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07 August 2009

Panic, Says Page 1; Don't, Says Edit

Screaming headlines declaring India's first 'swine flu' death followed by measured editorials advising people level-headedness, or the sight of people moving about masked followed by pacifying messages from doctors days later. Honey-I-Blew-Up-The-Kid has been the story of media's information management on the potential H1N1 worldwide pandemic, which in India is still merely an outbreak

When I left Frankfurt, Germany, I got on a deadly 747, and I am gonna go home on a deadly 747 and connect in Chicago, which happens to be a deadly airport, to get back to deadly Atlanta..." Daniel C Rutz, Global Health Communications Team Leader of the US Centers for Disease Control and Prevention, was reacting to the opening sentence of a report that had appeared in The Times of India, which said, "The deadly H1N1 swine flu virus continues to spread across school students in Delhi..."

Another report that had appeared in Mail Today found the "government in a tizzy" trying to handle the rising cases of the aforementioned variety of influenza. Does the sub-editor or his boss in the tabloid know how completely out of wits one should be to be in a tizzy? A reading of the report suggested no such extreme condition. There was merely a course correction in the governmental approach to tackling the outbreak.

An alternative vocation for the people who love to play with words is print advertising. So how would these editors fare as visualisers? They sure can sell FMCG, given their proclivity for Godzilla-style story headings. In a country where hundreds fall victim to terrorists' bombs and thousands of farmers commit suicide every year, they gave one (the first) death due to flu — the victim had acquired H1N1, but there was, till the time of reporting, no official confirmation she died of it — a 36-pt font size Page 1 headline!

We, the endlessly tolerant people of India, may have been numbed by the bombardment of reports of death on front page and prime-time television, but death due to a new cause still makes heads turn. This time, heads spun.

A discerning newspaper reader might infer that either Indians by and large do not appreciate the gravity of English words or the editors are plain lazy. From experience, this writer knows it's the latter. It sometimes gets frustrating for a reporter to see the person on the desk job trying to be unduly creative while assigning a title to his story, after just glancing through the submitted report. So, as Dan squirmed at reporters' lack of discretion, I told him he should have invited more editors than reporters to the workshop on H-N-subtype influenzas held at New Delhi's American Center on 27 July.

By representing the deaths in numbers, this writer intends no disrespect to Rida Sheikh's soul, or that of Fahmida Paanwala whose case got complicated due to diabetes and hypertension. The critique is aimed at the increasing lack of sense of proportion in India's media. It's not a malaise that is affecting television alone. The front page news editors want to be worthy competitors. And the result is visible in the streets of Pune. First, as prevention, they did not inform the people in the right measure; then, as cure, they psyched them! In the print medium, we have a saving grace in the form of The Hindu that qualified the report of the first death by adding "suspected" to "swine flu"; on TV there was none, not at least in the first three days after Rida's death.

Mercifully, after 53-year-old Fahmida died, one saw three doctors trying to allay fears on Times Now. For that matter, succeeding the report of the death in Pune, the editorials in all the newspaper this writer follows were found much better drafted, barring the Hindustan Times editorial, the premise of which was misplaced. The Hindu edit was again, expectedly many would say, bang on, the vital informative opinion being more useful as it was published a day before edits on the given topic in other newspapers. The only error in the piece was "swine-origin H1N1 flu virus". The expression was perhaps borrowed from the article by J Gowrishankar published on 2 July that said, "Known in the medical jargon as 'swine-origin Influenza A (H1N1) virus' (S-OIV), the swine flu agent is a novel variant of the influenza virus to which all of humanity represents a virgin (that is, immunologically susceptible) population." That's not accurate information.

Scientists entrusted with the nomenclature are now regretting the haste in which they named the disease as, though it may have crossed the species barrier by jumping from pigs to human beings, the pigs, in turn, had got the virus from birds. Aves in fact are the natural hosts to all H-N-subtype viruses including the so-called swine flu virus. Now it's wrong to call it swine flu also because the transmissions happening these days are human-to-human. If pork-eating were to cause it, Muslims and upper caste Hindus wouldn't have anything to worry. That's clearly not the case. The apparently providential coincidence that the first two Indian victims had to be Muslims rubs it in.

It's now tough to contain the panic. After all, more people read Page 1 than the edit page, and more are swayed by the sight of masked people roaming about the streets of Pune than that of three empanelled doctors saying, in effect, "Chill!" Social networking sites on the web are pleading with the government, "Do something!" Well, the government will do something if the situation merits it in the first place. Right now, the pressure to act is political, not medical. And the media is solely responsible for it.

Unease was growing in this writer for two months until this article couldn't wait any longer. A month ago, when television news channels reported 44 cases of 'swine flu' in the country, I wondered what the fate of a possible 44,000 cases of seasonal influenza would be. Yes, if you are careless about yourself and callous about others, and if the disease is left untreated, the ordinary flu can kill you too. Rarely, that is. That is exactly what H1N1 does. It can kill only if the patient is — or, in case of children, the parents are — ill-informed and careless, and they leave the disease untreated. If the incidents of cases are high in Pune, it's because, either ill-informed or callous, the people of the city went crazy watching the recent solar eclipse in massive crowds that certainly had participants carrying the viruses, both recessive and symptomatic.

