Swine Flu: Next Year Again?

Swine flu has taken more lives than ever this year. As the flu season recedes it is necessary to already start preparing for it next year. With a better armor. 

As the winters retreat after getting doused in colors, so are the horrific reports of people succumbing to swine flu that has caused more than a thousand deaths this year. The current morbid tally stands at 1370, still counting among more than 25000 infected. There is understandable anguish in the country about our helplessness in treating this disease, or preventing its spread. Unfortunately, the solutions are not easy since influenza is both very contagious, as well as very dynamic, constantly changing its nature. Superimposed upon this biological fatality is the systemic problem in the Indian healthcare apparatus that makes it very difficult for the affected to be fully treated for their symptoms. Therefore in order for this high toll numbers to be not repeated in the coming years, it is important to be well prepared much before the onset of winters. The strategy would require adequate availability and dissemination of medicines, public awareness campaigns, use of social media and mobile networks, care and quarantine of individuals after positive diagnosis.

The State of Health

India presents a unique public health problem as a poor tropical country with a dense population and one of the worst sanitation standards in the world. It suffers from a double whammy of continuing to suffer from the poor world’s communicable diseases, while having a huge load of rich world’s ills too. Therefore while we continue to struggle with diabetes, cancer, heart disease, there are continuous threats from dengue, malaria, tuberculosis, and even cholera that have stopped killing people in large numbers in the rich world. As such the burden on the public health system is enormous. Starting from a rudimentary base of one of the lowest availabilities of health workers in the world per capita, extremely low penetration of health clinics, and cumulatively low investment in public health, taking these burdens seem even more impossible.

Communicable diseases present a unique socio political problem in free societies. Since there are unforeseen liabilities to one’s actions (for example not taking a vaccination, or keeping hygienic surroundings), there is a strong case for a state role. In fact, with the negative consequences of one’s actions being dispersed to others, there is a significant disincentive to do what is responsible. As such, there is even a case of policing by the state.  Or to put it mildly, there is a case for mandating vaccinations, or regulating antibiotic prescription and compliance in drug usage. Though of course, mandates never ever work. But in a country like India, with very low penetration of health facilities the role of the state in preventing the spread of communicable diseases becomes even more important.

Why is flu so difficult to tackle?

Influenza virus (that causes flu, including swine flu) is one of the most rapidly changing viruses making it very difficult to counter with any vaccination. Worse, it can go through a process of antigenic shift, combining its traits across species (swine and human, or birds and human), making it very difficult to develop counter strategies to. However the usual death rate for typical flu virus is less than 1%, and those affected quickly develop their immunity that can last for a very long time. Influenza is rarely lethal by itself, in fact most of the deaths are due to superimposed infections. These are infections that arise because the immune system of those affected by flu is compromised. A good treatment is therefore just to treat the symptoms, and wait it out. Unfortunately, in India with its very shabby health infrastructure, even symptomatic management of patients is inadequate, resulting in many avoidable deaths.

Preparing before the battle

In view of the predictable onset of flu each year in India, and the panic it creates it is necessary to consider other options that are now more widely employed in the world. United States, for example makes available trivalent vaccination based on the predicted global flu strains by WHO. The effectiveness of these predicted vaccination is not perfect, in fact it could be quite low. This year, for example, the effectiveness of flu vaccine to prevent infection is about one in three. However, sustained public awareness programs have made it possible to reach a large number of people decreasing the cohorts of affected people, and preventing spread of disease. Since swine flu has started spreading in India in such large numbers, state should encourage development of vaccines each year. These vaccines are only useful for a year, since influenza virus comes in a new avatar each year. But even a modest penetration of the vaccination will significantly reduce the spread of the disease.

Another, and probably the more important method to counter spread of flu is to start a public awareness campaign way before the onset of flu season. Influenza virus spreads through air, and therefore the best way to avoid getting exposed to the virus is by avoiding close proximity or touch with any person with flu symptoms. The state, as well as the healthcare related NGOs should work towards educating the general public about basic hygiene, the need for washing hands frequently, using masks, and avoiding sneezing of coughing in public places. People with flu like symptoms should be encouraged to present themselves to a clinic as early as possible. This is important since Tamiflu or Relenza, if given within 48 hours of infection can prevent contagion to others. However, these medications should only be given to those considered affected, and not to the general population since it may result in greater resistance to these drugs in the virus.

More than anything, a general awareness campaign should be instituted guiding people on a course of action if they do catch flu. People with symptoms should be asked to present immediately to a clinic, and these visits should be subsidized by the state or philanthropists to reduce the chance of disease spreading to a larger population. Affected people should be encouraged to self-quarantine, and educated about etiquettes for sneezing and coughing in public. And surgical masks should be widely made available by NGOs and public health departments, may be as the single most effective and the cheapest way to prevent the spread of swine flu.

If only there were a pill

It is never a comfortable thought to realize that there is no pill to cure a disease. Worse, when the disease is not of your own making. But human endeavor has managed to counter nature partially, even in the case of influenza. Vaccines can be, and are made against swine flu. Though they may not be completely effective, even a partial effect may be useful in preventing sudden spread of the disease, allowing crucial moments for the health authorities to respond. However, short of vaccine availability, the best way to prevent the spread of the disease is to take the responsibility in our own hands. It is necessary to make arrangements for affected individuals to be self-quarantined, and to be encouraged to present themselves in the clinic, and to wear surgical masks. It is necessary to protect oneself and others by frequently washing hands, getting vaccinated if possible, and avoiding people known to be affected. But it is important to bear in mind that the state cannot possibly provide vaccination against flu for the general population for free. Vaccinations against flu are only partially effective, and need to be administered annually make it a very costly exercise if provided by one party. Therefore a greater public participation, and private administration of vaccines will be required.

Influenza is only one of the many communicable diseases India regularly suffers from. With a greater aggregation of population in the cities, increased humidity and warmer climate, probably the worse sanitation in the world, and a significant subpopulation malnourished and uncared for, the ground is fertile for most pathogens to spread. While we push for the availability of vaccines against these diseases, we should work towards making our surroundings better for humans and difficult for pathogens to thrive in.

P.S. The author would like to credit Dr. Gautam Sikka and Dr. Jatinder Goyal for their inputs.