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Epidemiology of Respiratory infections

Epidemiology of Respiratory infections and allergies: The Indian context

Respiratory diseases (trachea, bronchus and lung cancers, lower respiratory infections and chronic obstructive pulmonary diseases) have been noted among the top ten killers across high, middle and low income countries by the World Health Organization (WHO, 2008). For India, the WHO had projected that chronic diseases would be attributed 53% of all deaths in 2005 (WHO), 7% of which would be due to chronic respiratory diseases. Still, these have not caught the attention of epidemiologists as much as the cardio-vascular disorders or diabetes mellitus or even, morbidities like obesity or under-nutrition; and whatever research has been conducted has mostly restricted itself to the study of pulmonary tuberculosis, asthma and COPD. The probable reason seems to be the usual non-acute presentation of most respiratory ailments (-the reason why an unusual exacerbation of asthma or COPD or even a sudden flu epidemic engages so many of brains and eyes!). The detailed study of these diseases is usually taken up only when they are considered as epidemics. Consequently, mega-scale epidemiological assessments of chronic respiratory illnesses are mostly lacking in India and whatever research has been undertaken is marred with inadequate sample size and lack in uniformity of definitions, designs, methodologies and reporting techniques (Jindal, 2006). . While diseases that occur in common have been described with reference to their time, place and person distributions and compared in indices of absolute numbers and proportions, relatively rare morbidities have been enumerated in the form of case studies. The economic impact and overall burden of ailments have also been highlighted by researchers.

The chronicity of the conditions and incapacitating impact on the sufferer’s life warrants a close look at the distribution and determinants of the common respiratory morbidities. While the Tuberculosis-HIV/AIDS linkage has become the cynosure of attention of health programmers world-wide, the figuring in the United Nations Millennium Development Goals (MDG 6: combat HIV/AIDS, malaria and other diseases) is evidence of the concern it demands (UN).

Thus, even as scientific characterization of the respiratory illnesses is infantile, the policy implications are quite conspicuous. As an example, respiratory system involvement in various occupational set-ups has lead to redrafting of many an employee compensation act as well as development of pertinent preventive strategies. Notwithstanding the fact that each disease and the life it impairs are important, this chapter shall discuss the epidemiology of respiratory diseases of major public health importance.1

  1. Dean Academic Affairs & Professor in Community Medicine, S.G.T. University, Gurgaon,

  2. Deputy Director INCLEN, New Delhi

Thus, even as scientific characterization of the respiratory illnesses is infantile, the policy implications are quite conspicuous. As an example, respiratory system involvement in various occupational set-ups has lead to redrafting of many an employee compensation act as well as development of pertinent preventive strategies. Notwithstanding the fact that each disease and the life it impairs are important, this chapter shall discuss the epidemiology of respiratory diseases of major public health importance.

Acute Respiratory Infections & Pneumonia

Acute respiratory diseases (ARDs) are upper or lower respiratory tract illnesses, usually infectious in etiology, which can result in a spectrum of illnesses ranging from asymptomatic or mild infection to severe and fatal disease, depending on the causative pathogen, environmental, and host factors. In any population, ARIs would easily be reckoned as the most common infection. Acute respiratory diseases (ARDs) are among the leading causes of morbidity and mortality from infectious disease in the world (WHO, 2007) and the incidence in developing and developed countries have been noted to be similar. ARDs are also among the most frequent reasons for visiting a health-care worker or being admitted to a health-care facility (WHO, 2009). It has been estimated that each under-five child suffers from around five episodes an year accounting for about 30-50% of visits to health facilities and for about 20-40% of admissions to hospitals (WHO, 1999). Acute respiratory illnesses (ARIs) are known for their ease of transmission from person to person and short incubation period. Symptoms include fever, cough, and often sore throat, coryza, shortness of breath, wheezing, or difficulty breathing. About 90% of the ARI deaths are due to pneumonia (mostly bacterial).

