srkulhalli - 12 August, 2009 | Analysis | medical | public health | India | Others | Everything else | swine flu

These are actual lines taken from news websites

• Prime Minister Manmohan Singh  asked Azad to augment the response mechanism in the wake of the rapid spread of swine flu, which has claimed eight lives so far.
• Health Minister Ghulam Nabi Azad has asked Chief Ministers to take urgent measures to tackle spread of the dreaded virus in the country.
• A top Health Ministry official today said Azad spoke to 22 Chief Ministers on Monday night, impressing upon them the need to take measures to tackle the spread of the pandemic.
• The Chief minster has called on the chief secretary and asked him to beef up the adminstration in face of the virus threat.
• The chief secretary asked the district administration officals to ......
•  

 With so much action happening all around - you can really relax - no need to worry

• On the decision to rush senior officials to states, he has said, "As of now, we have been corresponding with the states only through letters, but it now seems that this is not enough, so we have decided to send them to various states."  ...  NOW ?
• Azad has announced a slew of measures like installing thermal scanners at all international airports to screen passengers ... NOW  ?

Recently my team-mate got tested for swine-flu and tested negative. I wasnt worried about the flu before, however am more now after the test.

He travelled by bus to the centre (Rajiv Gandhi Ins). There were 40 others who came in by various means of transport all huddled in the same room. There was no extra precaution for cross-contamination. And to top it all the test result came after 4 days. From what I read, the medicine should be started within 24 hrs to max 48 hrs to be effective.

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In my opinon, management has not been very good. Ability to think calmly, think ahead, think it through - is poor, it is more reactive. Ability to structure/break down the problem, get in clarity,  think strategically is poor.

To be fair, it is not the govt. is not doing anything, my problem is that it is more reactive.

You work and hope for the best case. BUT you have to be prepared and plan for the worst case. .

This is a management problem. Here is how I would have approached it.
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Problem : Swine Flu or H1N1 the new virus that is fast spreading around the world.
Goal : 1. Minimise fatalities (overriding goal)
          2. Minimise health impact and distruption to economic and social life

Three aspects : Detection, Containment and Treatment
Detection : Finding out if the person has swine flu
Containment : Preventing the spread
Treatment : Treating people who have the flu

For each, there are two dimensions, scale and quality
By scale, is a question of number of people, 100, 1000, 10,000, 100,000, 1 lakh, 1 million, 10 million, 100 million,  > 100 million
By quality, is depth or improving effectivenss. In each aspect, how do work on both the dimensions. For eg:

For detection
1. Scaling : What is the methodology for detection for each of the above numbers (100, 1000, ....)
        When we are at 100, the infrastructure for 1000 should be in place and preparation for 10,000 should be going on.
       If we are at 1000, the infrastructure for 10,000 should be in place and putting the infrastructure for 1 lakh should be going on ...
      At 1 million and above the methodology may have to change. Maybe we need to go for cluster based sampling. Whatever it is, the plan needs to be put in place...
      Can we filter by doing a preliminary clinical examination ? What is the probablity rate of  a positive case not getting through.

2. Quality : What is the effectiveness of detection (90% reliable ??). How do I improve it ?
      How much time does it take (Test takes 4 hrs, collection and sending sample ~ 3 days) how do I cut it down ?
      Whats it cost ? Does scaling reduce it ? Is it mainly equipment cost ? Cost of labour ?? How do I cut it down without reducing effectivenss
     What if virus mutates - how do I detect if virus has mutated ?

For Containment
1. Scaling :  For upto 1000, point of entry is airports. Ensure no case slips through. Even if this means a N hrs in the airport for quarantine for each passenger.
                  Quarantine each individual known case
       For upto 10,000 home quarantine or build capacity in local clinics to quarantine with adequate training (Identification of hospitals and training has to been done long before)
       Above 10,000 use public broadcasting services (television, radio) to give guidance on how to reduce spread, and increase it depending on severity.
       Above 1 lakh, go for cluster based approach, and shut down public places  (schools, malls etc) in clusters where the contamination rate is > x %
    
2. Quality : What measures are most effective ? We need to advertise only top 3 measures - give a laundry list and the priority will be lost on people. Whom do we target ? Should we have a compulsory class in schools. Do we train 5 teachers from each school etc ?

For Treatment
1. Scaling : First line of treatment : Medicine stocks as a function of number of cases. Its disbersment and availability. How does it reach patient immediately
      Second line of treatment
      Emergency care
2. Quality : Maintain database and feed in data of each case. Overtime, we will have a fanstastic information base for doctors, patients, vaccine manufacturers and policy makers alike: What was effective.
When should the medicines be given. What are the most likely complications and how does one treat them. What facilites are needed for complications. Identify hospitals capable of treating especially when the number of cases start to swell

Start research on vaccines/medicines or work with pharamecital companies. What if the virus mutates and becomes resistant. Work out strategy how to quickly detect and start work on a second drug in such a possiblity.

 

Interlinking/Common strategy :

Detection should result in better containment, not the other way around. Does it make sense to take the test to the individual ? Alternatively, should we have dedicated vehicles to pick up suspecting cases. Can we work with local clinics to ensure the person does not have to travel by Public transport and can walk to the clinic ? Can we give them special looking masks that can be picked up at pharamcies which will help reduce spread and warn fellow travellers to stay away ? How do I ensure that the people who are detecting dont get contaminated themselves ?
Detection directly results in treatment, so first line of treatment (tamiflu ?) should be available at each detection point. How is the communication channel between detection and treatment been setup.

Communication : Have single phone in number. Train 20 people (there were 4 months to train) for less < 10,000. Train 10 people for every 10,000 thereafter (this needs to be started way before hand)
  Preferably have nurses trained on all aspects of swine flu plus they are computer savy to pick up information about local hospitals/treatment centre etc. Have a call centre guy run this :)
  Have website with all information !

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These are just some quick jottings and needs to be developed a lot more- but would this result in better management than what the govt. is doing now ?. How would you tackle it if you were the health minister ?                   

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