The unvarnished facts about swine flu

‘Swine’ is not a nice word. We use it in a derogatory sense to describe people we don’t much like. ‘Pig’ on the other hand is fairly neutral. It could indicate a likeable animal. “The three little swine and the big bad wolf someone does not seem appropriate. Hence it is not surprising that the influenza pandemic, which no one can help but hear about, has been labelled ‘swine’ and not ‘pig’ flu.

It is caused by a virus that originally infected pigs and was labelled ‘H1’. This occasionally infected humans but, importantly, did not spread from person to person. As most of us are less likely to meet a pig than another human being, this meant the virus had a limited chance of spreading.

Viruses, which are one of the most basic of living beings, essentially consist of strings of DNA or RNA, which are the building blocks of all life. Viruses can change their DNA (or RNA) sequence fairly easily during replication, helping them evade the immune system of their hosts. This change can sometimes alter the character of the virus. The HI virus, which infected mainly pigs, did just that. The new avatar had the important characteristic of spreading from human to human; this change was of sufficient importance for it to acquire a new addition to its label.

Thus was born the H1n1 virus. Its DNA sequence is a mix of DNAs from three different viruses, affecting birds, pigs, and humans. Occasionally a human could infect a pig with H1N1 but the infection is predominantly among humans. The first time the H1N1 virus infected humans was in 1918. Over the years, several epidemics have occurred by similar strains, which were also called Human Influenza A (seasonal) and were also H1N1. The current pandemic probably resulted from cross transmission from pigs again, the first case occurring in a 17-year-old in Wisconsin, USA in 2008. This strain is sometimes referred to as S-OIV.

Viruses produce a wide range of diseases. Influenza, common cold, polio, small pox, chicken pox, encephalitis, rabies, and measles are some of the well known ones. Many viruses are yet to be identified and named but can still cause serious disease. Hundreds and possibly thousands of children die everyday in India from acute respiratory infections and acute gastroenteritis, often caused by viruses. Overcrowding, poor hygiene, and malnutrition increase the chances of not only getting infected but also dying of it.

The swine flu, like most flu, affects mainly the respiratory system. This facilitates its spread as the viruses travel through droplets dispersed while sneezing or coughing. The typical symptoms are fever, cough, body pain, lethargy and, in severe cases, mental obtundation and respiratory failure. When the patient dies, the virus dies. Hence, overtime, the more virulent strains die out and subsequent infections are milder. The flu viruses generally spread, almost inevitably, to infect large sections of the population in the course of a few months unless effective vaccines are developed and deployed quickly for the entire population. But vaccines can cause problems and the occasional fatality too.

For milder infections like the common cold and the milder forms of flu, it may be better to allow the spread of sub-clinical or mild infection for natural immunity to develop in the community. The H1N1 (S-OIV) virus is estimated to have infected about 2.5 million people in the United States. Previous epidemics of similar viral infections have left behind sufficient innate immunity in many, protecting them from fresh infection with the current pandemic.

Antibiotics have no effect against viruses. Specific anti-viral agents, namely Ostelamivir (Tamiflu), are effective against H1N1 if used early, preferably within the first two days. However, as early symptoms are non-specific, potentially millions of people with ordinary viral infections like the common cold will have to be tested and/or treated with anti-viral agents. Such a strategy may be impractical and without established benefit.

Swine Flu (H1N1 S-OIV) is one among many infections caused by viruses and bacteria. Many of these infections are more infections and dangerous than swine flu in India. TB kills a thousand people in India every day.

1. Most cases of swine flu are likely to recover with or without Tamiflu.
2. The virus may get less virulent with time.
3. Many may already have natural immunity against the virus.
4. In course of time, a significant proportion of the population will test positive for swine flu due to swine flu infection without disease. Because of this, there may be a danger of misdiagnosing many other conditions for swine flu.

Possible beneficial outcomes:

1. Greater awareness of the nature of infections and their spread. Better hygiene and preventive methods for all infections may evolve.
2. Preventive methods may curb the spread of their infections like TB.
3. The government and the public may become more aware of the lacunae in health care delivery and corrective steps may be taken.

Possible deleterious effects of excessive publicity:

1. Mass hysteria and panic, leading to inappropriate and useless actions.
2. Diversion of scarce funds from other badly needed areas to activities with little benefit.
3. False expectations of medical interventions from doctors and institutions.

