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H1N1 (SWINE FLU)
PUNJAB
INTEGRATED DISEASE SURVEILLANCE PROGRAMME (IDSP)
DEPARTMENT OF HEALTH & FAMILY WELFARE
Report on H1N1 in Punjab
Introduction
Four flu pandemics have occurred since 1918 each with different
characteristics. During the 1918 pandemic, nearly 20% to 40% of world
population became ill and nearly 50 million persons died.
In 2009, it was called “swine flu” because virus was similar to those found in
pigs. H1N1 virus is currently a seasonal flu virus found in humans contains
glycoproteins i.e. Haemagglutinin & Neuraminidase. Haemagglutinin causes
red blood cells to clump together and bind the virus to the infected cell.
Neuraminidase hydrolase enzyme which help to move the virus particles
through the infected cell and assist in budding from the host cells.
Structure of H1N1 Virus
Some strains of H1N1 are endemic in humans and cause a small fraction of
all influenza-like illness and a small fraction of all seasonal influenza. H1N1
strains caused a small percentage of all human flu infections in 2004–
2005. Other strains of H1N1 are endemic in pigs (swine influenza) and in
birds (avian influenza).
Magnitude of Disease
Latest influenza pandemic due to Influenza A (H1N1) began in May 2009
spread to all over the world and became global by July 11 2009. On
10th
August 2010, pandemic was declared to be an end with more than
18,449 deaths reported worldwide by end of the month.
In India, first positive case of H1N1 was reported in May 2009 and by the
end of year 2010, 20604 cases with 1763 deaths were reported. The
country experienced three waves during the period of pandemic of 2009-
2010, first one in 2009 September, followed by second wave in December,
and third peak in August 2010 when the end of pandemic was declared.
Symptoms of Disease
Swine flu is contagious about one day before symptoms develop to about
five to seven days after symptoms develop but some patients may be
contagious for a longer time period.
It can cause mild to severe illness, and at times can lead to death. People who
have the flu often feel some or all of these symptoms:
Fever with or without chills (not everyone with flu will have fever)
Cough
Sore throat
Runny or stuffy nose
Muscle or body aches
Headaches
Fatigue (tiredness)
Some people may have vomiting and diarrhea, though this is more
common in children than adults.
People at High Risk for Developing Flu-Related Complications
Children under 5, especially children younger than 2 years old
Adults 65 years of age and older
Pregnant women
Persons having medical conditions including:
Asthma
Neurological and neurodevelopmental conditions
Chronic lung disease
Heart disease
Blood disorders (such as sickle cell disease)
Endocrine disorders (such as diabetes mellitus)
Kidney disorders
Liver disorders
Metabolic disorders
Weakened immune system due to disease or medication
People younger than 19 years of age who are receiving long-term
aspirin therapy
In addition, some studies have shown that obese persons (body mass index
≥30) and particularly morbidly obese persons (body mass index ≥40) are at
higher risk, perhaps because they have one of the higher risk conditions
above but do not realize it.
Emergency warning signals
In children
Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough
Fever with a rash
In adults
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting
Flu-like symptoms that improve but then return with fever and worse
cough
Do’s & Dont’s in H1N1
DO Cover your mouth and nose with a handkerchief or tissue when you
cough or sneeze.
Wash your hands often with soap and water or use an alcohol based
hand gel.
Avoid touching your eyes, nose or mouth.
Avoid crowded places
Stay more than an arm's length from persons afflicted with flu
Get plenty of sleep
Drink plenty of water and eat nutritious food
DO NOT: Shake hands or hug in greeting
Spit in public
Take medicines without consulting a physician
IF YOU THINK YOU HAVE H1N1 FLU: Visit the nearest H1N1 Screening Centre or Contact 0172-2621506 for
assistance
Stay at home, if advised by the doctor.
Do not travel or go to work or school.
Avoid close contact with others for 7 days after your symptoms begin
or until you have been
Symptom-free for 24 hours whichever is longer
Report to nearest identified health facility if symptoms aggravate
H1N1 Cases Scenario in Punjab
In the first phase from April 2009 to April 2010, 39% H1N1 positivity was
reported among suspected cases of category- C. 16% mortality was reported among
laboratory confirmed cases during this period.