The unease worsened the next day when the editor of a prominent weekly insinuated on Twitter that the section of the media that was spreading the scare might be colluding with pharmaceutical companies that produce medicines for the flu. Indeed, the news television channel he heads, going against its general behavioural pattern, refrained from hyperbole in the case of the novel flu. But following the second death, this time in Mumbai, it must have feared losing the scaremongering competition, it seemed last evening (8 August).

In the CDC workshop, this writer brought up the issue of alleged media-pharmaceutical company nexus. Dan didn't make much of the conspiracy theory. But he defended the "noble profession" of medical practitioners and did not comment on the business of pharmacists.

The suspicion remains. Given the non-biological background of most editors, chances are higher that the media inadvertently became a part of the game. But was everything as innocent with the last government? The manner in which the last health minister of the country splurged, buying Tamiflu, in the wake of the Avian influenza outbreak, was puzzling. More so as, being a doctor himself, Anbumani Ramadoss should have known that sitting on a stockpile of the medicine he was importing made no sense. The drug oseltamivir phosphate, developed originally by Gilead Sciences and marketed by Hoffmann-La Roche under the trade name Tamiflu, is effective only when administered at a crucial time after a patient is infected: It must be taken within 12 to 48 hours from the first appearance of flu symptoms. So, how many patients did the state hope it could rush to, all at the respective critical timings? Mind you, it was a tougher call as the bird flu outbreak had happened in patchy clusters of villages, not well-structured urban locales.

As for the drug manufacturer's social responsibility, it must not put in fine print the 1% cases of side effects; the percentage is not medically insignificant. Patients should be told that so many of participants in Tamiflu's clinical trials had complained of nausea, vomiting, diarrhoea, abdominal pain and headache. Though rarer, other adverse drug reactions should also be known: hepatitis, sudden spurt in the production of liver enzymes, rash, allergic reactions including anaphylaxis* and Stevens-Johnson syndrome (a fatal skin disease). The side-effects are sought to be played down in the product literature issued by Roche.
* Anaphylaxis is an acute, multi-system and severe hypersensitivity allergic reaction.
Moreover, a vital component of relevant information is not being highlighted enough: Influenza viruses change over time. If the H1N1 virus or any other H-N-subtype virus, which is being subjected to the drug, mutates or the causative agent turns more virulent, it might diminish the clinical benefit of any antiviral drug; Tamiflu is no exception.
As of now, India has a stock of 10 million capsules of oseltamivir. Some stocks are also committed by pharmaceutical companies for exclusive use by government. This drug is only available through the public health system and its retail sale is banned as indiscriminate use may lead to development of resistance. If there is widespread infection, the Ministry of Health and Family Welfare will review the decision.
Unfortunately, however, as Health Minister Ghulam Nabi Azad says, Tamiflu is probably the best we have besides the neuraminidase inhibitor* that was developed before it, Zanamivir, which was developed by Dr Peter Colman and is marketed by GlaxoSmithKline under the trade name Relenza. But then, that is not the point. Why hoard what may not be necessary, is. A hundred thousand tablets despatched to affected parts of the country — that's a monumental waste necessitated by two things: paranoia created by the media and a probable effort on the part of UPA Government-II to justify an action of UPA Government-I.
* A neuraminidase inhibitor is an antiviral drug that attacks such flu viruses that block the function of the viral neuraminidase protein; this stops the virus from multiplying.
A viral neuraminidase is an enzyme on the surface of an influenza virus that enables its release from the host cell. If this releasing act is stopped, the virus's 'reproduction' is contained.
It's normal that most people do not have these details. Having heard about Tamiflu and hardly anything more, they are rushing to government hospitals demanding stocks of the drug (and when not obliged, fuming with rage at the government). This factor, which is causing the panic, is more a cause for concern than the disease, the fatality rate of which is much less than that in bird flu caused by H5N1.

That the masses at large are ignorant is witnessed also in the now-ubiquitous masks around the few hospitals designated by government to diagnose and treat the disease in Pune and Ram Manohar Lohia Hospital in Delhi. A chance glimpse of a masked man rubbing his eyes with his fingers on our TV screen showed his information is incomplete. If his hands have been exposed to the H1N1 virus, and have not been cleaned thereafter, it could get into his body even through the eyes.

The situation warrants nothing but a massive awareness campaign. Now. Thankfully, the language used in the Indian media and the tenor of speech have begun showing gradual improvement.

It would help further if we desist from our incorrigible habit of finding a whipping boy in the government. This government is not guilty of under-performance; rather, it's saner than its predecessor that over-performed while ordering the antidote.

Why private hospitals are not being authorised for the prognosis, diagnosis and treatment is an undue question. One, it's beyond their wherewithal. Two, health care, especially of this nature, involves a certain degree of pro-active philanthropy (socialism, if you will). Are private hospitals ready for it? Will they voluntarily, as the WHO guidelines expects of governments, maintain and study statistics of "cluster(s) of cases of unexplained ILI (Influenza-like Illness) or acute lower respiratory tract infection, severe, unexplained respiratory illness, changes in the epidemiology of mortality associated with the occurrence of ILI or lower respiratory tract illness, an increase in the number of deaths observed from respiratory illness or an increase in the occurrence of severe respiratory disease in previously healthy adults or adolescents and/or among pregnant women, or abnormally high levels of absenteeism in a school or workplace setting"?