Childhood ARI/pneumonia is a significant public health problem in India with pneumonia accounting for approximately one-fourth of the total deaths in under-five children, in India. Pneumonia affects children irrespective of socioeconomic status. However, the incidence is higher among the poor; higher risk has been noted among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. A study on under-fives in Tripura has calculated the incidence of ARI as 23% in the urban area and 17.65% in the rural area, an overall mean incidence of 20.32%. The incidence of pneumonia was 16/1000 children and 5/1000 children in the urban and rural areas, respectively, with the incidence of pneumonia highest among infants. Immunization played a protective role against pneumonia. The relative risk for for respiratory infections in malnourished children as against the normally fed was found to be 2.3. Urban pollution was more related to bronchial asthma than to pneumonia. The study reports protective role of breast feeding against pneumonia and severe disease and links bottle-feeding to a greater risk of pneumonia. Children of lower socioeconomic status were at higher risk of ARI episodes, with ARI decreasing as per capita income increased (Deb, 1998)

A study done in a private, not-for-profit medical college hospital, in Vellore, India, in mid-2008 on children aged 2–36 months admitted with severe pneumonia with no underlying chronic disease reports total cost to health care provider for one episode of hospitalized childhood pneumonia treated at secondary level as US$ 83.89 (INR 3524) and US$ 146.59 (INR 6158) at tertiary level. At both levels the greatest single cost was the hospital stay itself, comprising 74% and 56% of the total cost, respectively with diagnostic investigations, supportive treatment with nebulization and oxygen therapy added to the costs. Mean household expenditure on secondary level was US$ 41.35 (INR 1737) and at tertiary level was US$ 134.62 (INR 5655), the largest single expense being medicines in the former and the hospitalization in the latter. (one US$=INR 42.1 at time of study) (Madsen et al, 2009).

The common aetiological agents for Acute Respiratory diseases are mostly viral viz., rhinovirus, respiratory syncytial virus, parainfluenza virus, severe acute respiratory syndrome-associated coronavirus (SARS-CoV) and influenza virus (WHO, 2007). . For community acquired pneumonia, Bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common aetiological agents. In-vitro resistance to cotrimoxazole has also been detected as high by researchers. (Mathew et al, 2011)

Among adults, community-acquired pneumonia (CAP) remains a common and serious illness despite the availability of potent new anti-microbials and effective vaccines. Pneumonia is increasingly common among older patients and those with co-morbidity like COPD, DM, renal failure, congestive heart failure, CLD and other conditions (Marrie et al, 1989). In the United States, pneumonia has been reported as the sixth leading cause of death from infectious diseases. Twenty percent cases require hospital admission and mortality ranges from 1-5% in OPD settings to upto 25% in ICU settings (Garibaldi, 1985) through ~14% for the in-patient wards (Shah et al, 2010). The problem is even more acute in the developing countries – pneumonia is the most common cause of hospital attendance in adults (Macfarlane, 1987). Poor prognostic factors at the time of admission are advanced age (>60 years), altered sensorium, respiratory failure, hypotension, leucocytosis, staphylococcus pneumonia and undetermined microbial etiology. Two major variables that influence the spectrum of etiologic agent and initial approach to therapy are the severity of initial presentation and presence of either co-existing illness or advanced age. Patients with severe community-acquired pneumonia (CAP) have different distribution of etiologic pathogens than those with other forms of pneumonia viz., hospital acquired pneumonia (HAP), and ventilator acquired pneumonia (VAP) or pneumonia in immune-compromised persons. Similarly, the presence of co-morbidity or advanced age can determine the likely pathogens involved (American Thoracic Society, 1993). Responsible pathogens are not identified in 50% of the patients even when extensive diagnostic tests are performed (Fang et al, 1990; Marrie et al, 1989). Studies from India have showed sputum culture positivity in 10-33% of patients (Kulpatti et al, 1980; Kulpatti & Kumar,1988; Sharma et al, 1988). The low sputum positivity is usually due to prior use of antibiotics, inappropriate sputum production and non-productive cough.