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Plan to utilize equipment at university for swine flu test

The State Health Department is planning to use the advanced laboratory equipment available at Madurai Kamaraj University for conducting swine flu tests.

Since the requisite machines for testing the samples were not available in private hospitals in the city, the officials of Directorate of Public Health have approached the university which has the ‘Real Time-PCR Test’ equipment needed to carry out A (H1N1) influenza tests.

Official sources told The Hindu here on Sunday that a team of health officials visited the MKU on Saturday to assess whether the proposal was feasible. The university has two PCR machine at the laboratories in School of Biological Sciences and the School of Biotechnology.

Asked about the proposed move by the Health Department, Vice-Chancellor R.Karpaga Kumaravel said, “The University is ready to extend its facility if the State Government is satisfied with our laboratory equipment. We have a social obligation to support the Health Department.”

A two-member team comprising Deputy Director of Health Services A. Palanichamy and faculty member of Madurai Medical College Jhansi Charles visited the university’s ascertain if the university’s equipment met the specifications given the Directorate of Public Health.

Even while agreeing to share the infrastructure, Dr.Karpaga Kumaravel said that the Health Department must arrange for the requisite trained manpower to carry out the swine flu tests.

When contacted, the Director of Public Health S.Elango said that the university would be the immediate option available for diagnosing swine flu. A senior faculty member at the university in the field of genomics P. Gunasekaran said that the Health Department has asked for BSL-3 bio-safety specification whereas the Real TimePCR machine in the university was only of bio-safety-2 level. “Our university is working in the field of molecular biology and not in pathogenic levels. Since the handling of machine is different in the case of swine flu, it is for the Health Department to decide. They will have to upgrade our PCR machine,” Dr. Gunasekaran said.

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Number of swine flu cases rises to39 in west Bengal

Even as the number of people who tested positive to swine flu in west Bengal rose to 39 on Sunday, the health department issued guidelines to collect throat swabs on a priority basis.

A large number of people rushed to the city’s three swine flu clinics to undergo test. “Seven new A (H1N1) positive cases were detected on Sunday”, said Dr.Taposh Sen, nodal officer of the state health department’s swine flu wing. He said 21 people were undergoing treatment at various state-run facilities.

The large number of samples being sent in to the National Institute of Cholera and Enteric Diseases (NICED), the only swine flu testing facility in West Bengal, has created a backlog, Dr.Sen said.

“This is causing delays in the detection of patients in the detection of patients in the most vulnerable groups”, he added.

A case in point is that of Akash Chowdhury, who was admitted to the R.G.Kar medical college hospital on Tuesday but doctors had to wait till Saturday to know his results. Admitted to the hospital’s intensive care unit, his condition was critical and remained unchanged on Sunday, said Dr.Sen.

The other 20 victims, who are currently undergoing treatment, have been kept in the isolation wards of the Infectious Diseases (ID) Hospital at Beliaghata and the M.R.Bhangur Hospital. As the combined capacity of the two hospitals was only 28 beds, the authorities will have to find alternative isolation facilities.

The health department has issued guidelines that samples collected from four categories of patients will be given priority-children up to 5 years and people above 65 years, a person with an underlying disease such as diabetes, asthma or a pregnant woman, a suspect suffering from breathing difficulties, high fever or diarrhoea and an individual who has travelled abroad or has come in contact with a swine flu victim.

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Swine flu testing labs to be ready in 20 days

With the health department having initiated the process of setting up swine flu testing laboratories in Madurai and Tirunelveli, these facilities will start functioning in 20 days.

The state government had announced, after a review meeting in Chennai on Tuesday, that testing laboratories for A (H1N1) flu would be established at government medical colleges in Madurai, Coimbatore and Tirunelveli. ”Formalities for providing the testing equipment have started and training is being given to lab technicians at the king institute of preventive medicine in Chennai”, health minister M.R.K. Pannerselvam told The Hindu on Thursday.

Training in conducting the laboratory tests was an important component in fighting the swine flu as the tests could not be done properly if trained personnel were not available in government hospitals. The testing equipment cost around Rs.30 lakh and once it was available locally, samples of suspected cases need not be referred to the king institute, the minister said and appealed to the people not to panic.

Officials in the directorate of public health said that the Real Time PCR test equipment for carrying out swine flu tests would be given to Government Rajaji Hospital/ Madurai Medical College and Tirunelveli Medical College. Adequate number testing kits would also be made available, an official said.