Being a member country of the WHO entails that we keep the UN agency updated on health statistics as a responsible constituent of the world. To that end, government is required to notify the WHO immediately...
  • any changes in the epidemiological, virological or clinical presentation that are likely to be of significance for global risk assessment;
  • any unusual or unexpected public health events, including clusters of severe unexplained acute respiratory illness or unexplained deaths due to respiratory disease, and
  • the ever-fluctuating mortality data ‐‐ the number of deaths due to acute respiratory disease (by age group if available).
If a plethora of private hospitals are in the fray, diagnosing and treating the disease, it will become a Herculean task to manage the data.

What's more important, health care offered by the Indian private sector may dazzle with spic-and-span nursing homes and smart receptionists, but they are nowhere in sight in the horizon of serious medical research. Entrusted with the onerous task of tackling a pandemic, they will be all at sea. The training of private medical practitioners by the National Institute of Virology, Pune, will be time consuming; by that time, for all we know, the virulence of the disease's causative agent may subside or disappear altogether. And the WHO's demand for coordination with it, when data from the private participants will have to be updated regularly, will turn the government from the welfare manager that it currently is into an over-tasked statistician. No prizes for predicting, people — provoked once again by the media — will blame the authority for that too.

Yet another problem with private participation in tackling the spread of the disease has been highlighted by the spat between the health minister and Rida Sheikh's family. With a broader national perspective, Azad was within his rights to remark that the deceased girl, going around in private clinics seeking treatment, might have spread the disease to several other people. While one can sympathise with the mental frame of the members of bereaved family, such a family cannot naturally be expected to appreciate hard, scientific truths right in the wake of the loss of their dear one. The fourth estate would be wrong if it were to use their grievance as a weapon to target the government, which has faltered only on one count: not spreading enough awareness about the H1N1 virus among the masses. The specific complaint of the Sheikh family that can be looked into is why no visible action has been taken on their FIR against the directors of Ruby Hall Clinic and Jehangir Hospital and Dr Sanjay Agarwal of Jehangir Hospital.

The only domain where a few private players have been identified by the government to be competent is vaccine development (ref: Q&A towards the end of this post).

In short, the government is equipped to handle the situation and is working in adequate measure. If its performance seems leaving a lot to be desired, blame the inflated sense of fear that has gripped society due to irresponsible journalism. It may be noteworthy for the media that the CDC has stopped counting the cases of H1N1 as even subjects that show no symptom could be carrying the disease. It's for the same reason that airport screening too will not be effective. Just like in cases of seasonal flu, a patient may begin infecting others a day before he develops symptoms to up to 7 days after he gets sick. Children, especially younger children, might stay contagious for longer periods.

To fight novel H1N1, you need not be a technical genius. If you are sick for a week or longer, stay home and keep away from others as much as possible; avoid travel, going to work or school for at least 24 hours after your fever is gone except to get medical care or for other necessities. "Your fever should be gone without the use of fever-reducing medicine," advises CDC.
The Government of India advisory:
Under the new guidelines, any person with flu like symptoms such as fever, cough, sore throat, cold, running nose etc. should go to a designated government facility for giving his/her sample for testing for the H1N1 virus. After clinical assessment, the designated medical officer would decide on the need for testing. Except for cases that are severe, the patient would be allowed to go home (This was not allowed under the existing guidelines).
The sample of the suspect case would be collected and sent to the notified laboratory for testing. If tested as positive for H1N1 and in case the symptoms are mild, the patient would be informed and given the option of admission into the hospital or isolation and treatment at his own home.
In case the patient opts for home isolation and treatment, he/she would be provided with detailed guidelines/safety measures to be strictly adhered to by the entire household of the patient. He/she would have to provide full contact details of his entire household. The house hold and social contacts would be provided with the preventive treatment.
Notwithstanding the above guidelines, the decision of the doctor of the notified hospital about admitting the patient would be final.
In case the test is negative, the patient will accordingly be informed.
These guidelines have been issued by the Government in public interest and shall be reviewed from time to time depending on the spread of the pandemic and its severity in the country. These guidelines would however not apply to passengers who are identified through screening at the points of entry. The existing policy of isolating passengers with flu like symptoms would continue.
The unaffected, instead of crowding government hospitals in a state of panic, should do something as commonplace as wash hands regularly. If you happen to be in a village with scarce amenities, rub your hands with ash when soap is not available. One with quirks of digging the nose, rubbing the eyes and cleaning the teeth with nails after a sumptuous meal must get over such idiosyncrasies immediately; if he is not bothered by onlookers finding such behaviour repulsive, he should at least be bothered about his health.

The writer, Surajit Dasgupta, is a health journalist and, since July 2009, the chief editor of CII's life sciences journal Pharma Communiqué. He is seen in the photograph below, standing next to CDC's Daniel Rutz. Also seen are journalists from news agencies and regional newspapers. Health beat journalists of all prominent national newspapers, except The Hindu, were conspicuous by their absence in the meet though the American Center had sent invites to all of them. The workshop on H-N-subtype influenzas began at 11:30 am and ended before 1:00 pm, not a rush hour for print media journalists

Shockers more, shockers galore:

To put the record straight...
(Courtesy: CDC, WHO, ICMR, MoHFW)

What is novel H1N1 (swine flu)?
Novel H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people. This new virus was first detected in people in the United States in April 2009. This virus is spreading from person-to-person worldwide, probably in much the same way that regular seasonal influenza viruses spread. On June 11, 2009, the World Health Organization (WHO) signaled that a pandemic of novel H1N1 flu was underway.