The bacteriological profile of community-acquired pneumonia is different in different countries and changing with time within the same country. This is probably due to indiscriminate use of antibiotics, changes in environmental pollution, increased awareness of the disease, changes in life expectancy (Shah et al, 2010) and better isolation tools. Streptococcus pneumoniae is the commonest organism for CAP leading to community acquired pneumonia in most parts of the world, including Delhi (Capoor et al, 2006) and Shimla (Bansal et al, 2004). Pseudomonas aeruginosa predominates as an etiological agent in blood culture positive CAP in Ludhiana (Oberoi et al, 2006).  Klebsiella pneumoniae was identified as the most common pathogen leading to admission to a medical intensive care unit in Singapore (Lee et al, 1996).   S. aureus usually complicates viral illness esp. influenza. E.coli may also be identified. It has been reported that old age, smoking and COPD impair pulmonary defenses and pre-dispose to CAP caused by gram-negative bacteria. Smoking, COPD, structural lung disease, diabetes mellitus, altered sensorium, and chronic alcoholism are the most common risk factors for pneumonia in adults.

Pneumonia is a common nosocomial infection. Hospital-acquired pneumonia (HAP) is associated with significant morbidity and mortality (upto 70%) and increased costs of treatment. Many of these deaths may be caused by ventilator-associated pneumonia (VAP), which is believed to be the most frequent infection in patients admitted to the intensive care unit (ICU). Nosocomial pneumonia is often difficult to treat. Pseudomonas species, Acinetobacter baumannii, MRSA and K.pneumoniae have been reported as the most common cause of HAP (Chawla, 2008).

Pneumonia may complicate the pulmonary functioning of immunocompromised. Among PLHA (people living with HIV-AIDS), Pneumocystis carinni pneumonia tends to occur when the CD4+ T-helper cell count falls below 200/microlitre and manifest with a dry cough with shortness of breath. person-to-person transmission has been suggested by hospital outbreaks of Pneumocystis carinni pneumonia (PcP) and by molecular epidemiologic analysis of isolates. Data suggest that the cyst is the transmissible form.

Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis and emphysema. Chronic bronchitis has been described as a productive cough for at least 3 months of each of 2 successive years for which other causes have been ruled out. Emphysema describes destruction of the lung architecture with enlargement of the airspaces and loss of alveolar surface area. Because COPD develops slowly, it is most frequently diagnosed in people aged 40 years or over.

COPD prevalence increases with age, smoking, pollution (indoor and outdoor) and exposure to vapours/chemicals/dusts in occupational settings. Frequent lower respiratory infections in the childhood have also been mentioned as a cause of COPD. Smoking increases the incidence and mortality and lung function loss. Cigar smokers are reported to have a 45% higher risk of COPD when compared to nonsmokers by some researchers but there are studies reporting a lower prevalence of COPD in pipe and cigar smokers (Olson et al, 1960; Higgins et al,1959; Robertson et al, 1969). The loss in function is dose-dependent with the number of cigarettes smoked and non-reversible to a great extent. On the contrary, whatever effect smoking has on cardiovascular functioning, is mostly reversible on quitting. Consequently, as many ex-smokers have quitted smoking now and prevalence of smoking in many countries is showing a declining trend, the cardiovascular death rates have fallen leading to identification of COPD as an increasing cause of death. In high and middle income countries, smoking is the most common cause of COPD while in the low income countries, exposure to indoor air pollution due to biomass fuel use in cooking is the main culprit. Thus, the prevalence of COPD is more in women in the East than West. At one time, COPD was more common in men, but because of increased tobacco use among women in high-income countries and the higher risk of exposure to indoor air pollution (such as biomass fuel used for cooking and heating) in low-income countries, the disease now affects men and women almost equally. (WHO, 2012).

