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

Graph Showing the H1N1 Cases and Deaths in Punjab, 2012-2016

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)

Map showing the Distribution of H1N1 Deaths in Different Districts of

Punjab, 2016

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.

COMPILED AND ANALYZED BY:

1. Dr. Gagandeep Singh Grover MD, PCMS-I

State Surveillance Officer, IDSP, Punjab

2. Dr. Satish Kumar MD, PCMS-I

Epidemic Intelligence Surveillance Officer (EISO)