Situation in India – June 28, 2010

There have been a number of recent reports of increased pandemic H1N1 activity in India. These have been associated in some news pieces as due to the monsoon season. In the tropics, flu outbreaks are distributed throughout the year to a greater extent than in the temperate zone. In addition, because the equator runs through India, one might expect that flu cases in the northern India peak during the northern hemisphere winter while cases in southern India might peak during the southern hemisphere winter (now). This split pattern of outbreaks has been reported in Brazil, another populous country bisected by the equator. Further study will be necessary to determine whether the same pattern is occurring in India with pandemic H1N1.

Reports coming out of India indicate some disturbing features of the H1N1 pandemic virus.

From The Times of India, June 26, 2010

…the BMC [Brihanmumbai Municipal Corporation] summoned close to 300 doctors from its health posts and peripheral hospitals on Friday to alert them about the changing symptoms of the flu and protocols to treat them. Among other concerns, one was how to treat those who suffer from a relapse or a second swine flu attack. “Second attacks are quite common and quite severe too,’’ said infectious diseases consultant Dr Om Srivastava.

Experts have observed that about 20% of those who tested positive for swine flu in the city last year have had a second swine flu attack. Confirming this, Srivastava said that there were no concrete studies about the intervals at which one could suffer a second attack. “It could be a few weeks to a few months Relapse patients have to be treated with a combination of two drugs,’’ he said.

A 20% incidence of a second attack of influenza virus within one year is quite surprising. The most obvious explanation for this phenomenon would be that the virus currently circulating in India has changed significantly. So much so, that the patient’s immune system can no longer recognise the virus. This would suggest that the current vaccine is unlikely to be effective against this new strain. An alternative explanation would be that pandemic H1N1 virus has the ability to form a latent infection in humans and reactivate. This would be extremely unusual for a flu virus but is typical of other viruses such as Herpes Simplex and HIV.

There has also been a report of an increased incidence of neurological symptoms in the new wave of infections in India.

From The Mumbai Mirror, June 26, 2010 [hat-tip, Pixie].

That the H1N1 virus – which has claimed six lives in June alone – is mutating is well-known. However, what has caught city doctors unawares is patients’ inability to write, type and, in some cases, even stand.

The effect the new mutation is having on patients’ nervous system and muscle control prompted civic authorities to call an emergency meeting of 500 doctors from the three major and 16 peripheral hospitals on Friday.

Dr Om Shrivastav, Kasturba Hospital, who is in-charge of the swine flu control unit, said the medical professionals were baffled by the new complications. “The weakening of muscles to the extent that patients can’t write is new for medical professionals. We have found the virus, in recent cases, affects the neck, back, spine and even the brain.”

According to World Health Organisation (WHO) guidelines a classic case of infection is known to cause high grade fever, a sore throat and severe breathlessness.

“We have now told doctors to be on the look out for symptoms like muscular weakness and poor neuro-motor coordination,” said Dr Shrivastav who added, “We have asked for the vaccine to be given to all suspected patients.

We are admitting only very serious patients. Others are being advised to rest at home and not interacting with others.”

Muscle weakness could be due to damage to the muscle itself, peripheral nerves that innervate muscle, the spinal cord or the brain. However, the report above specifically mentions brain involvement. If this is accurate, it would be disturbing news. Brain damage has been reported as a result of influenza infections, but is generally considered a rare occurrence. If there is a new strain of H1N1 that is causing brain damage, this would obviously be of considerable importance. Further information on this topic would be useful.

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