In post pandemic phase i.e. August 2010 to December 2011 & January 2012 to
December 2012, positivity was 19% and 14% respectively. In 2013, 32% positivity was
reported in suspected category C cases while it was 21% in 2014. Mortality was 23% in
laboratory confirmed cases in 20013. In 2015, positivity rate was 31% among the
category C suspected cases and mortality was 19% among the laboratory confirmed
cases.
Table Showing H1N1 cases and deaths in Punjab from 2009-2015
Time Period of H1N1
cases in Punjab
Category-
B
Category-
C
Total
number of
cases Lab.
confirmed
Total
Contact
cases
given
treatment
Total
No. of
deaths
Patients
from other
States died
in Punjab Treatment
without
testing
Suspected
cases
April 2009-April 2010 305 641 252 3843 40 --
Aug 2010 to Dec 2011 27 239 46 592 23 4
Jan 2012 to Dec 2012 2 101 15 93 4 0
Jan. 2013 to Dec.2013 0 582 183 2395 42 5
Jan. 2014 to Dec. 2014 0 121 27 92 3 3
Jan 2015 to Dec 2015 267 833 300 501 57 4
Table Showing the Distribution of H1N1 (Suspected Category C)
Patients according to their District of Residence in Punjab, 2016
S No. Name of District No of Cases % (Case Load)
1 Amritsar 9 2
2 Barnala 9 2
3 Bathinda 40 9
4 F. sahib 6 1
5 Fazilka 9 2
6 Ferozepur 28 7
7 Faridkot 39 9
8 Gurdaspur 5 1
9 Hoshiarpur 7 2
10 Jalandhar 13 3
11 Kapurthala 7 2
12 Ludhiana 108 25
13 Mansa 11 3
14 Moga 20 5
15 Muktsar Sahib 31 7
16 SBS nagar 4 1
17 Patiala 25 6
18 Ropar 6 1
19 SAS Nagar 22 5
20 Sangrur 25 6
21 Taran Taran 3 1
Total 427 100
H1N1 cases were reported from all the districts of the state. 25% of cases were
reported from only district Ludhiana. According to three regions of state, maximum
cases (88%) were reported from the Malwa region while 8 % cases were reported from
Doaba region and 4% cases from Majha region.
If we see the distribution of patients in Private hospitals, we can see that 47% of
patients were admitted in Private hospitals of Ludhiana city mainly DMCH (19%),
CMCH (17%), SPS Hospital (9%) and Fortis hospital (2%). 14% of total patients were
admitted in hospitals of Chandigarh mainly PGIMER, Fortis Hospital, Mohali and
GMCH 32 Chandigarh. 10% of patients had their treatment from GGSMC, Faridkot.
For seeking treatment, patients did not opt for district hospitals of state, GMC Patiala
and GMC Amritsar. The following table shows the preference of patients for their
treatment.
Distribution of H1N1 Patients according to the Place (Hospital) of
admission in Punjab, 2016
Name of Hospital No of Patients
admitted
%
DMCH, Ludhiana 80 19
CMCH, Ludhiana 72 17
GGSMC, Faridkot 60 14
14 Distt.Hospitals, Punjab 44 10
PGIMER, Chandigarh 39 9
SPS Hosp. Ludhiana 37 9
Fortis H Mohalli 17 4
Columbia Hosp. Patiala 11 3
Max H Mohalli 8 2
Fortis Hospital, LDH 7 2
Rajindra Hospital, Patiala 6 1
Adesh Hospital, Bathinda 5 1
GMCH, Chandigarh 5 1
GNDU, Amritsar 5 1
SGRD, Amritsar 4 1
Other Pvt. Hospitals in State 27 6
In suspected C category, youngest age affected was 3 days and highest age was 92
years. Cases of category C were reported among all age groups.65% of cases belong to
25-59 years age group and 22% of cases were above the age of 60 years.
Table showing Distribution of H1N1 (Suspected Category C) patients
according to their Age groups in Punjab, 2016
S No Age group No. %
1 <1 12 3
2 1-4 16 4
3 5-14 8 2
4 15-24 18 4
5 25-44 124 29
6 45-59 155 36
7 60 & above 94 22
Total 427 100
Table showing Distribution of H1N1 (Suspected Category C) patients
according to the Gender in Punjab, 2016
S No. Variable No %
1 Male 221 52
2 Female 206 48
Total 427 100
Both the genders were affected almost equally. 58% of cases belong to the urban area.