Meanwhile, the director of the public health and preventive Medicine, S.Elango, said that there was no increase in incidences of fever cases in Tamil Nadu, as corroborated through monthly data from government and private hospitals. “Our analysis has shown that 10 per cent of the state’s population will normally have common cold at a given point in time, of which half of them will have normal fever. These cases cannot be construed as swine flu”, Dr.Elango said.

Seeks nod

To step up testing and treatment facilities for swine flu cases in Madurai region, vadamalayan Hospitals here has approached the state Government for its permission. Right now, the Government Rajaji Hospitals (GRH) here has an isolation ward to patients suspected to the GRH with swine flu symptoms were discharged from the hospital on Thursday.

Sangili Murugan (18), a student from Oddanchatram in Dindugal district, and Balamurugan (32) of palanganatham here were admitted on Wednesday with complaints of fever, cough and sore throat. Samples were sent to the king institute in Chennai for tests and the results are awaited. “They were discharged on Thursday morning itself since they did not have fever,” S.M. Sivakumar, Dean in-charge, GRH, said.

Authorities in Vadamalayan Hospitals are of the view that private hospitals can join hands with the government in fighting the flu. “If the government gives permission, we will create an isolation ward and procure testing kits.”

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Swine flu less severe than expected: European centre

The current swine flu pandemic is less severe than might be expected, says the European Centre for Disease Prevention and Control (ECDC). The ECDC has published the planning assumptions that European countries could use to prepare for the major first pandemic wave expected in the coming autumn and winter months. The Centre has drawn heavily on the planning assumptions put out by Britain’s Cabinet Office and its Department of Health last month.

The swine flu’s death rate, known as the ‘case fatality ratio’, is expected to be similar to that of seasonal flu that people catch each year.

Peak absenteeism:

The British had predicted a peak absenteeism rate of 12 per cent of the workforce, which fitted with the mild illness seen for most people, observed the ECDC. This suggested that “the social disruption effects of the pandemic will be less than feared for other pandemics and that severe social interventions will not be necessary given good business continuity planning,” it remarked.

‘Hope for the best and plan for the worst’ is at the heart of much contingency planning. The ECDC and British planning documents give a glimpse into what ‘the worst’ in the current pandemic, involving a virus that the World Health Organisation describes as moderate in its severity, might be like. The British planning document is based on analysis and modeling of data from swine flu outbreaks that have occurred both inside and outside the country.

Both ECDC and U.K. documents emphasise that the planning assumptions they describe should not be seen as a prediction of how the pandemic will develop. A number of parameters were involved, each taken at their ‘reasonable worst case’ value, noted the British document.

Taken together, these parameters “represent a relatively unlike scenario.” However, the use of such parameters ensured that the plans remained robust against all likely circumstances, it pointed out.

In order to plan for extreme contingencies, the British document assumed that up to 60 per cent of the population could catch the virus. But about half of them may show no or insignificant symptoms.

Up to 30 per cent of the population may therefore become clinically ill in the first major wave of infection. Children are more likely to be ill than older people. However, the latter are more likely to suffer from complications if they do become ill.

“Shoter and Sharper”

The British planning document indicates that 6.5 per cent of the population could fall ill each week at the peak of the pandemic. But since local epidemics are “often shorter and sharper,” the proportion of the local population that falls sick could be higher than national rates, the ECDC noted.

The document also suggests that up to 2 per cent of clinical cases in Britain might require hospitalization, a quarter of whom could need intensive care. Hospitalization rates for seasonal flu that occurs every year are typically in the range of 0.5-1.0 per cent for that country. However, the case fatality ratio – the proportion of clinical cases who die of flu during the complete wave of infection – is expected to be in the same range as for seasonal flu, 0.1 -0.35 per cent. “Current experience from abroad suggests a figure closer to 0.1 per cent at present,” the document observed.

“It is also important to appreciate that [the case fatality ratio] is especially subject to social effects,” the European centre remarked. In poor social settings such as Africa, even seasonal flu could result in death rates that were higher than seen in pandemics, it pointed out.

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Why should we be afraid of swine flu?

We are not really afraid of typhoid, tuberculosis, leptospirosis, diabetes, HIV, malaria and a host of other infectious and non infectious diseases which are flourishing in our country. The apathy towards the basic issues in health care is really appalling. Why should we be afraid of swine flu alone? The medical profession is busy and happy treating diseases, confining to its own insulated and compartments. I happened to read with concern the comments made by some that we are not equipped to face the threat of swine flu, as if we are already well equipped to face the threat of all other communicable diseases; they go on to assert that the problems we face are due to lack of dedicated infections disease departments and dearth of WHO-trained doctors in the medical colleges of Kerala.

