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Tuesday, December 12, 2017

Influenza burden

Wednesday, 11 October 2017 12:29
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The Indian health authorities appear to have failed miserably in tracking the Swine Flu virus during the past few years particularly ever since the influenza virus better known as H1N1 landed on Indian shores in 2009, its outbreak in epidemic form has become an annual feature. It is surprising why the Indian authorities have been found lagging in tracking this virus that was the worst in 2015, when an estimated 2990 people lost their lives. And this year, 2017, the virus appears to have been quite active and the mortality stood at 1873 till the end of September and the toll may touch the 2015 levels across the country. The outbreak of virus in 2016 appears to have been on lower side with only 265 deaths due to this virus. This figure is an aggregate because of the fact that some of the deaths due to this virus have not been reported from some of the states in the country due to lack of diagnostics and failure to investigate the deaths of the patients. Another problem with the official figures, however, is that they only capture H1N1 numbers, a practice that has been adopted in response to the severity of the 2009 pandemic. But there is no denying the fact that the influenza was present in India even before 2009 in the form of H3N2 and Influenza B virus types. Out of these, H3N2 is capable of causing outbreaks in an epidemic form as big as H1N1, and yet India does not track H3N2 cases as extensively as it does H1N1. This means that seemingly benign years such as 2016 may probably not be benign at all. This is because of the fact again that the data from outside government surveillance systems are making this fact apparent. For example, a surveillance project for acute febrile illnesses, anchored at the Manipal Centre for Virus Research in Karnataka, has found that influenza accounts for nearly 20 percent of fevers across rural areas in 10 Indian States - fevers that often remain undiagnosed and classified as 'mystery fevers'. During the years when the H1N1 burden is low in these regions, H3N2 and Influenza B circulation tends to spike. Similarly, there is total denial by the authorities about the Dengue fever and related deaths in the country. The low figures only expose the lack of awareness not only among the common masses but also the medical fraternity, who have utterly failed in finding the cause of death of the patients. The jumble up in the figures about deaths caused by different virus in India only shows that the country's surveillance systems are too poor to track the viruses and underestimate the influenza burden substantially. If numbers are not satisfactorily tracked, so are changes in the viral genome all across the country. As a 2015 commentary by a pair of researchers from the Massachusetts Institute of Technology pointed out, India submits a woefully small number of H1N1 genetic sequences to global open-access databases for a country of its size and population. In fact, the estimates made by the international organizations on the state of affairs in India, only indicate that something is wrong somewhere in tracking the viruses. In this field, sequencing is important because it can detect mutations in genetic material that help the virus evade human immune systems, making it more deadly. Because India does not sequence a large enough sample of viral genomes, it would be missing mutations that could explain changes in the lethality of the virus. Put together, the numbers data and sequence data will enable sensible vaccination decisions. Vaccination is the best weapon that India has against this menace, because Oseltamivir, the antiviral commonly deployed against flu, is of doubtful efficacy unless administered early enough to treat the patients well in time. Yet, India has thus far stayed away from vaccinating even high-risk groups such as pregnant women and diabetics, because influenza is thought to be a more manageable public health challenge compared to mammoths such as tuberculosis. Better surveillance of influenza will possibly change this perception by revealing the true scale of this public health issue. 


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