Table showing distribution of H1N1 (Suspected Category C) patients
according to the Gender in Punjab, 2016
S No Variable No %
1 Rural 178 42
2 Urban 249 58
Total 427 100
In Punjab, 16% of deaths were reported from the patients belonging to district Bathinda.
75% of deaths of H1N1 patients were reported from the Malwa region i.e. Bathinda,
Ferozepur, Faridkot, Ludhiana, Moga, Muktsar sahib, Sangrur and Patiala districts. 11%
of deaths were reported from patients belonging to Majha region of Punjab.
Distribution of H1N1 Patients (Death) in Various Districts of Punjab in
2016 and 2015
S No Name of District No of Patients
N (%)2016
No of Patients
N (%)2015
1 Bathinda 10 (16) 2 (4)
2 Ferozepur 7 (11) 1 (2)
3 Faridkot 6 (10) 2 (4)
4 Ludhiana 6 (10) 6 (11)
5 Moga 5 (8) 1 (2)
6 Muktsar Sahib 5 (8) 1 (2)
7 Sangrur 4 (7) 4 (7)
8 Gurdaspur 3 (5) 0 (0)
8 Patiala 3 (5) 2 (4)
10 SAS Nagar 3 (5) 5 (9)
11 F. Sahib 2 (3) 2 (4)
12 Mansa 2 (3) 0 (0)
13 Tarantaran 2 (3) 3 (5)
14 Amritsar 2 (3) 8 (14)
15 Jalandhar 1 (2) 8 (14)
16 Fazilka 0(0) 2 (4)
17 Kapurthala 0(0) 3 (5)
18 Hoshiarpur 0(0) 2 (4)
19 Pathankot 0(0) 2 (4)
20 Barnala 0(0) 3 (5)
Graph Showing Suspected Category-C cases & H1N1 Deaths in Punjab,
2016
70 % of patients who died from H1N1 were in the age group of 25-59 years and 21%
were more than 60 years.
Table showing H1N1 patients Deaths according to Age Groups in
Punjab,2016
S No Age group No of Patients %
1 <5 2 3
2 5 to 14 2 3
3 15-24 1 2
4 25-44 22 36
5 45-59 21 34
6 60 & above 13 21
Total 61 100
Out of these patients, 54% were females and 62% of patients have rural background.
Table showing the H1N1 patients Death according to their Gender in
Punjab, 2016 & 2015
S No Variable Number of Patients
n (%) 2016
Number of Patients
n (%) 2015
1 Male 28 (46) 29 (51)
2 Female 33 (54) 28(49)
Table showing the H1N1 patients Death according to their Residence in
Punjab, 2016 & 2015
S No Variable Number of
Patients n (%)
2016
Number of
Patients n (%)
2015
3 Rural 38(62) 28 (49)
4 Urban 23(38) 29 (51)
Majority of the patients (58%) who died were treated in the Private hospitals in the state
while 20% in PGIMER, Chandigarh. 10% of patients who died were treated in state
medical colleges in 2016.
Table showing the H1N1 patients according to their place of treatment
and place of Death in Punjab in 2016 & 2015
S No Name of Hospital N (%) 2016 N (%) 2015
1 CMCH, Ludhiana 6 (10%) 3 (5)
2 DMCH, Ludhiana 12 (20%) 6(11)
3 PGIMER, Chandigarh 12 (20%) 10(18)
4 GGSMC, Faridkot 8 (13%) 2(4)
5 Fortis/ SPS Hossp. Ludhiana 2 (3%) 6(11)
6 Fortis/ Max/Ivy Mohalli 3 (5%) 2(4)
7 Rajindra Hosp. Patiala 1 (2%) 1(2)
8 GMC, Amritsar 1 (2%) 2(4)
9 GNDH, Amritsar 4 (7%) 5(9)
10 Others (Home, On way &
Regional Pvt. Hospitals, DH)
12 (20%) 20 (35)
Out of the H1N1 patients who died, 53% of patients have reported to health institution
between 3-5 days and 16% reported in 7 days. 14% patients reported after more than 7
days.
