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Flu in the air -M Sai Gopal
-The Hindu

Public health experts agree that the response to the pandemic depends on constant surveillance and monitoring the evolution of the viral strain

A viral storm is raging across the country. More than 200 deaths due to Influenza A (H1N1), known as swine flu, have been recorded within a short period of over a month. Telangana, has the dubious distinction of recording over 50 deaths and more than 600 H1N1-positive cases since December.

In January alone, according to Union Health Ministry statistics, the total deaths in India came to 191. With more than a month of winter ahead, it is expected to have a big impact on public health and the economy in the next few months.

After the H1N1 pandemic of 2009, the World Health Organisation (WHO) and researchers had anticipated sporadic outbreaks of H1N1 influenza virus, but of a smaller magnitude in subsequent years.

However, the large number of fatalities and H1N1 positive cases within a short period of time in 2015 has raised the question whether Indian healthcare professionals, researchers and policymakers did not see it coming this year. Or has the H1N1 virus sprung a surprise when researchers least expected it to?

Public health experts agree that response to a pandemic depends on constant surveillance and monitoring of the evolution of the viral strain already endemic to India.

"If you see SARS, swine flu, Middle East Respiratory Syndrome (MERS) and Ebola, all of them are zoonotic in nature. That means, the virus starts from animals and gets transmitted to humans. Worldwide, this is the phenomenon and India is not an exception. There are factors like deforestation and captive animal breeding that creates a conveyer belt for viruses to move from its wild to human habitat. And when the virus through humans board a plane, train or bus, it transmits rapidly," K. Srinath Reddy, president, Public Health Foundation of India (PHFI), says.

According to Manish Kakkar, a member of the WHO's International Group on Strategy and Management of Zoonotic and Public Health Risks at Human-Animal Interface, from the second half of 2009 till the first quarter of 2011, A (H1N1) was the predominant influenza virus in India.

"The second half of 2011 showed lower activity of this strain, while A (H3N2) and B group viruses dominated this half. However, from the beginning of 2012, the pandemic strain of A(H1N1) has reappeared and co-circulated with group B and A(H3N2) viruses," Dr. Kakkar says. Quite remarkably, the H1N1 of 2009 and 2015 spreads through the same way that regular seasonal influenza viruses spread, mainly through coughs and sneezes of people who are H1N1 positive. It could also spread by touching infected bodies and then touching the nose or mouth. The symptoms too are common, including fever, sore throat, body aches, headache, chills, fatigue, nausea, vomiting and even diarrhoea.

However, the clinical assessment of severe cases is very different from that of seasonal flu.

"Here we have seen severe cases generally begin to deteriorate within three to five days after the onset of symptoms. The deterioration is swift and anti-viral drugs such as Tamiflu and Oseltamivir seem to have no effect at all. We are losing patients within two days," says the swine flu coordinator for Telangana, K. Narasimhulu.

All swine flu vaccines in India are imported. As a result, each swine flu shot costs anywhere between Rs. 500 and Rs. 1,000.

But the H1N1 vaccine could have been made available for just Rs. 100 in India. "Authorities effectively killed the Indian swine flu vaccine after promoting it initially. They backed out leaving millions of unsold shots in 2010-11. We could have offered a better version of H1N1 vaccine for just Rs. 100," says Krishna Ella, chairman and managing director of the Hyderabad-based Bharat Biotech.

Back then, the Union government had an understanding with Bharat Bio-tech, Serum Institute, Pune, and Panacea Biotech, New Delhi, to produce affordable indigenous H1N1 vaccines. "The GoI gave us Rs. 10 crore to manufacture affordable vaccine when the H1N1 pandemic was at its peak. Later, they pulled the plug and we even returned the money," he said.

After the peak of 2009 and 2010, the cases of swine flu started to dip and the need for a vaccine was not felt, doctors privy to the issue said. In 2010-11, millions of doses of indigenous H1N1 vaccines were destroyed because there were no takers. They were produced in the hope that government agencies would stock them for healthcare workers and the public would get vaccinated for prevention. The WHO and the Indian Academy of Paediatrics (IAP) have recommended trivalent influenza vaccine that should be administered to high-risk groups just before the monsoon.