UNCLAS SECTION 01 OF 04 NEW DELHI 001671

SENSITIVE
SIPDIS

HHS FOR OGHA AND PASS TO ANNE CUMMINGS AND DANIEL MILLER
CDC ATLANTA FOR CCID AND PASS TO NANCY COX, STEPHEN BLOUNT, ANN MOE
AND STEVE REDD
PASS TO NIH FOR ROGER GLASS, THOMAS MAMPILLY, JAMES HEDDINTON AND
GRAY HANDLEY
PASS TO FDA FOR MAC LUMPKIN AND MARY LOU VALDEZ
PASS TO AIAG FOR AMBASSADOR ROBERT LOFTIS, HELEN REED ROWE, AND
CRAIG SHAPIRO
USDA PASS APHIS AND FAS
DOT PASS SHATLEY
FAA PASS TNASKOVIAK

E.O. 12958: N/A
TAGS: KFLU AEMR ASEC CASC KFLO TBIO KSAF KPAO PREL PINR
AMGT, MG, EAGR, EAIR, ECON, PREL, SOCI, IN
SUBJECT: INDIA - FIRST PANDEMIC H1N1 DEATHS

REF: A. NEW DELHI 860

B. NEW DELHI 879

C. HYDERABAD 63

D. NEW DELHI 1286

E. STATE 82155


1. (SBU) SUMMARY: India experienced its first confirmed pandemic
H1N1 influenza related death on 3 August, and has had a total of
seven reported deaths over the past week. The number of positive
cases rose to 959 as of 10 August. The Ministry of Health and
Family Welfare (MOH) has announced new home quarantine procedures
for self-reporting patients, though incoming air travelers reporting
flu-like symptoms will still be subject to quarantine in a
government facility. Under Indian law, state governments retain
primary control for dealing with the outbreak and some are clashing
with central government recommendations. The Government of India
(GOI) is pushing to produce its own pandemic H1N1 vaccine by
September, as well as exploring potential new sources for a key
Tamiflu ingredient. Significant U.S. Mission intervention has
resulted in much improved, albeit spartan, government quarantine

facilities. The Mission is reviewing tripwires and procedures in
light of lessons learned. END SUMMARY

FIRST DEATH INCITES PUBLIC PANIC, CASES CONTINUE TO RISE


2. (U) On Monday August 3, a 14-year-old girl who had presented with
severe illness and was misdiagnosed as having pneumonia died from
H1N1-related complications in Pune. Since then, the MOH has
confirmed three additional deaths in Pune, one in Mumbai, one in
Chennai, and one in Gujarat (a U.S. LPR) for a total of seven
pandemic H1N1-related deaths as of 10 August. Following the highly
publicized deaths, and exaggerated newspaper accounts of potential
H1N1 risks, hospitals have reported being overwhelmed with the
worried well. In Mumbai, for example, Kasturba Hospital noted that
over 600 people had self-reported for testing in recent days. Many
of the patients told the press that while they lacked symptoms or
their private practice doctors did not believe they had H1N1,
newspaper stories had prompted them to seek testing and treatment in
order to "not take chances." The number of samples has increased
sufficiently to overwhelm one of the two government-approved testing
facilities; the GOI previously claimed that additional laboratories
would be made available for diagnostic testing, but Mission has seen
no indications this has actually happened.


3. (U) The number of cases continues to rise rapidly, with a total
of 959 as of Monday 10 August. An Embassy review of MOH reports
suggests an increasing trend towards in-country contact transmission
over imported cases. Data on the recent deaths is not yet clear,
though in at least some of the cases underlying co-morbid conditions
contributed to the fatalities. In addition, diagnostic test results
are being impacted in some areas by the normal flu season. Some of
the severe cases tested for pandemic H1N1 are coming back positive

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for seasonal influenza, forcing the GOI to reexamine its assumptions
about the danger of seasonal flu outbreaks and somewhat complicating
the public health response effort to pandemic H1N1. (NOTE: Northern
India has bi-modal influenza season that typically peaks in
July-August and again in November-December, while Southern India has
year-round flu with smaller peaks in November-December. END NOTE)

NEW HOME QUARANTINE GUIDELINES, INTERNAL TRAVEL RESTRICTIONS


4. (SBU) The MOH released on August 6 new quarantine guidelines
directing that for self-reporting patients, a designated medical
officer at a government facility will conduct a clinical assessment
and decide on the need for testing. Except in cases of severe
illness, the patient will be allowed to await results at home. If
the sample tests positive for H1N1 and the symptoms are mild, the
patient will be given the option of admission into the hospital or
home isolation and treatment. Patients opting to stay at home will
be provided with detailed guidelines and safety measures to be
followed by the entire household. The designated medical officer
will have the final decision regarding hospital admission
requirements. According to Embassy contacts, the MOH internally
discussed discontinuing airport health screening procedures because
they are ineffective at preventing the spread of pandemic H1N1.
However, press leaks about the conversation created a political
uproar and they were forced to step back and declare that screening
would continue. (NOTE: This example of political pressure
interfering with medically sound practice is not isolated, and we
expect politics will continue to exert a heavy hand, and even trump
medical facts, in India's responses to the pandemic. END NOTE)


5. (SBU) Despite the new GOI guidelines, State governments continue
to make their own decisions about quarantine procedures.
-- In Chennai the Director of Public Health invalidated the MOH's
guidelines and said his state would continue their quarantine
procedures.
-- Hyderabad continues to follow the previous quarantine procedures.

