With the monsoon just round the corner, Kerala can expect relief from the summer heat soon. But the state is bracing for a particularly bad flu season with the rains this year. The H1N1 or swine flu virus has already claimed 41 lives in the state in just four months. Health officials say that, unlike any other infectious disease, swine flu cases have been reported from every district in the state.

The swine flu outbreak this year has also affected many other parts of India, with Maharashtra being one of the worst hit states.

The last time swine flu hit Kerala hard was in 2015 when more than 70 people died. This year, the state could have more casualties than in 2015, with 500 cases already being reported. Once the monsoons hit Kerala on May 30, health authorities expect the number cases to rise dramatically.

What makes an imminent swine flu epidemic worse is the simultaneous rise in dengue and other fever-related illness. Government hospitals are already packed with such cases. From the beginning of the year till May 18, more than eight lakh patients had been admitted at government hospitals with fever of various kinds. The symptoms of swine flu are similar to other kinds of influenza and is also transmitted through droplets in the air. Swine flu deaths occur mostly due to severe respiratory failure.

“The situation is certainly worse than 2015 when we had the last major outbreak of H1N1,” said Dr R Reena KJ, additional director of health services who is worried about the outbreak escalating with the advent of the monsoons. “The humidity in the air is not going to help a bit in containing the disease as it will easily get transmitted. We don’t want to create panic but we are actually looking at a pretty bad picture in the next few months.’’

Spread of swine flu

Swine flu first hit Kerala in 2009 during the swine flu pandemic that affected many parts of the world. Thiruvananthapuram recorded its first H1N1 casualty on August 12, 2009. Other bad years in terms of the severity of the swine flu infection in the state were 2010 and 2015.

Doctors are wary of the extent of the outbreak this year but not surprised.

“This is so typical of influenza viruses,” Dr Amar Fettle, nodal officer for H1N1 control in Kerala. “They keep on changing their major and minor characteristics. When the minor characteristics change, the symptoms of disease also change.”

Fettle is referring to major characteristics changing when a virus mutates into a new strain – a phenomenon called antigenic shift. Minor characteristics change due to another mechanism called antigenic drift. Researchers have observed that influenza viruses constantly undergo small genetic changes that allow them to appear slightly different from the original virus. A person who has been exposed to the original virus may have developed immunity to the old virus but will not be immune to this newer version created by such an antigenic drift.

While fever is the primary symptom of all influenza infections including H1N1, other symptoms like respiratory distress, body pain and vomiting can manifest depending on the change in the virus.

Fettle thinks that the reason there were no swine flu deaths in 2016 was the absence of antigenic drift in the virus and so the population was already immune to existing forms of the H1N1 virus.

“But this time we have a serious concern that the virus might have changed its pattern of attack,” he said.

Health officials observe that swine flu has been spreading quickly this time around. . According to numbers released by the Directorate of Health Services, the state reported only six H1N1 deaths till February 19. By May 19, 36 people had died.

According to Fettle, the rate of infection is seen in a test called swab positivity coverage, which is the number of people in every group of 100 who test positive for H1N1 infection in a throat swab test. Everyone who goes to a government hospital with symptoms of flu is made to undergo a swab test. In 2015, the swab positivity rate was 26% and this year it is between 27% and 30% right now. Swab positivity coverage in 2016 was just one percent.

Health officials who have been monitoring the pattern of infection say that during the swine flu outbreaks between 2009 and 2014, infections had been monsoon-related and cases of influenza were reported as the rains came in. But since 2015, the virus started causing infection from January itself.

“Just like we fight the virus, the virus too has its own way of adapting to the situation and fighting its way through for survival,” said Reena. Doctors in the state are watching this adaptation in the virus’ ability to cause infection even in summers, a phenomenon not observed in Kerala till 2014.

“Amidst all the other types of fever that is currently in the state we are most worried about H1N1 because if this is the intensity now, then it will be very difficult to predict what pattern it will take when the rains come down,” Reena added.

Lower temperatures, during the monsoon could aid the spread and longer lifespan of the virus.

Dengue not far behind

Kerala is already in the middle of another health crisis. As of May 18, the state had recorded 3,535 dengue cases – 1,259 cases and two deaths have been reported in May alone. While almost every part of the state has reported dengue cases, Thiruvananthapuram has had the burden of the outbreak with 2,500 cases.

The government general hospital in the city has turned into one big ward for fever patients and doctors are pressed to find enough beds for those with dengue.

Padmavati from Vithura in the suburban of Thiruvananthapuram was struggling to her six-year-old son admitted to the hospital. The boy had been down with dengue for four days.

“I brought him directly to the general hospital rather than going to private hospitals as we cannot afford it,” Padmavati said. “But here we are even finding it tough to get space for him. We are waiting to even get a bed.’’

The hospital has formed a makeshift ward for only fever patients. All dengue cases are being shifted to this particular ward to create more space for other emergency services.

The situation is no different at the Medical College Hospital, the leading government hospital in the city. The hospital’s fever ward is packed and authorities are scrambling to make arrangements to accommodate more people.

Drought makes it worse

Kerala’s acute drought this year has made the dengue outbreak worse. Dr N Zulfi, the incoming state secretary of the Indian Medical Association, explained how the scarcity of water has affected the spread of dengue and the carriers of the disease – the Aedes aegypti mosquitos.

Aedes aegypti breeds only in fresh water,” he said. “In the last few months due to water scarcity people have been collecting and storing clean water at their homes which had become perfect breeding grounds for these mosquitoes.’’

The extent of the outbreak is also due to the government’s failure to take preventive action in advance. But officials at Directorate of Health Services say that it cannot undertake awareness campaigns alone.

Health activist PK Raju said that the problem lies in resorting to stop gap solutions.

“You are talking of lack of awareness campaigns in the middle of an outbreak,” he said. “What were you doing six months before when you should have done this door to door? Don’t you know that every year you have a monsoon in June? What levels of accountability can you expect from such an administration?”

This reporting project has been made possible partly by funding from New Venture Fund for Communications.