At least 354 people have died of H1N1 virus infections, more commonly called swine flu, in Gujarat since January this year. In the past week there has been a sudden spike in the number of cases and 79 residents across the state have died in this period alone. However, Gujarat health authorities have not carried out vaccinations against swine flu as the national communicable diseases authority had recommended earlier this year.

In May, the Integrated Disease Surveillance Programme or IDSP identified Gujarat as a high-risk state for the spread of H1N1. The programme found that Gujarat was one of six states that had active transmission – passing of the H1N1 virus between people spreading infection. Despite this warning from the IDSP, Gujarat health authorities say that the surge in cases in August has been “sudden”.

Both the World Health Organisation and the India’s Ministry of Health and Family Welfare recommend vaccination as the most effective tool against H1N1 virus infections. Other standard measures to control the spread of infection include creating awareness about symptoms, early diagnosis and early treatment of the disease.

In 2010, India’s health authorities started using a nasal spray vaccine against H1N1. Initially, health ministry recommended vaccination of only healthcare workers who came in close proximity of infected patients. In 2015, the health ministry issued an advisory to vaccinate pregnant women and people with certain pre-existing medical conditions who were more susceptible to H1N1 infection. These pre-existing conditions including diabetes, hypertension, and chronic obstructive pulmonary disorders.

In April 2017, the health ministry reiterated these measures to control the spread of infection. The health ministry based its recommendations on data from past outbreaks across the country, which showed that more than 50% of those with H1N1 infections had co-morbidities like diabetes or hypertension. Along with directions to carry out vaccinations, the health ministry’s swine flu guidelines also lay down protocols to prevent the H1N1 transmission, like the use of masks for swine flu patients in hospitals as well as for those infected kept in home isolation.

According to the Dr Umang Mishra, medical officer with the Gujarat health department, most people who died of H1N1 infection in the state were suffering from other co-morbidities. “Many had hypertension, diabetes or chronic obstructive pulmonary disease,” he said.

In fact, audits of 329 swine flu deaths in the state this year show that about 57% were cases of people with pre-existing conditions including diabetes, hypertension and lung ailments.

No vaccination

Despite the health ministry’s advisory to vaccinate these groups of vulnerable people, Gujarat has not carried out vaccinations among high-risk populations.

Health authorities in Gujarat dismissed the need for vaccination to control the spread of swine flu. Dr PV Dave, additional director of health department of Gujarat, told that the department did not consider vaccination and refused to elaborate on other flu-control strategies adopted by the state.

“H1N1 is so common in India that it is called seasonal flu,” said Dave. “The rate of death among accidents is higher but nobody worries about that.”

Dr AC Dhariwal, director of National Centre for Disease Control, said that all high-risk states including Gujarat were asked to follow the guidelines issued by the health ministry to control H1N1 transmission. “It is the responsibility of each state to vaccinate its people,” he said.

Vaccine efficacy

All states that have witnessed H1N1 outbreaks this year have seen similar trends of swine flu deaths among people with other ailments and those with compromised immunity including elderly, children and pregnant women.

In Maharashtra, another state identified as high-risk for H1N1, health authorities have vaccinated more than 30,000 vulnerable people.

“These are just people who took vaccination at our centres, many are taking vaccine from their private doctors,” said a senior health official from Maharashtra who did not want to be identified.

Although Maharashtra has recorded the highest number of swine flu cases and deaths this year, the official claimed that there has been a significant reduction in the number of pregnant women catching H1N1 infections after the vaccine was introduced.

Gujarat has only asked health workers to get vaccinated.

The health ministry advisory states that, when the appropriate vaccine is used for the flu strain in circulation, the efficacy of the vaccine is between 70% and 80%.

“The vaccine works, but it is not 100%,” agreed Dr Om Shrivastav, infectious disease consultant from Mumbai. “Inadequate and delay in treatment have led to a higher morbidity and mortality this year. If people were put on treatment early, the medicine is working well.”