Why is novel H1N1 virus sometimes called “swine flu”?
This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs (swine) in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and bird (avian) genes and human genes. Scientists call this a "quadruple reassortant" virus.

Is novel H1N1 virus contagious?
Yes. It is contagious and is spreading from human to human.

How does novel H1N1 virus spread?
Spread of novel H1N1 virus is thought to occur in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing by people with influenza. Sometimes people may become infected by touching something – such as a surface or object – with flu viruses on it and then touching their mouth or nose.

What are the signs and symptoms of this virus in people?
The symptoms of novel H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. A significant number of people who have been infected with this virus also have reported diarrhoea and vomiting. Severe illnesses and death has occurred as a result of illness associated with this virus.

How severe is illness associated with novel H1N1 flu virus?
Illness with the new H1N1 virus has ranged from mild to severe. While most people who have been sick have recovered without needing medical treatment, hospitalizations and deaths from infection with this virus have occurred.

In seasonal flu, certain people are at “high risk” of serious complications. This includes people 65 years and older, children younger than five years old, pregnant women, and people of any age with certain chronic medical conditions. About 70 percent of people who have been hospitalized with this novel H1N1 virus have had one or more medical conditions previously recognized as placing people at “high risk” of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease.

One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of novel H1N1-related complications thus far. CDC laboratory studies have shown that children and few adults younger than 60 years old do not have existing antibody to novel H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus. It is unknown how much, if any, protection may be afforded against novel H1N1 flu by any existing antibody.

How does novel H1N1 flu compare to seasonal flu in terms of its severity and infection rates?
With seasonal flu, we know that seasons vary in terms of timing, duration and severity. Seasonal influenza can cause mild to severe illness, and at times can lead to death. Each year, in the United States, on average 36,000 people die from flu-related complications and more than 200,000 people are hospitalized from flu-related causes. Of those hospitalized, 20,000 are children younger than 5 years old. Over 90% of deaths and about 60 percent of hospitalization occur in people older than 65.

The novel H1N1 flu has caused greater disease burden in people younger than 25 years of age than older people. At this time, there are few cases and few deaths reported in people older than 64 years old, which is unusual when compared with seasonal flu. However, pregnancy and other previously recognized high risk medical conditions from seasonal influenza appear to be associated with increased risk of complications from this novel H1N1. These underlying conditions include asthma, diabetes, suppressed immune systems, heart disease, kidney disease, neurocognitive and neuromuscular disorders and pregnancy.

How long can an infected person spread this virus to others?
People infected with seasonal and novel H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after. This can be longer in some people, especially children and people with weakened immune systems and in people infected with the new H1N1 virus.

Isn't the death rate alarming?
It's certainly a cause for concern, but there is no reason for alarm. The fear factor got augmented by the fact that the H1N1 virus was identified just recently (April 2009) and many people died because they were caught unaware. Even then, those who died constitute a minuscule percentage of all those who were infected.
The characteristics of the novel (new) virus are still not fully known. However, what is certain, the mortality rate is quite low. Death by this flu can be altogether avoided if everybody is made aware of the disease, if people take precautions that are necessary and get themselves treated if they suspect they are affected, without wasting time.

What is the strategy of the Government of India to tackle the outbreak of the H1N1-associated influenza?
The details are available on the website of the Ministry of Health & Family Welfare. You may download the first three documents on top of the website's page and keep them as ready reckoners.

Prevention & Treatment
What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against novel H1N1 virus. However, a novel H1N1 vaccine is currently in production and may be ready for the public in the fall. As always, a vaccine will be available to protect against seasonal influenza. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza.

Take these everyday steps to protect your health:
  • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
  • Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners* are also effective.
  • Avoid touching your eyes, nose or mouth. Germs spread this way.
  • Try to avoid close contact with sick people.
  • If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Keep away from others as much as possible to keep from making others sick.
Other important actions that you can take are:
  • Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.
  • Be prepared in case you get sick and need to stay home for a week or so; a supply of over-the-counter medicines, alcohol-based hand rubs,* tissues and other related items might could be useful and help avoid the need to make trips out in public while you are sick and contagious
When will the vaccine be available?
It takes approximately five to six months for the first supplies of approved vaccine to become available once a new strain of influenza virus with pandemic potential is identified and isolated. These months are needed because the process of producing a new vaccine involves many sequential steps, and each of these steps requires a certain amount of time to complete. The vaccine development process from start (obtaining a virus sample) to end (availability of vaccine for use) involves: Identification of a new virus, preparation of the vaccine strain (called vaccine virus, verification of the vaccine strain, preparation of reagents to test the vaccine (with reference reagents), optimization of virus growth conditions, vaccine bulk manufacture, quality control, vaccine filling and release, clinical studies and regulatory approval.
In a best case scenario, the first final pandemic vaccine lot would be available for distribution and use in another six months.