A mater of approach

It is true that we need infectious disease units in each medical college, like the ones we already have; but the only problems is that we do not have an adequate number of doctors to spare to improve the services, to do research and surveillance.

The issue can be solved easily by posting a few more doctors for this purpose alone rather than hunting for WHO-trained doctors. Why not the existing system be made to tackle the problem by reorienting and reorganizing than compartmentalizing? In health care (no disease care), there is only doctor-oriented planning and implementation and no community-oriented planning.

A properly trained MBBS doctor or even an educated person with common sense and some training is more than enough to manage the threat of any public health issue. The general medicine department of any medical college can easily tackle all these if they have a few more doctors and isolation wards. We ignore health care and literally manufacture disease of all colour and shades, and finally we have a museum of all diseases. We have already become the diabetic capital of the world, and now we are trying to overtake sub Saharan Africa to win the first place in the number of AIDS cases, malnutrition and environment-related infections, which produce more morbidity and mortality than swine flu.

The developed countries are worried since they have controlled all infections by proper waste management, safe drinking water and good nutrition for all and press the panic button the moment they come across any one of them.

They would have shown similar panic if typhoid, viral hepatitis, leptosirosis or TB occur in much lesser numbers than we see in India. Why we are not similarly worried about these diseases which kill several thousands annually? Let us not panic merely to show that we are also developed and evolved.

The basic issues:

All communicable diseases are flourishing here because of lack of basic health amenities, malnutrition, poor environmental hygiene, unsafe drinking water, etc. people are now exposed to unchecked consumerist forces promoting lifestyle disorders with an even greater impact on us.

One more world environment day had passed – we behaved like the developed world by planting one or two trees here and there and having a talk on ozone layer and green house effect and that is it. We overlook environmental issue like poor waste management and unsafe drinking water everywhere.

We always ignore basic issues and go for knee-jerk reactions to appear big in front of developed countries. We need to do some homework and introspect and bring well-meaning leaders with a vision for the people on top of every system and make changes to achieve health and prosperity and then start panicking at problems like swine flu. We must try to achieve good environmental hygiene and provide safe drinking water for everyone. We must prioritise and spend on health care first and then on disease care.

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Swine flu triggers panic in Pune

Parents in Pune have pressed the panic button after the death of Rida Shaikh, the first in the country to fall to swine flu, on August 3. On Wednesday over hundreds of people thronged Pune’s Naidu Hospital to get themselves or their children screened for swine flu. Over 300 went to the Aundh Hospital, the only other government-designated hospital in Pune dealing with swine flu cases.

Speaking to The Hindu, Dr. V. Satarkar of the Pune Municipal Corporation (PMC) that runs the Naidu Hospital said, “People have got scared after Rida’s death. Over a thousand people with cold cough and free came to our hospital today. Our team of 10-12 doctors has been checking them since morning. On Tuesday night checking went on till 11.30.”

As tempers soared because of the skewed patient to doctor ratio, police had to be called to control the crowd, he added. The hospital had 13 positive cases as of Tuesday.

At the Aundh Hospital, people came not just to get themselves checked but also to know about sine flu. The throat swabs of 17 people were sent to the National Institute of Virology (NIV) in Pune and their results were awaited. At present, the hospital has three positive cases.

Additional Commissioner of the PMC and head of Pune’s joint coordination committee for the containment of swine flu M.S. Devnikar said, “There is no reason for people to panic. We are doing everything from our side. At Naidu, the present capacity is 20. But about 100 can be accommodated in our new building. We are going to conduct a meeting with the headmasters of schools to give them guidelines. NGOs on-governmental organizations should also come forward to help create awareness.”

Meanwhile, five more people tested positive for swine flu in Pune on Wednesday, three of them being students of St. Anne’s High School, where Rida Shaikh studied.

Mumbai too witnessed some panic and people made a rush to the Kasturba Hospital, the only centre treating swine flu cases in the city.

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New insights into swine flu from animal models

The swine-origin H1N1 influenza viruses responsible for the recently declared pandemic cause more lung damage than a seasonal influenza strain in animal models, but are still sensitive to antiviral drugs, finds a study.

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