A wake-up call

Active government intervention through the public health system is necessary to control the spread of swine flu and the panic among the people about the seasonal influenza which thrives on the lack of public awareness about it.

Pupils wearing masks as a precaution against swine flu in a school in Hyderabad on January 22.

THE outbreak of H1N1 influenza, or swine flu, is causing panic among the public as it is reported to be spreading across States affecting thousands of people and claiming hundreds of lives.

Although the winter is slowly coming to an end, the seasonal flu virus has shown no signs of losing its vigour. According to the data provided by the Union Ministry of Health and Family Welfare, as of February 22, as many as 13,760 people had tested positive for H1N1 and 829 patients died. However, health specialists working at the State level said that the number of people affected could be much higher because many patients, especially those in rural areas, were not reaching the health centres. Poor awareness about the influenza and its symptoms acts as a barrier in the infected people accessing medical care in time.

Reporting late for treatment makes the patient vulnerable because by then the virus would have attacked the host immune system, often leading to multiple complications and even death. One reason for the delay in seeking medical help is that health workers are not equipped or capable of tackling routine influenza, which makes families travel to district or State hospitals for treatment.

In order to take precautionary measures before the commencement of the flu season, it is necessary to have epidemiological data. According to Satyajit Rath, a scientist at the National Institute of Immunology (NII), New Delhi, the biggest impediment in understanding the actual disease burden and the scale of the problem is the absence of a robust disease surveillance system that can monitor the virus and its spread and impact across all categories.

Although seasonal flu occurs every winter, according to officials at the Integrated Disease Surveillance Programme (IDSP), the department steps in to undertake surveillance only when the States request it after an outbreak occurs or when cases begin to be reported.

The surveillance team investigates whether the flu is a mild form of infection, called influenza-like illness, which is self-limiting, or a virulent strain that can be life threatening. If the surveillance is carried out at regular intervals every year before the onset of the flu season, perhaps the States can be better prepared to address any outbreak.

No lessons seem to have been learnt by the Union and State Health Departments from the experience of the first swine flu pandemic, in 2009. The government has not paid enough attention to the cyclical nature of H1N1 and the way it has been circulating since that outbreak.

In 2009, as many as 27,236 swine flu cases and 981 deaths were reported. The virus was found to be virulent and absolutely new in the country; the strain was different from the endemic one that causes the seasonal flu. H1N1 influenza cases have been reported every year since that year.

Since the H1N1 virus is known to mutate fast, serious questions have been raised: Is the 2015 strain a new variant, and, if yes, will the drug Tamiflu (oseltamivir) be effective in treating the infection? Will the vaccine in use now be effective in fighting the virus?

Fortunately, the swine flu virus does not appear to have mutated since 2009. According to reliable sources in the National Institute of Virology (NIV), Pune, and the National Centre for Disease Control (NCDC), New Delhi, the strain is not virulent. The Centres for Disease Control and Prevention (CDC) in the United States has found that the H1N1 virus, which had caused a global pandemic in 2009, is now a regular human flu virus, circulating worldwide seasonally and is not deadly.

According to the World Health Organisation (WHO), infants and young children, pregnant women, aged people and those who suffer from chronic illnesses are the ones at high risk. The health care system needs to pay special attention to these groups. The public must be made aware that the majority of those who lost their lives succumbed to the disease because they had serious co-morbid illnesses such as cancer and lung infections, other serious medical conditions or low immune systems, or had an organ transplant, or were on steroids.

Despite the fact that H1N1 is a seasonal influenza, no campaigns were undertaken by the Health Ministries to spread awareness about how to recognise swine flu symptoms, how to protect oneself from getting exposed to the virus, and how to prevent infection and death.

Health workers, who face great risks because they are most likely to come into contact with patients tested positive for H1N1, have now been given vaccines as well as protective gear such as masks and hand sanitisers. All doctors and nurses handling H1N1 patients in all Central hospitals are being provided N95 masks. The Union Health Ministry has only 10,000 masks in stock, of which 1,500 have been sent to Uttar Pradesh. The Ministry is procuring 1.5 lakh doses of vaccines for State health workers. Since the virus has not mutated, the vaccine will remain effective for one year. Children up to five years of age and the aged can be administered the vaccine. But if the virus mutates during the next flu season, their immunity will be compromised.

M.C. Mishra, Director of the All India Institute of Medical Sciences, New Delhi, said simple measures such as community hand hygiene, carrying sanitisers to work, and maintaining a distance from family members who show symptoms of high fever, cold and cough by isolating them in a room can help prevent the spread of the flu. Schoolgoing children should be told that since H1N1 is airborne and spreads through droplets made when people cough or sneeze, using hand sanitisers and regularly washing hands is necessary so that they do not contract the virus.

Although the public is aware of the preventive measures needed to be taken, the rising number of deaths has created panic about the disease. As a result, across all States, people are buying Tamiflu from private dealers and consuming the drug. Doctors warn that this can increase the risk of resistance to the drug. Besides, indiscriminate purchase has resulted in a shortage of Tamiflu and patients who have tested positive are unable to get the medicine.

The Health Ministry has distributed 55,000 Tamiflu tablets to Jammu and Kashmir, West Bengal, Gujarat, Madhya Pradesh, Punjab, Nagaland, Uttarakhand, Tripura, Mizoram and Assam. Rajasthan has placed an order for procurement. But the drugs are not enough to cater to the rising number of cases.

The States have to be blamed for the non-availability of the drug as they did not place orders for it in time. After the 2009 pandemic, the government procured four million tablets, which had a shelf life of five years, that is, until August 2014. Since there was no demand, pharmaceutical companies did not manufacture Tamiflu. Rajasthan placed an order for the drug only in October last year, but since manufacturers need time to produce the drug, the shortage remains. According to the Union Ministry of Health, many States are yet to place orders for Tamiflu, making drug shortage a major obstacle in the treatment of H1N1 patients.

Mishra said that instead of approaching doctors people were getting themselves tested arbitrarily in private laboratories even if they had minor symptoms. Some are testing false positive, which is a cause for alarm. Private laboratories are cashing in on the fear factor. Reliable sources in the Health Ministry said private laboratories were charging between Rs.6,000 and Rs.7,000 for a test for swine flu. Mishra said the government should regulate private laboratories so that the public did not get fleeced. The Ministry has stepped in to ensure that the outbreak is not exploited. The Indian Medical Association (IMA) has been asked to sensitise the private sector by sharing its guidelines with it.

A letter was sent to the Delhi government to put a ceiling on the amount charged by laboratories to do the nasopharyngeal swab test and the price of drugs and protective masks, which the public is buying in large numbers. The laboratories are permitted to charge Rs.4,500 for a test. Chemists demand Rs.200 and Rs.250 for the two varieties of masks, which cost Rs.40 and Rs.56 each. The Delhi government notification has put a cap of Rs.60 and Rs.67 for a mask.

The government said it was monitoring the swine flu outbreak closely. In order to prevent outbreaks such as H1N1 and other epidemics, the public health system should be more proactive.

Mohuya Chaudhuri is an independent journalist.