According to WHO estimates, 65 million people have moderate to severe chronic obstructive pulmonary disease (COPD). More than 3 million people died of COPD in 2005, which corresponds to 5% of all deaths globally. Most of the information available on COPD prevalence, morbidity and mortality comes from high-income countries. Even in those countries, accurate epidemiologic data on COPD are difficult and expensive to collect. It is known that almost 90% of COPD deaths occur in low- and middle-income countries. Globally, COPD has been predicted by WHO to become the 3rd most leading cause of death by 2030. It is already the 5th leading cause of loss of ‘Disability Adjusted Life Years’ (DALYs) as per projection of the Global Burden of Disease Study (GBDS) (Murray & Lopez, 1997).

The burden of COPD in Asia is currently greater than that in developed western countries, both in terms of the total number of deaths and the burden of disease, as measured in years of life lost and the number of years spent living with disability, and is mainly linked to the epidemic of tobacco exposure and indoor and outdoor air pollution in Asian countries. (Lopez et al, 2006). Treatment aims in Asian countries are based on evidence-based management guidelines. Barriers to the implementation of disease management guidelines are related to issues of resource conflict and lack of organizational support rather than cultural differences in medical practice (Tan et al, 2008).

More than 12 million adults with COPD in India with prevalence rates varying depending upon the population studied and the methodology used. Lower prevalence of COPD has been reported from South India as compared to North India and in females as compared to males (ICMR-MRC, 2009). It has been seen that the prevalence among males is slightly increasing in trend (from 4.2% in 1970 to 4.9% in 1990s) while has been consistently same in females (2.7%) in India. The aggregate national health care costs of COPD has been estimated at Rupees 483 billion in 2016 (Murthy & Sastry, 2005).

 

Treatment cost of COPD (in Rs) per patient per year in India

(Murthy & Sastry, 2005)

 

The increasing epidemiological trend needs to be acknowledged and preparations should be made accordingly.

Bronchial asthma

Asthma is a syndrome characterized by airflow obstruction that varies markedly, both spontaneously and with treatment. Asthmatics have a hyperactive immune response than non-asthmatics to a wide range of triggers, leading to excessive bronchoconstriction with symptomatic wheezing and dyspnea. The increasing global prevalence of asthma, the large burden it now imposes on patients, and the high health care costs have led to extensive research into its mechanisms and treatment.

Asthma is the most common chronic disease among children and among the common chronic diseases for adults too, globally. According to WHO estimates, 235 million people suffer from asthma (WHO, 2012). Approximately 10–12% of adults and 15% of children are affected by the disease. Even as asthma may present at any age, it peaks at the age of 3 years with a male female ratio of 2:1(Barnes, 2012). As children grow the ratio becomes 1:1. In half the cases the onset is before 10 years of age. Asthma is thought to affect about 3% of the population in most countries. The highest prevalence (almost 30%) is found in New Zealand. The prevalence in a number of countries falls in the range of 10%–17% (Johnston & Holgate, 2003)

Asthma is not just a public health problem for high income countries: it occurs in all countries regardless of level of development. Over 80% of asthma deaths occurs in low and lower-middle income countries. The prevalence of asthma now seems to have stabilized after being on the rise in affluent countries for more than last 30 years In developing countries where the prevalence of asthma had been much lower, there is a rising prevalence, which is associated with increased urbanization. Genetic predisposition is the most common predisposing cause for asthmatics. Most patients with asthma in affluent countries are atopic, with allergic sensitization to the house dust mite Dermatophagoides pteronyssinus and other environmental allergens (Barnes, 2012).