By when will Indian researchers be ready with a vaccine? In case we are late, shall we import it from the country that produces it first?
The Indian Council for Medical Research (ICMR) has taken the initiative to fast-track the indigenous production of an H1N1 vaccine in the country. In this regard, the ICMR is presently identifying prospective investigators to undertake phase-I and/or phase-II trials of the vaccine which is being developed by three Indian biotech companies. So far, the government has granted licences for the H1N1 vaccine to three companies, Serum Institute of India, Panacea Biotec and Bharat Biotech and the preventive vaccine against the H1N1 flu is expected to be ready for clinical trials in humans by December.
As India has also joined the international community's effort to make a vaccine for the H1N1 pandemic that has affected 135 countries in the world, it has to identify labs to conduct the human trials as early as possible. The government is not restricting its search for labs to government sector alone. It is an open call for all including the private sector to join the government effort to fast track the indigenous development of the swine flu vaccine in the country.
The difference between the tentative dates by which the anti-H1N1 virus vaccine is expected to be ready in any medically advanced country and India is of just one month. Given this scenario, India may not import the vaccine, unless there is a valid concern that Indian scientists might take much longer to develop it.

What is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick with flu-like illness, stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.)
Keep away from others as much as possible. Cover your mouth and nose with a tissue when coughing or sneezing. Put your used tissue in the waste basket. Then, clean your hands, and do so every time you cough or sneeze.

If I have a family member at home who is sick with novel H1N1 flu, should I go to work?
Employees who are well but who have an ill family member at home with novel H1N1 flu can go to work as usual. These employees should monitor their health every day, and take everyday precautions including washing their hands often with soap and water, especially after they cough or sneeze. Alcohol-based hand cleaners are also effective. If they become ill, they should notify their supervisor and stay home.
Employees who have an underlying medical condition or who are pregnant should call their health care provider for advice, because they might need to receive influenza antiviral drugs to prevent illness. For more information please see General Business and Workplace Guidance for the Prevention of Novel Influenza A (H1N1) Flu in Workers.

What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water or clean with alcohol-based hand cleaner*. When you wash your hands -- with soap and warm water -- wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.
If you are in a remote human settlement where neither soap nor any other industry-manufactured sanitiser is available, rub your hands with ash.

What should I do if I get sick?
If you live in areas where people have been identified with novel H1N1 flu and become ill with influenza-like symptoms, including fever, body aches, runny or stuffy nose, sore throat, nausea, or vomiting or diarrhoea, you should stay home and avoid contact with other people. You should stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Stay away from others as much as possible to keep from making others sick.Staying at home means that you should not leave your home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings.

If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed.

If you become ill and experience any of the following warning signs, seek emergency medical care.

In children, emergency warning signs that need urgent medical attention include:
  • Fast breathing or trouble breathing
  • Bluish or gray skin color
  • Not drinking enough fluids
  • Severe or persistent vomiting
  • 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
In adults, emergency warning signs that need urgent medical attention include:
  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion (disorientation about time and space)
  • Severe or persistent vomiting
  • Flu-like symptoms improve but then return with fever and worse cough
Are there medicines to treat novel H1N1 infection?
Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with novel H1N1 flu virus. Antiviral drugs are prescription medicines (pills, liquid or an inhaled powder) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current pandemic, the priority use for influenza antiviral drugs during is to treat severe influenza illness (for example hospitalized patients) and people who are sick who have a condition that places them at high risk for serious flu-related complications.

What are "swine flu parties"?
They are gatherings during which people have close contact with a person who has novel H1N1 flu in order to become infected with the virus. The intent of these parties is for a person to become infected with what for many people has been a mild disease, in the hope of having natural immunity novel H1N1 flu virus that might circulate later and cause more severe disease.

CDC does not recommend "swine flu parties" as a way to protect against novel H1N1 flu in the future. While the disease seen in the current novel H1N1 flu outbreak has been mild for many people, it can be severe and even fatal for those affected by other medical conditions. There is no way to predict with certainty what the outcome will be for an individual or, equally important, for others to whom the intentionally infected person may spread the virus.

It is recommended that people with novel H1N1 flu avoid contact with others as much as possible. If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Stay away from others as much as possible to keep from making others sick.

Contamination & Cleaning
How long can influenza virus remain viable on objects (such as books and doorknobs)?
Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface.

What kills influenza virus?
Influenza virus is destroyed by heat (167-212°F [75-100°C]). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols are effective against human influenza viruses if used in proper concentration for a sufficient length of time. For example, wipes or gels with alcohol in them can be used to clean hands. The gels should be rubbed into hands until they are dry.

What if soap and water are not available and alcohol-based products are not allowed in my facility?
Though the scientific evidence is not as extensive as that on hand washing and alcohol-based sanitizers, other hand sanitizers that do not contain alcohol may be useful for killing flu germs on hands.
(CDC officers at work in Indian villages recommend the use of ash as a cleanser.)

What surfaces are most likely to be sources of contamination?
Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk, for example, and then touches their own eyes, mouth or nose before washing their hands.

How should waste disposal be handled to prevent the spread of influenza virus?
To prevent the spread of influenza virus, it is recommended that tissues and other disposable items used by an infected person be thrown in the trash. Additionally, persons should wash their hands with soap and water after touching used tissues and similar waste.

What household cleaning should be done to prevent the spread of influenza virus?
To prevent the spread of influenza virus it is important to keep surfaces (especially bedside tables, surfaces in the bathroom, kitchen counters and toys for children) clean by wiping them down with a household disinfectant according to directions on the product label.

How should linens, eating utensils and dishes of persons infected with influenza virus be handled?
Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first.
Linens (such as bed sheets and towels) should be washed by using household laundry soap and tumbled dry on a hot setting. Individuals should avoid “hugging” laundry prior to washing it to prevent contaminating themselves. Individuals should wash their hands with soap and water or alcohol-based hand rub immediately after handling dirty laundry.