However, Shrivastav stressed that vaccination is the only way to prevent the spread of disease and that one would have to immunise a sizable population for it to work. “We need to vaccinate about 40 to 60% of the people in high risk groups to bring down the infection rate,” he said.

When to vaccinate?

Even if Gujarat starts vaccinating vulnerable groups now, it may not be enough. Vaccinations should ideally be done between April and July, before outbreaks occur.

“Vaccinating people when the transmission is going on may not be of any benefit,” said Dr Lalit Dar, professor of microbiology at the All India Institute of Medical Sciences in Delhi. Dar is a part of a central government team which visited Gujarat to suggest steps to control the transmission of the virus. He said that vaccinations must be carried out before the virus starts spreading.

Dar, however, pointed out that the availability of vaccine in the pre-monsoon period has been a problem in the past. “We are trying to ensure that the flu vaccine for the year reaches Indian markets earlier,” he said. New flu vaccines are developed and manufactured every year as per the virus expected to be in circulation.

Dar said that the spread of the virus is on the decline in Maharashtra and the team anticipates that the number of cases in Gujarat may also decrease within a few weeks.

Change in virus?

Gujarat health officials have said that this year’s outbreak has been due to a change in the H1N1 virus. Genetic changes in influenza viruses occur in two ways. Sometimes, there is an abrupt significant mutation that creates a new strain of virus. The phenomenon is called antigenic shift and can cause dangerous outbreaks like the H1N1 pandemic of 2009. But influenza viruses more often undergo small genetic changes that create viruses that are only slightly different from the original virus. A person who has been exposed to the original virus may have developed immunity to it but will not be immune to this newer version created by such an antigenic drift.

The National Institute of Virology reported such antigenic drifts in H1N1 strains circulating in India. But bigger antigenic shifts have also occurred. The institute said that India has started witnessing the spread of the Michigan strain of the H1N1 virus this year. Earlier, India had recorded cases of only of the California strain.

“We have found that all the cases from Gujarat are of the Michigan strain,” said Dar.

The current vaccine being used by health authorities is supposed to confer immunity against all H1N1 strains in circulation, including the Michigan strain.

Delay in treatment

Doctors treating H1N1 patients in Gujarat said that most patients get to hospital days after the onset of symptoms. Oseltamivir, the only drug which is effective against the H1N1 virus, works best when administered within 48 hours of the patient complaining of symptoms. Those suffering from H1N1 complain of fever, sore throat, running nose and body pain among other symptoms.

“In most cases where patients have succumbed to H1N1, there was a delay in diagnosis and administration of Oseltamivir,” said Dr AN Shah, professor and head of medicine department at Ahmedabad civil hospital in Gujarat.

Most patients who are being admitted to the civil hospital in Ahmedabad, Shah said, were referred from private hospitals and nursing homes. “The doctors there did not suspect H1N1 and only when the patients deteriorated, they referred them to our hospital.”

Even though Gujarat has relatively better rural health services than other parts of the country, Dar suggested that the gaps in healthcare in rural areas have contributed to the delay in treatment and to greater swine flu fatality.

“People from rural areas were reaching hospitals late,” said Dar. “Also many people were neglecting the symptoms of cough and not seeking help early.”

Vaccination is recommended for persons with chronic illnesses like:

  • Chronic obstructive pulmonary disease
  • Bronchial asthma
  • Heart disease
  • Liver disease
  • Kidney disease
  • Blood disorders
  • Diabetes
  • Cancer  and other conditions that compromise immunity

Vaccination is recommended for children with chronic diseases like:

  • Asthma
  • Neuro-developmental conditions like cerebral palsy, epilepsy, and stroke
  • Heart disease
  • Congestive heart failure
  • Blood disorders like sickle cell disease
  • Diabetes
  • Metabolic disorders
  • Conditions that compromise immunity