Urbanization has been associated with an increase in asthma. According to the National Family Health Survey (NFHS 3), the prevalence of asthma in India was 1,600 persons / 100,000. (NFHS 3, 2007). The urban rural distribution has been shown in the table below:

 

The estimated case load of Asthma in India *

(Murthy & Sastry, 2005)

Estimates based on NFHS 2 (1998-99) data. Urban population taken as ~ 28% of total population

 

The fundamental causes of asthma are not completely understood. The strongest risk factors for developing asthma are a combination of genetic predisposition with environmental exposure to inhaled substances and particles that may provoke allergic reactions or irritate the airways, such as:

  • indoor allergens (for example, house dust mites in bedding, carpets and stuffed furniture, pollution and pet dander)

  • outdoor allergens (such as pollens and moulds)

  • tobacco smoke

  • chemical irritants in the workplace

  • air pollution.

Cold air, extreme emotional arousal such as anger or fear, and physical exercise can also precipitate attacks. Even certain medications can trigger asthma: aspirin and other non-steroid anti-inflammatory drugs, and beta-blockers (which are used to treat high blood pressure, heart conditions and migraine).

Deaths from asthma are uncommon, and in many affluent countries have been steadily declining over the last decade. The more widespread use of inhaled corticosteroids (ICS) in patients with persistent asthma is responsible for the decrease in mortality in recent years. Major risk factors for asthma deaths are poorly controlled disease with frequent use of bronchodilator inhalers, lack of corticosteroid therapy, and previous admissions to hospital with near-fatal asthma.

 

The economic burden of Asthma in India*

(Murthy & Sastry, 2005)

  • Calculated based on NFHS 2 (1998-99) data

 

Asthma is under-diagnosed and under-treated, creating a substantial burden to individuals and families and possibly restricting individuals’ activities for a lifetime. Case management protocols need to be defined and guidelines specified for use by all community based health workers. This can improve the quality of life of asthmatics and drastically reduce the cost. It has been noted that primary health care is a cost effective mechanism. This notion is applicable to the management of asthmatics at the grassroots. IEC activities and smoking cessation campaigns can also help.

Pulmonary Tuberculosis

Tuberculosis can affect almost any organ of the human body. The most common form of primary tuberculosis is pulmonary tuberculosis. The problem is huge in terms of morbidities and mortality in developing countries while developed countries are experiencing the resurgence of TB as a co-infection with HIV-AIDS after achieving a good control in the yesteryears. The WHO identifies TB as the greatest killer disease due to a single infectious agent, world-wide (WHO). In 2010, 8.8% contracted TB and 1.4 million died. Of all TB cases, 85% occur in South East Asia Region (34%), Africa (31%) and Western Pacific (20%) regions of WHO (WHO, Mar 2010). Over 95% of TB deaths occur in low- and middle-income countries, and it is among the top three causes of death for women aged 15 to 44. TB is the most common killer in HIV-AIDS and the synergism alongwith the advent of drug resistance, makes TB the most dreaded of all infectious diseases. The good news is that the incidence and mortality of TB has been showing a declining trend over the past few years and with strict implementation of DOTS the cure rate is also improving. Death rate under the Revised National Tuberculosis Control Programme has been reported to be around 4% among smear positive cases (GoI, 2010). In 2007, the cure rate of DOTS of 85% was exceeded for the first time (WHO, Feb 2010). The programmatic challenge is to bring all TB sufferers into the DOTS net and ensure complete cure.

India has the highest number of TB cases in the world (~20%)

TB infection (Mycobacteria tb) is mostly asymptomatic. However, as much as 10% experience a lifetime risk of developing active disease. However, immune-compromised persons, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a much higher risk of falling ill. Unlike the adult form, childhood tuberculosis is more likely to acquire disseminated form. The mortality amounts to almost two-thirds of all TB patients without proper medical care.