Eating utensils should be washed either in a dishwasher or by hand with water and soap.

Exposures Not Thought to Spread Novel H1N1 Flu
Can I get infected with novel H1N1 virus from eating or preparing pork?
No. Novel H1N1 viruses are not spread by food. You cannot get infected with novel HIN1 virus from eating pork or pork products. Eating properly handled and cooked pork products is safe.

Is there a risk from drinking water?
Tap water that has been treated by conventional disinfection processes does not likely pose a risk for transmission of influenza viruses. Current drinking water treatment regulations provide a high degree of protection from viruses. No research has been completed on the susceptibility of novel H1N1 flu virus to conventional drinking water treatment processes. However, recent studies have demonstrated that free chlorine levels typically used in drinking water treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination. To date, there have been no documented human cases of influenza caused by exposure to influenza-contaminated drinking water.

Can novel H1N1 flu virus be spread through water in swimming pools, spas, water parks, interactive fountains, and other treated recreational water venues?
Influenza viruses infect the human upper respiratory tract. There has never been a documented case of influenza virus infection associated with water exposure. Recreational water that has been treated at recommended disinfectant levels does not likely pose a risk for transmission of influenza viruses. No research has been completed on the susceptibility of novel H1N1 influenza virus to chlorine and other disinfectants used in swimming pools, spas, water parks, interactive fountains, and other treated recreational venues. However, recent studies have demonstrated that free chlorine levels recommended by CDC (1–3 parts per million [ppm or mg/l] for pools and 2–5 ppm for spas) are adequate to disinfect avian influenza A (H5N1) virus. It is likely that other influenza viruses such as novel H1N1 virus would also be similarly disinfected by chlorine.

Can novel H1N1 influenza virus be spread at recreational water venues outside of the water?
Yes, recreational water venues are no different than any other group setting. The spread of this novel H1N1 flu is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

[Click on the headline for a December 2007 overview of how flu-related stories should be handled by journalists]


Dsylexic said...

well, not sure if you know that there was a similar swine flu media-cum-govt hype in 1976. its deja vu all over again for people who can recall that more people died from the side effects of a vaccine administered then than the actualy virus.

nassim taleb is right when he says that human brains cannot understand risks on a relative basis.we tend to underweight 'small' risks that can cause serious damage (crossing road carelessly) while hyping up stuff like the swine flu.

i wouldnt rule out a concerted campaign by tamiflu makers behind keeping this hype going.

swati said...

One needs only to look to our neighbor, China, to see the ill effects of indiscriminate drug use. In the last avian influenza outbreak of the H5N1 virus, the Chinese government prescribed the use if the anti-viral amantidine to chickens in a bid to curb the spread of the virus from birds to humans. The resultant was a virus resistant to the most ... Read Morecommonly available and cheapest drug amantadine, and human infections had to resort to pricier and less widely available oseltamivir and zanamivir.

I only hope that the present government, goaded on by an irresponsible media, is not inspired to take any rash measures.

Anonymous said...

Your admiration for Times Now is inexplicable. Even after rightly chastising much of the Indian media for the panic they have succeeded in generating, you point out that it was on Times Now that doctors made clarifications, conveniently ignoring the spectacular hue and cry raised by its infamous and supercilious anchor. You forget that the only channel that has pointed out the symptoms and precautions while putting things in perspective and mentioning the similarities with a common flu, is NDTV 24/7, albeit aided by it's anchor's tendency to adopt a stance and then use his channel as a bully pulpit. A trait that is shared by the hopelessly annoying Goswami chap. The picture you have provided tells you a story. Every death is being seen as breaking news. Shameful that the Times group would allow their televised product to fall into such inept and puerile hands. Someone needs to stop that buffoon.

suneeta said...

The post is as comprehensive as it could get. Thus far, the best post in the blog.

Surajit Dasgupta said...

The language used in the post by 'Anonymous' is, hazarding a reasonable guess, that of a journalist. If it's of an employee of NDTV 24x7, I won't be surprised. I wish such scribes are truthful enough to stick their necks out instead of shooting from behind the veil of anonymity. You do not call a peer a "buffoon" and not let him get even with you.

Yes, Arnab Goswami's interventions are indeed annoying. And they are irritating perhaps because they are not smart. Or else, no TV news channel, not even NDTV 24x7, trails in the competition for undue interruptions. They are all biased and a majority is laden with left-of-centre prejudice. Times Now may, however, look out of place because it attempts political neutrality desperately.

But did I praise the Goswami-led channel? I don't remember doing so. I read my own passage again to check if I was suffering from selective amnesia. My lines are/were: "... In the print medium, we have a saving grace in the form of The Hindu that qualified the report of the first death by adding 'suspected' to 'swine flu'; on TV there was none, not at least in the first three days after Rida's death."

"Mercifully, after 53-year-old Fahmida died, one saw three doctors trying to allay fears on Times Now."

This is true to the best of my knowledge. And this is a mere statement of fact, not an encomium. What is not a fact is the hidden journo's statement, "... the only channel that has pointed out the symptoms and precautions while putting things in perspective and mentioning the similarities with a common flu, is NDTV 24x7,..."

