Swine Flu in India

The last situation update from WHO puts the number of positive cases worldwide at over 296,471 with at least 3486 deaths (http://www.who.int/csr/don/2009_09_18/en/index.html).

India's Ministry of Health and Family Welfare (MoHFW) puts out daily updates on the swine flu situation in the country (http://mohfw.nic.in/press_releases_on_swine_flu.htm). The updates started on August 1, 2009, by which time there were already 534 positive cases but no deaths. The first death, a 14-year old schoolgirl from Pune, was reported on August 3, 2009. Since that time, the number of positive cases have gone up steadily. As I write this, the last MoHFW update from September 21, 2009 reports that samples from 35,148 persons have been tested across the country, 8153 (23 .1%) have been found positive and 257 persons have died as a result of this infection.

The mortality rate in India stands at 3.1%, compared to a global average of 1.1%. What is the reason for this higher mortality in India? We don't know as there is no epidemiological analysis available. The reasons could be
(a) virological - increased virulence of the virus circulating here,
(b) host genetics - maybe Indians are genetically predisposed to get more severe disease
(c) environment -  poor healthcare infrastructure, late reporting of cases, selection bias with only severe cases being tested, etc.
It could also be an interesting mixture of all of the above.

The point is - unless we look at these issues systematically, we will not know.

I have made a graph on the situation in India based on MoHFW updates. The plot shows positive cases and deaths every 5 days from the start of updates (Aug 1, 2009) for the first 50 days of reporting.

 

It is quite clear from the graph that the outbreak in India is growing at a steady rate. Since early in the outbreak, the number of cases have gone up  at the same rate. The pink line in the graph has a constant slope. Curiously, the death curve shows a hint of biphasic nature to it. The death rate seems to be picking up lately. After running almost parallel with the positive cases curve for some time, the death curve has now intersected it.  Will it continue its upward spiral? In the absence of any analysis or models, only time will tell.

India has done well in gearing up resources to put testing in place. Scientists and technicians involved in testing for swine flu have done an admirable job. They have used all the resources at their command to test quickly and have adhered to quality.

But this is only half the job done. We should be analyzing this outbreak. The Indian Council of Medical Research (ICMR; http://www.icmr.nic.in/), whose mandate is medical research, should be driving this. We have a National Institute of Epidemiology, an ICMR institute in Chennai (http://www.icmr.nic.in/pinstitute/nie.htm). What are those guys doing? What are the public health experts at the  Public Health Foundation of India (http://www.phfi.org/) doing? The PHFI website has H1N1 flu advice (http://www.phfi.org/h1n1flu/index.html), but no analysis.

It is the same case with virological analysis. No genomic data is available on the virus circulating in India. The Influenza Virus Resource uploads genomic data in the public domain on a daily basis. See http://www.ncbi.nlm.nih.gov/genomes/FLU/SwineFlu.html. There is no data in the public domain from India. And it is truly shameful.

Is the virus in India showing genomic signatures of increased virulence? How many mutations will it take to make it highly virulent? Are we beginning to see the H274Y mutation in the NA protein, which is reported to be associated with Oseltamivir (Tamiflu) resistance? WE DON'T KNOW.

Should we not have science drive policy? Where is the science? It is time for ICMR, PHFI, Ministry of Health, Ministry of Science and the scientific and biomedical research community at large to ask these questions.

In India, our flu season is just beginning. Wake up.