Lancelot Pinto is a Consultant Pulmonologist and Epidemiologist at PD Hinduja Hospital, Mumbai
Dr Camilla Rodrigues is a Consultant Microbiologist and Head of the Department of Microbiology at PD Hinduja Hospital, Mumbai
Views are personal.