"Only"? That's not true. Now every commentator is trying his/her hand at sanity and sense. But till the death of Fahmida Paanwala, none did. And most certainly, NDTV 24x7, the channel I was watching first that evening, didn't. I switched to Times Now, which I admittedly find a less evolved channel than NDTV 24x7 on other counts, only after finding no medical clarifications issued by Prannoy Roy's channel with respect to the latest death for the newsy reason. Of course, a day later, you've had some good interviews with doctors, enlightening the viewers on the disease.

I seize this opportunity to appeal to all editors of the mainstream media to do one more favour to the country, now that they have shunned panic and entered the phase of counselling people. Stop counting the dead. What objective do you think is being met by the display of those morbidly scary numbers? Will your pacifying advices succeed in striking a chord if the 'death population clock' keeps ticking prominently in your headlines?

The only medium my article praises is The Hindu. Sadly, the said newspaper too is counting the dead on Page One.

newnimproved said...

By Dr Mercola

A New Swine Flu Vaccine is Coming

In June 2009, the World Health Organization raised the level of the swine flu pandemic alert from phase 5 to phase 6, their highest warning level that indicates a pandemic capable of widespread human infection.

As I predicted in my first swine flu alert (which was the most popular one I ever published), a fast-tracked swine flu vaccine was promptly ordered, and will be available as early as this month.

Although many governments and health organizations are probably celebrating this feat, just as they did back in 1976, you have no reason to join in the festivities. In fact, you have good reason to fear being exposed to this new swine flu vaccine more than the swine flu itself.

You are virtually guaranteed that no safety evaluations will be performed prior to the reckless unleashing of this untested vaccine, and if history repeats itself (as it so often does), it could potentially be the cause of countless permanent injuries and deaths.

Making matters worse, there is a campaign underway to turn schools into virtual vaccination clinics, and children will be the first to be injected with experimental swine flu vaccines.

As in the past, health officials are positioning this mandatory vaccination as a panacea to prevent "explosive outbreaks" of the swine flu. But if you dig even slightly below the surface you easily find that the swine flu is often times very mild.

Should You be Afraid of the Swine Flu Pandemic?

Now that the swine flu is officially being called a pandemic, it conjures up images of overflowing hospitals and people wearing protective masks just to avoid becoming the next statistic.

In reality, the word 'pandemic' only means that a new virus is spreading across the world. It says nothing about its level of physical danger. That level of severity, according to The World Health Organization, is only “moderate.” And they go on to say:

“On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery, often in the absence of any form of medical treatment.

Worldwide, the number of deaths is small. Each and every one of these deaths is tragic, and we have to brace ourselves to see more. However, we do not expect to see a sudden and dramatic jump in the number of severe or fatal infections.”

To put matters even more into perspective, the swine flu has claimed a mere 429 lives WORLDWIDE (as of July 15), while the regular flu (not the swine flu) has allegedly killed 13,000 in the United States since January (although there is strong support that even these types of figures are grossly exaggerated to increase vaccine sales).

So the fact remains that the regular flu at this point in time is FAR more dangerous than the swine flu, and were you worried about the regular flu before the media started hyping up this exotic new "killer flu"?

Just like in 1976, today there is clearly a lot of fear-mongering going on, fear-mongering that has a noticeable subplot -- preparing you for draconian measures to combat a future pandemic as well as forcing you to accept the idea of mandatory vaccinations.

This is not the time to fall for hype. These public scare-tactics are designed to make money, not protect your health.

So I urge you to review the vast supply of information available on the National Vaccine Information Center (NVIC) Web site, and join Barbara Loe Fisher in her urging to take action against the potential threat of mandatory swine flu vaccinations.

Surajit Dasgupta said...

If I am permitted some metaphysical indulgence here, I would call a vaccine the pharmacological equivalent of the maxim, ‘two wrongs make a right’. That is to say that a vaccine makes your body fight an evil foreign body by introducing another evil (but milder) foreign body, so that you develop antibodies by the time the real enemy strikes. In that case, if the real enemy never strikes, your being ‘poisoned’ by the doctor serves no purpose of yours; it just adds up to the doc’s bill, a part of which would serve the manufacturer and marketer of the ‘poison’ aka vaccine!

Having said so, however, it must be added that in the comment above, the scare scenario interpreted from the past and extrapolated to paint a grim picture of the future is taking things a bit too far. Those who romanticise science wouldn’t know that none of the several types of vaccines that may be administered to us is capable of killing somebody unless he/she is a special medical case (i.e., already ridden with several debilitating diseases).

If the vaccine given to you is a killed micro-organism, it cannot kill you. If the vaccine given to you is attenuated — that is, it comprises live micro-organisms cultivated in labs in a way that leaves them with no virulence — it cannot kill you either. If it is a toxoid, it can’t kill because the toxicity of the compound was inactivated before it was injected in your vein. If it’s a protein subunit, your body will, in due course, balance the surplus by absorbing a part of it, excreting another and extracting from your food other components to negate the effect. If the vaccine is a protein linked to a bacterial polysaccharide coat, your body will ‘think’ it’s an antigen and fight it. The possibility of using recombinant vectors, DNA vaccination or the T-cell receptor approach is ruled out to target the H1N1. So tell me, ‘Dr Mercola’ (alias Sunil Shibad), what is the kind of vaccine that kills (normal, healthy people)?

