Swine flu, a chance to rebuild public health system

The recent outbreak of influenza A H1N1 is seen in almost all parts of the country. Worst affected are the western parts of India including Rajasthan, Gujarat and Madhya Pradesh. Influenza is a seasonal disease of mild nature, with maximum impact during this time of the year. But this year, the cases and more importantly, the mortality associated with influenza seems to be on the higher side.

As per the official records from January 1 till February 22, the number of cases reported of swine flu was 14,673 and 841 deaths (death rate 5.7 of cases) in the country. But as in any epidemic, this may be a gross under count as in India, many patients go to private sector and they do not report data to the government system and in majority of the deaths, the cause of death is not properly identified. Many deaths have occurred in patients with other co-morbid conditions such as lung disease, liver disease, kidney disease, blood disorders, diabetes etc, and due to immune-compromised patients. This is usually the case in flu.

Influenza is caused by viruses of three types – A, B and C. It is the type A virus which has caused major pandemics and epidemics across the globe. This is because influenza A type of virus has the tendency to undergo rapid mutation known as “shift” against which the affected population may not have sufficient immunity. There are several subtypes of influenza A virus include H1N1, H2N2 and H3N2.

The first pandemic of this virus began in 2009. WHO in August 2010 declared that pandemic H1N1 virus would continue to circulate as a seasonal influenza virus for some years to come. The National Institute of Virology, Pune, which is part of ICMR, and the National Centre for Diseases Control, Delhi, have found that cases of influenza A being detected now are the same virus as of 2009 and there is no mutation in the virus. Hence, the treatment protocol and guidelines used during the time of pandemic 2009-2010 remains effective for present outbreak also.

The recent outbreak of swine flu gives a valuable opportunity for reflection on the preparedness of epidemic detection and control system and the healthcare system in India for such outbreaks. Both Central and the state governments are making a lot of efforts for containment of the impact of H1N1 epidemic by active screening, risk categorisation of patients, clinical case management and ventilator treatment in very severe cases.

  The mainstay of treatment is drug Oseltamivir for treating influenza A H1N1. The best part is that the drug is manufactured in India. But, it is not available easily as it is only sold through a chemist with license under Schedule X of the Drugs and Cosmetics Act.

Besides treatment, efforts should be focused on preventing transmission of the disease to the households and healthcare professionals who come in contact with the patients. Overuse of Oseltamivir can result in resistance to the drug which is reported in other parts of the world. We need to undertake studies to monitor resistance to the drug in India. There is a vaccine to prevent this flu, but for full effect, it has to be taken for a month before the epidemic season.

The Government of India has recommended vaccine only for healthcare workers, as vaccination for general public is not advocated as a feasible public health strategy to control the outbreak. Immunity from vaccine lasts only for about a year. Moreover, vaccination may not provide full protection against the virus. 

Surveillance system

The Integrated Disease Surveillance Programme (IDSP) collects data regularly on outbreaks of communicable diseases including influenza H1N1 from different parts of the country. The IDSP largely captures data from public health facilities and a few private providers. India needs to develop better and enhanced surveillance system. Use of mobile technology can be very useful for recording and mapping of hot spots and early detection of the outbreaks. Quick system of reporting may assist to get the data analysed to facilitate quick response to contain outbreaks.

For confirmation of swine flu, the Central government has developed a network of laboratories across different parts of India for providing free testing facilities for influenza A H1N1. But these are very few and the test in private sector is expensive. India needs to build sufficient capacity and availability of diagnostic labs across country, and where feasible PPP model can be explored to increase lab capacity. We should try to make the test cheaper.

The mainstay to control the outbreak still remains enhancing awareness of the general public by massive `Information -Education -Communication (IEC)’ campaign using all available channels. The IEC should focus on how to prevent the transmission of the disease such as covering nose and mouth while sneezing and coughing, washing hand frequently, avoiding hand shake and avoiding crowded places.

Treatment should start with the onset of symptoms such as cough, fever etc. People with flu-like symptoms should remain at home. We need to use all possible mechanisms and sources to address this important tool to control and contain the outbreak.

Lastly, the country needs to develop a national and state-level public health service to combat such rapidly spreading epidemic diseases like flu. The government should develop research, education and management capacity for infectious disease. There is a need to establish strong public health training programmes to build capacities of existing healthcare system and develop a new generation of young public health professionals who can be valuable resources for preventive and promotive care. Flu can be a real opportunity to rebuild India’s public health system.

(The writer is Director, Indian Institute of Public Health, Gandhinagar)