TB is more prevalent among adults of the economically productive age group (15-55 years) – more than 80% with almost 2/3rds of the cases occurring in males. However, almost over half of the cases in females occur before the age of 34 years (GoI TB India 2010). The implication is huge as it compromises fertility and prospects of a healthy pregnancy with added stigmatization. The most common source of spread is an open case of sputum positive pulmonary tuberculosis who spreads the infection to 10-15 persons annually. The spread is through droplet infection and nuclei that are formed during coughing and indiscriminate disposal of sputum and is higher to the immune-compromised and malnourished and is more likely to occur in the lower socio-economic groups, in overcrowded, poorly ventilated, warm and humid environments. It takes usually 3-6 weeks to develop a positive tuberculin from the time of receipt of the TB infection. Fomites do not transmit the infection. Moreover, the infection does not spread to all due to infection immunity rendered by past exposures. The most effective strategy to control TB is early diagnosis and treatment. It not just captures the active case but reduces his chances of transmission to healthy contacts. The infectivity is reduced by 90% within 48 hours of initiation of DOTS. The case finding in TB is through passive surveillance. It has been seen that over 60% of the cases seek medical advice on their own. With increased awareness campaigns and community support and networking, this proportion can be increased further. Cow’s milk has also been identified as a potential source of spread (especially for abdominal tuberculosis) but in India, milk is mostly boiled before consumption reducing the chance of spread.

The tuberculosis estimates for India for the year 2008 are available. With a total of 1181 cases, India is home to the maximum number of TB cases in the world. The annual incidence for all types of tuberculosis (pulmonary/ extrapulmonary and sputum positive and negative) has been reported as 170 per 1 lac population of which 75 are new smear positive cases. The prevalence of tuberculosis per lac population is 185 against the STOP TB target of 150. The annual mortality again exceeds the STOP TB target of 15 and is reported as 24. This highlights the challenge faced by DOTS for universalization. Primary multidrug resistance TB (MDR TB) is seen in 2% of the incident cases while with previously treated cases, it ranges from 12-17%. When these proportions are converted to absolute numbers, the count is huge and service upscaling task faced by India is gigantic.MDR cases are difficult to cure and the cost of treatment and associated complications are high. In recognition of these, the Government of India has decided to expand the DOTS PLUS centres across the country in the 12th Five Year Plan. MDR-TB services have already been extended to 14 more States thus now covering 24 States (GoI, 2011).

Childhood tuberculosis accounts for nearly 1/5th of all cases of TB in India. A case of childhood tuberculosis indicated that there are active open adult cases of tuberculosis in the community, someone with whom the child is in close contact. The active case needs to be captured failing which the permanent cure of the child is difficult. Unlike adults, children are rarely sputum positive and more likely to develop progress rapidly to active disease post infection. Clinical signs are non-suggestive and a chest x-ray might help. The BCG vaccination in children doesnot protect against M.tb infection. It only reduces the chance of complicated tuberculosis like TB meningitis and miliary tuberculosis. The most common age-group of childhood TB disease is within 1 to 4 years. Any symptomatic child with positive Monteaux (>= 10mm) is to be treated as a case. The BCG vaccination status of the child should be ignored in such instances. If the mother is a case, then the child should receive INH prophylaxis. According to WHO, tuberculosis would be declared as controlled in a population if the prevalence of natural infection in the 0-14 years age group is <1% (WHO, 1964).

For TB in people living with HIV-AIDS (PLHA), the challenges are different. PLHA show a higher rate of sputum negative tuberculosis. The affirmative diagnosis in such situations would demand a sputum culture which could take upto 6 weeks. With impaired immunity, the tuberculin skin test also fails in them. Lesser cavitation means decreased help from chest radiography. To add to the difficulty, the chance of extrapulmonary tuberculosis is higher in PLHA. With primary infection, these people progress more rapidly and frequently to active disease. Thus, these patients should be immediately treated failing which the mortality is high. Moreso, the chance of spread to others is noteworthy. People who are infected with both TB and HIV are 25-30 times more likely to develop active TB than people with just TB. The activation rate of dormant TB over the life span of an infected person is 10%. This rate is increased to the annual risk of 10% if co-infection with HIV exists. Thus, the strategy of cross-referral of patients is adopted between the TB clinic and the ICTC. The TB-HIV intensified package activities have been extended to 11 more States and now implemented in 22 States (GoI, 2011).