Where you are right is in citing an example that establishes the fact that — I quote Dr AK Banerjee, chairman, National Pharmaceutical Pricing Authority, whom I interviewed last month — "pharmaceutical companies are not producing what most people need or can pay for; they are producing what a niche segment of customers will pay for, whatever be the price". Indeed, though poverty is a problem for a large section of India, the government of the country is virtually free to spend from its treasury on any good that catches its whim (unless the issue threatens to turn into an electoral plank to be exploited by the opposition). That makes the GoI a rich customer, one that any multi-national pharmaceutical company would fancy having in its targeted, niche market segment.

At the price of $81.99 for 10 capsules of 75 mg each, 10,000,000 Tamiflu capsules sure is good business for Roche.

Surajit Dasgupta said...

This gives me an opportunity to correct what I had written earlier about media bias. No, the entire media is not left-of-centre (Oops, what a slip!). That was too prompt a reaction to the holier-than-thou NDTV fan. However, biased they all are.

Much of the Indian media positions itself as left-of-centre only vis-à-vis the religion-politics mix. With respect to economics, the bulk of the media now is right-of-centre verging on the extreme right: ‘the market is god, it cannot be wrong, blah’. What both sides in the debate conveniently overlook is the fact that the market is still not free; it never was; perhaps it never will be (except in politically less significant countries like Switzerland). So, each time people appear financially troubled, the socialist commentator claims to have been prescient, claiming, ‘I told you so; it (the market) won’t work.’ And the capitalist commentator, to stay relevant to the context of this debate, has long forgotten that the pre-1 January 2005 promise of competition in the market of medicinal drugs has not been honoured; yet he conveniently refuses to raise the issue because to him, ‘market’, at least the general perception of what it means, is sacrosanct, much as it may not be the dream market he had sold to us, gullible customers, when India was about to bid farewell to the licence-quota raj. Now government — or the motley group of competition-wary private parties that arm-twist it — simply does not allow the market to open up any further. Hence no competitive pricing. Hence no pressure on R&D labs to innovate. Hence, the customer must buy from the few options available.

It will help if both socialist and capitalist commentators target the common enemy: cronies.

Dsylexic said...

Before all fears of the vaccine killing only people who are already horribly sick are dismissed,note that vaccine studies should ideally take multiple years.especially if they contain carcinogenic stuff like aluminium.however,the life cycle of trials is now drastically reduced and quite a few vaccines without much data is being sold.

also one has to consider possible correlations between high incidence of asthma in the affluent societies -who are more likely to be injected with vaccines .even in the absence of dust or other usual triggers,children born into affluent families,even in india,are increasingly afflicted by asthma. its a modern phenomenon,coincident with the increase in childhood vaccinations

Anonymous said...

My dear sir,
I have neither a google account nor an OpenID. I don't post on this blogger application too often. It's rather difficult to fathom how merely neglecting to mention one's name can cause one to be labelled an NDTV employee. You seemed, also, to have ignored my dig about Prannoy Roy's "bully pulpit" ways, which you yourself so aptly touched upon in your piece on the homosexuality debate. At the risk of now being termed a hidden CNN IBN employee, I would go so far as to say that as far as news anchors go Rajdeep Sardesai seems the keenest to appear neutral, contributions by his leftist spouse and the daughter of the rightist Subramnian Swamy notwithstanding. I recall first coming across your site a few months ago. Suitably impressed by your qualifications, I decided to search for your articles in The Statesman, upon which I came acress your Facebook public search profile, which said:

Fan of:
Products: TIMES NOW

In any event, must every articulate person necessarily be a journalist?
Keep up the good work.


Surajit Dasgupta said...


Well, if my guess was wrong, I am sorry. But I wonder if you have really read "Gagging with Gay Abandon". If you had, you would have rarely come across as trenchant a critique of Arnab Goswami as is found in my piece of research on homosexuality.

I can't help it if Facebook couldn't coin a better word than "fan" to describe a member of a discussion group. My admiration for Times Now is limited to that for its political neutrality (admittedly, imposed at times). Otherwise, I indulge in this soliloquy a moment before I switch to the channel every evening: "Who's Arnab quarrelling with tonight?"

It so happened that on one of the three days when I surfed English news channels to comment on their reporting standards, I found Times Now interviewing some doctors who tried their best to allay unnecessary fears surrounding the so-called swine flu [aptly, Novel A(H1N1)]. Goswami was not the presenter of that particular bulletin. However, I did not say the said channel was the "only" one to bring about sanity in the discourse, though it was certainly the first in the given case. Just minutes ago, I had read a caption damning the government on NDTV. Of course, the next day they cleared the air by conducting a thorough discussion on the subject outside the format of news in the form of a talk show. In that regard, I found NDTV India's panel of medical practitioners better educators than those on NDTV 24x7. Here, perhaps both fared better than Times Now. But since it was a scenario of nationwide panic, the damage had already been done. In such situations, the more you delay dispensing the right information, the less people are likely to lend you a patient ear.

Your calling my mention of doctors on Times Now my "admiration" for the channel was misplaced; more so as the object of your abhorrence was not the anchor of the particular bulletin in which the experts had appeared. That coupled with your "the only channel that has pointed out the symptoms and precautions while putting things in perspective and mentioning the similarities with a common flu, is NDTV 24/7" made my guess appear rather safe.

Now if you say you are 'Varun', I have to take your word for it!

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