-- In the state of Jharkhand, media reports in general are
sensationalized, particularly in one case where a patient with a
positive test was reported to have gone missing. The Jharkhand
state government, currently under president's rule since it cannot
form a government, sent contradictory messages about whether or not
the patient was under quarantine.
-- Following India's first pandemic H1N1 death, the Government of
Maharashtra invoked the Epidemic Act in Pune and Satara, which
allows health authorities to forcibly admit and quarantine suspected
H1N1 patients. With state assembly elections scheduled in October,
it appears unlikely that the State of Maharashtra will heed the
GOI's dictates for handling and treating pandemic H1N1 patients. In
addition, the State of Maharashtra issued guidelines for schools
which explain that H1N1 came to India "through tourism" and that
children who have traveled and have flu symptoms should report to

NEW DELHI 00001671 003 OF 004


the designated public quarantine hospital, Kasturba, for testing,
but that others should be treated at home. Local press reports the
voluntary closure of some local schools after a student tested
positive for H1N1.


6. (U) The GOI has issued no further travel restrictions. However,
the Tamil Nadu State Government issued a travel advisory this week
warning people to avoid the districts of Pune and Satara in
Maharashtra.

PUSHING FOR INDIGINOUS VACCINE AND TREATMENT OPTIONS, BUT NERVOUS
ABOUT QUALITY


7. (SBU) India has accelerated its efforts to develop an indigenous
pandemic H1N1 vaccine. In addition to working with an imported H1N1
strain, the GOI has approved three companies - Bharat Biotech, the
Serum Institute, and Panacea Biotech - to develop vaccines. Two of
those companies have reportedly assured Dr. Srivastava, Director
General of Health Services (DGHS,) that they would be able to
produce the vaccine in India by the end of September. Recent ESTOFF
conversations with Dr. Sumathy, Associate Director R&D of Bharat
biotech, and an ESTOFF visit to the Panacea Biotech facility suggest
that while both are actively and intensely engaged in H1N1 vaccine
development, neither have a definite timeline for completion of the
vaccines or associated safety and efficacy testing.


8. (SBU) Prof. Ramanan Uma Shankar from the Department of Crop
Physiology at the University of Agricultural Science, Bangalore
claims to have discovered in the Indian Western Ghats seven plants
whose leaves produce shikimic acid, a key ingredient used to make
Tamiflu. Professor Shankar told ESTOFF that only 100 Kg of leaves
were required to produce 5 Kg of shikimic acid, and that these new
sources would result in a more sustainable and less expensive
process. The veracity of this reported discovery remains to be
seen.


9. (SBU) Despite their push for indigenous treatment capabilities,
GOI officials have also indicated to EMBOFFs that they are worried
about the quality of home-grown diagnostic reagents that would be
used for identification of the virus. The officials indicated they
would prefer to either acquire the reagents from U.S. companies at a
lower cost, or to be given a waiver of patent rights so that they
can produce the proven reagents themselves. (NOTE: This is not a
new request. The GOI has consistently held that patent waivers
and/or low cost medications and vaccines should be made available
for developing nations like India to deal with pandemics and other
health and disease concerns. END NOTE)

MISSION HELPED IMPROVE HOSPITAL CONDITIONS, STILL NOT THE TAJ


10. (U) On a positive note, active intervention by the Mission with
the Central and State governments has directly resulted improved

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government hospital quarantine facilities. While the facilities
remain very basic by U.S. standards, they now generally follow
better hygiene practices, and the staffs have improved their patient
interaction practices to prevent miscommunications and cultural
misunderstandings. In addition, many of the facilities have become
much more proactive about contacting Mission staff about pandemic
H1N1 cases involving potential American Citizens. Mission remains
engaged with Indian government officials, as well as other foreign
missions, on these issues.

MISSION ACTIVITIES


11. (SBU) Mission is reviewing procedures, including pandemic
tripwires, internal Mission education practices, and external
websites for public dissemination of information, in response to our
lessons learned and Reftel E State guidance. In addition, our
Public Affairs section continues a timely campaign to educate the
Indian media on how to accurately report on pandemic diseases.
Mission Medical Officers have been in touch with representatives
from our American Schools in New Delhi and Mumbai to clarify testing
and treatment options, including school closures.

ROEMER