TB is considered as a social barometer. It not just indicates the socio-econo-sanitation status of the population and the effectiveness of the TB Control Programme but also hints at possible stigma and discrimination that is usually association. It has been estimated that each single case of TB in the Indian set-up leads to loss of 2-3 months of income. On an average, 3–4 months of work time are lost if an adult has TB, resulting in the loss of 20%–30% of annual household income. An average of 15years of income is lost if an individual dies of the disease (Government of India 2004b). Every year, TB costs India more than Rs 13,000 crore. In addition, every year, TB patients spend more than Rs 645 crore in seeking private care for TB. It has been estimated that if the GOI spent even US$ 200 million (Rs 900 crore) per year on effective implementation of Directly Observed Treatment, Shortcourse (DOTS), the tangible benefits to the Indian economy would be worth at least US$ 750 million per year (Rs 3375 crore) (WHO 2004). Special action needs to be taken for difficult-to-access communities, urban areas and migratory groups as the riskof drop-out and discontinuation of treatment is high in such groups.(Murthy & Shastry, 2005)

The flu pandemics

The world has seen recent killer pandemics caused by the influenza virus and India, too, is a witness to it. The WHO at one point of time in 2009 had sounded the higher level of alarm (Phase 6) for the H1N1 pandemic but later in August, 2010 announced that the disease has entered the post-pandemic phase. (WHO, 2010) India was commended for the prompt containment by the Secretary General of WHO, Margaret Chan, in her press release- In fact, the actions of health authorities in New Zealand, and also in India, in terms of vigilance, quick detection and treatment, and recommended vaccination, provide a model of how other countries may need to respond in the immediate post-pandemic period”.

The H1N1 strain had overtaken the spread of other strains of the influenza virus during the pandemic but now, the patterns have changed. The 15 different Hemagglutinin (HA or simply, H) antigen of Type A influenza form different combinations with 9 Neuraminidase (N) giving rise to many strains of potential flus. Vaccines are effective against the specific strain for which it has been prepared. The droplet spread, high infectivity, short incubation period and restricted spectrum for vaccines, make the spread rampant.

Oseltamivir proved an effective drug against H1N1 while vaccines are also available. The Indian Academy of Pediatrics recommends a live vaccine to be administered in the nostrils and an inactive vaccine to be given intramuscularly. (IAP)

The usually recommended prevention strategy for any acute respiratory infection is applicable to the H1N1 influenza as well viz., avoid overcrowding, put a handkerchief on the nose while sneezing, wash hands frequently and adequately, use a mask to protect yourself while in public gatherings (N95 masks) and isolate the patient till he recovers.

For infective aetiologies like TB, safe disposal of sputum (either bury or burn) is essential for preventing transmission apart from the above mentioned precautionary steps. Vaccines are available against many diseases transmitted through the respiratory route viz., diphtheria to pneumonia and should be strictly considered when indicated.

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Written by:

Dr.S .C Mohapatra, MD ( BHU ), MPHC (Liverpool),IAPSM,DYSc is former Professor and Head in Community Medicine, BHU and Coordinator of NTTC,IDSP,ICDS, Tele-Medicine and founder of UGC Centre For Population Education, Extension and Research (CEPRE) . He has been former HOD Community Medicine, Dean Faculty of Medicine and Health sciences, SGT University,Gurgaon. Presently he is working in IQAC as a Dean Academic Affairs in SGT University, Gurgaon.

He had 32 Projects and organized more than 100 Conferences, Seminars and workshops He has 182 Publications. He is Author of a Text Book “A Treatise in Health Management’.He has been an international committee member of Bhopal Gass Disaster and contributed Chapter in a book in Russian Language ‘Ku Integracji Krajow Baltyckich : Problem Katastrof’.He contributed Chapters in 21 books.He has been Governing Body Member/ Cosultant in 8 national bobies and Editorial Board member in 10 Indian and 7 International Journals.

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