S No Onset of Symptoms ( in
Days)
No of Patients (Data
available-43)
%
1 2 Days 7 16
2 3-5 Days 23 53
3 6-7 Days 7 16
4 >7 days -12 Days 5 12
5 30 Days 1 2
Table showing distribution of Patients according to their Clinical
Presentations in H1N1, Punjab, 2016
In 70% of the cases, history was available. Most common presentation of the patients
who died in hospitals was fever, cough and breathlessness in 72% cases, 30 with sore
throat and 14% were afebrile.
S No Variables No. %
1 Fever, cough, Breathlessness 31 72
2 Afebrile 6 14
3 Sore throat 13 30
4 Running nose 9 21
5 Diarrhea 2 5
6 Blood in sputum 2 5
7 Chest pain 1 2
In X ray findings mainly suggests diffuse consolidation both lungs, B/L fluffy
infiltrates, cotton wool opacities, changes suggestive of ARDS or pleural effusion.
Out of detail of 42 sputum report of H1N1 available, in 5 cases reports were available
on same day, after 1 day in 15 patients, after 2 days in 16 patients and in 5 cases, reports
were available after more than 3 days.
Table showing Receiving of Nasopharyngeal Swab report in days from
the testing Laboratory, Punjab, 2016
S No. Sputum Report in days No of Patients
1 On same day 5
2 After 1 days 15
3 After 2 days 16
4 After 3 days -
5 More than 3 days 6
In the following table we can see that Tamiflu treatment was started on time irrespective
of the sputum report.
Table Showing Start of Treatment with Tamiflu to H1N1 patients In
Punjab, 2016
S No. Start of Treatment in days No of Patients
1 Before Sample collection 10
2 On Same day 33
3 Within one day 11
4 More than one day 11
H1N1 patients who died also presented with different co morbid conditions. Out of
62 patients who died, record of 46 was available. 33 (72%) H1N1 died patients reported
with co morbid condition and 17 (37%) presented with multiple co morbid conditions
(Diabetes Mellitus, Cardiovascular Disease, Liver disease, Kidney Disease). Diabetes
mellitus 14 (30%), Cardiovascular disease 9 (20%), liver disease 6 (13%) and lung
disease (13%) was mainly reported in individual patients. Patients who died also
reported to have other co morbid conditions like addiction, renal disease, Hepatitis
(B&C), Hypothyroidism and Pregnancy. 34% (17/50) patients had prior treatment from
their local doctor before seeking admission in tertiary level hospitals. 61% (33/49) of
H1N1 admitted patients’ required mechanical ventilation.
Table showing the Reported Co -morbid conditions H1N1 patients
admitted in various Hospitals in Punjab, 2016
S No
Variables
No of Patients
1 Multiple comorbidities 14
2 DM 13
3 CV Disease 9
4 Liver Disease 6
5 Lung disease 6
6 Addiction 5
7 Renal Disease 4
8 Hepatitis (B& C) 2
9 Hypothyroidism 2
10 Pregnancy 1
To summarize, 75% cases were reported from Malwa region of state, 65% cases
were in age group of 25-59 years, 58% belong to urban area but 62% cases reported
death belong to rural area. It has been observed that the cases are reported from the
different areas of the districts and there is no clustering of cases. We are not able to
establish the epidemiologically link of these cases.
47% cases were admitted in Private hospitals of Ludhiana. Patients had not opted
for district hospitals of state, GMC, Patiala and GMC, Amritsar for treatment. H1N1
patients who died reported with co-morbid conditions such as Multiple co morbidity in
17(29%) patients, Diabetes mellitus in 13(21%), Cardiovascular disease in 9(15%)
patients, Liver and Lung disease in 6(10%) patients each. The died patients also
presented with other co morbid conditions like drug addiction, Renal disease, Hepatitis
B&C, Hypothyroidism and pregnancy. 61% of patients required mechanical ventilation
during their stay of admission. There is a need to sensitize the community regarding
presentation of disease as 63% reported after 3-5 days and 30% reported after 6 days of
disease.
As the patients were reported from all over the state, so there is a need to strengthen the
district hospitals as well as medical colleges of state for the management of
H1N1patients along with availability of ventilator support. H1N1 data collecting
proforma needs to be revised to gather more information.
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