The flow of patients with influenza-like-illness (ILI) has been increasing throughout the country. Dozens of patients are visiting the Sukraraj Tropical and Infectious Disease Hospital in Teku each day for the treatment of such flu like cases. Most of them exhibit symptoms of high fever, dry cough, weakness, chills, sore throat, runny nose, fatigue, diarrhoea in children, and headache; these symptoms are associated with the swine flu virus. The H1N1 influenza A (pdm09) virus, known more commonly as the swine flu virus, was first detected in people of Mexico in April 2009. 

The virus has claimed the lives of 12 people and has been confirmed in over 100 patients around Nepal over the past two weeks. With more people being diagnosed with swine flu and the death toll rising, people are worried about the spread of the virus and its consequences. Similar cases have been reported in Myanmar and some states of India. The recent outbreak is worrying because it seems to be the same strain of swine flu that caused a pandemic in 2009, and a major outbreak in Jarjarkot in 2015. Scientists have claimed to have found at least two new strains very similar to the pdm09; these three strains are wreaking havoc all around the world.

Most of the patients diagnosed with swine flu have died because of pneumonia. TU Teaching Hospital (TUTH) organised a vaccination program for all their staff recently and used a new vaccine called the Influvac 2017. This particular vaccine has been recommended by World Health Organisation (WHO) and has proven effective against flus in 2017. Influenza viruses are the major determinant of morbidity and mortality caused by respiratory diseases. Influenza has been responsible for millions of deaths worldwide and causes annual outbreaks of variable intensity. The frequency at which the influenza virus mutates and creates new strains means that it is always a challenge to stay a step ahead and battle the flu. Influenza type A is highly variable and is responsible for most of the epidemic cases; type B may exhibit genetic changes and sometimes cause epidemics; type C is stable and causes mild illness in individuals with an immunity deficiency. 

According to the Epidemiology and Disease Control Division (EDCD), this year, there have been more cases of influenza in comparison to last year. For the past month, seasonal flu has been spreading rapidly and it’s becoming difficult to treat all patients in time. EDCD has warned that the “as being a highly communicable viral disease, the flu may spread heavily throughout the country and there is no care except sanitation and awareness”. The timing of this viral disease is very unpredictable and can vary in different parts of Nepal and from season to season. The number of cases of ILI increased drastically in the past weeks.

Transmission and pathogenesis

The influenza virus mainly attacks the upper respiratory tract. It poses a serious risk for the elderly, the very young, and people with underlying medical conditions such as kidney, lung, or heart problems, cancer, or diabetes. Influenza virus spreads from person to person by airborne droplets or by contact with contaminated surfaces or hands. The incubation period from exposure to the virus to the onset of illness varies from one to four days; it depends on the size of the viral dose and the immune status of the host. The virus multiplies within eight to 10 days and spreads to adjacent cells, where the replicative cycle is repeated. Infection causes cellular destruction and peels off the upper membrane protecting the lung cells. Within a short time, many cells in the respiratory tract are infected and killed. Symptoms of classic influenza normally appear abruptly and include headache, chills and cough, followed closely by high fever, malaise, muscular aches and anorexia. Fever induced seizures can occur in children, along with the swelling up of air passages. The mortality of an influenza epidemic is reflected in the excess deaths due to pneumonia and other heart and lung diseases. Flu infection enhances susceptibility of patients to bacterial infection. Combined viral-bacterial pneumonia is three times more dangerous than viral pneumonia. 

Diagnosis and prevention

The only place for diagnosing influenza in Nepal is the influenza centre at the Nepal Public Health Laboratory, Teku. In the absence of required rapid diagnostic kits and equipment, this virus is often misdiagnosed as the regular flu. Specimens for diagnosis are taken through nasal washings, gargles, and throat swabs. Samples should be collected within the first three days after the onset of symptoms. Reverse-transcription polymerase chain reaction (RT-PCR) helps in the direct detection of viral RNA or specific viral antigens in collected specimens. However, this is not currently available in all clinical facilities in Nepal. 

There is no specific drug against this viral infection to date. Only the symptoms can be managed to ease the patient. Patients should drink plenty of liquids, and should get bed rest. If complications develop, a doctor should be referred to immediately. For secondary bacterial infections, physician should prescribe the Azithromycin antibiotic for a regular five day course. The government should conduct awareness programmes and provide medical experts throughout the country with ample diagnostic kits. The Ministry of Health should additionally launch seasonal flu vaccination programmes on time, at least for vulnerable groups. Health authorities should run screening protocols. Washing hands with soap and water, or the use of alcohol based hand sanitizers is highly effective in reducing the chance of infection. Individuals should stay away from the crowded areas, and should wear facemasks while outdoors. 

Rayamajhee holds an MSc in medical microbiology from Tribhuvan University