Is swine flu more dangerous than other types of influenza or seasonal flu?

I knew I had to write this post when my domestic worker came to me in a panic. She was wearing a hankerchief over her mouth and was convinced that if she gets swine flu she will die. When I told her that most healthy people do not need medicine to be cured of the flu she didn’t believe me. On television they are saying something else she said. Well, this may not be exactly right but what is true is that every single channel, in every language, has nothing to talk about but swine flu and how dangerous and contagious it is. It does seem as if the plague has hit us!  These screaming headlines are doing nothing to keep people calm.

Yes, there are doctors who are taking questions and informing the public not to panic, that it’s curable even without medication, that swine flu is a mild disease, that only vulnerable people get complications and die, but we are being bombarded with so much information and it is so continuous that people have become confused. And the images on television are disturbing. Disturbing enough to worry the most enlightened people. Images of panicky people, long lines for testing, news of  increasing deaths, and also contradictory statements by doctors. One says that the earlier you take Tamiflu the better it is or it might lead to serious complications, another who says that wait and watch and see if it gets cured on its own. One says Tamiflu has to be given in the first 48 hours or it is of no use, and another says that one should only give it only if the patient is seriously ill, because of the serious side-effects. I am sure all of these statements must have some truth in them but most non-medical people don’t know what to make of it. One doctor actually said that we don’t know enough about the flu so one cannot be sure how exactly to deal with it! Well, I am sure humans don’t know enough about most diseases, but such statements confuse people.

And there is no doubt that some channels are being alarmist. I mean, for heavans sake this evening Times Now was talking in terms of “survivors”!!

Lets see what swine flu actually is. How fatal it is.

Is swine flu more dangerous than other kinds of flu?
The most important thing we need to know is whether swine flu kills more people than other kinds of flu. I don’t want to talk in terms of symptoms because symptoms vary. It’s the death rate that we should check. In India we are so used to flu that we treat it very casually, secure in the knowledge that we are not going to die. So is there something more virulent and fatal about swine flu? We can compare statistics of western countries because in India there are no flu statistics available.

The mortality rate for swine flu is believed to range from 0.1% to about  0.5%, meaning that about one to five people die for every 1000 people infected. Some consider this to be an overestimation because of “the unknown number of infected people, who recover at home without notifying their doctors that they are ill, or receiving a diagnosis”. In poorer countries with not so efficient health systems (say Mexico, where a large number of deaths were reported) the proportion of such people will be higher, leading to a wrong estimation of the death rate for swine flu. I am sure that in India too hundreds of people have had mild swine flu symptoms and have recovered without knowing they had it.

The mortality rate from normal influenza is more than 0.5% and can rise to even 25% or more in certain countries!! If you have any doubts check the following links which give this information. [1], [2], [3]. There are many many types of flu, some worse than others, but it doesn’t seem as if swine flu is the worst one.

However, swine flu does seem to be more contagious and while some sites say the symptoms are more severe, no one says that the death rate is more than that of other types of flu. Yes, vulnerable people like pregnant women, the elderly, young children and others with health problems should be careful not to go out to crowded places during this time. Or during any flu season. Hand hygeine is a must at all times, for all. It’s not just flu that we in India can catch. It’s also Typhoid and Cholera.

Calculating flu deaths
Ever wondered why India doesn’t usually report flu deaths although we have flu here all round the year? In developed countries a large number of people die from different strains of flu and they take flu vaccines too.  Hardly anyone in India does that. We just live with the flu. In India, when one’s flu progresses from a simple influenza to pneumonia and the patient dies, it is commonly referred to as death from pneumonia, not flu. In western countries this is not the case. For some strange reason, probably due to pressure from the WHO, India is has now changed its strategy and is now reporting deaths arising from complications of swine flu, as swine flu deaths. I am not saying its wrong, in fact its right, but it can give the wrong impression to people. They have never heard of flu deaths, but now they are hearing of swine flu deaths. Naturally, they think this flu is deadly. But is there any evidence so far to tell us that swine flu is more dangerous than some other types of influenza?

Dubbing a death from pneumonia, brought on by a flu virus, as a flu death, is something we in India are not familiar with. So used as we are to diseases like Typhoid and Malaria and TB that any disease being a contributory cause has not ingrained itself on our psyche. In fact there are those in the west who believe that even deaths of heart patients who have died from from heart attacks and strokes (to which flu has contributed) should also be categorised as flu deaths. In some cases, and in some countries, they are, although one does not know exactly how it is all calculated.

It is important I think to  make a distinction between a flu death and a flu associated death and this has been explained nicely here. It is an opinion that not all doctors would agree with, or feel comfortable with, but it made sense to me. A Harvard University graduate, Peter Doshi, wrote in the British Medical Journal:

US data on influenza death may be more PR than science, argues a Harvard University graduate student in this week’s British Medical Journal. The Centers for Disease Control and Prevention (CDC) acknowledges a difference between flu death and flu-associated death yet uses the terms interchangeably. Compounding these problems is a marketing of fear – a CDC communications strategy in which medical experts “predict dire outcomes” during flu seasons, he adds.

Whatever is the truth, the public should know clearly which is an actual flu death and in which cases the flu has simply aggravated an underlying condition. If it is the latter, then people have the right to know that swine flu is not the major cause and/or that it is not more dangerous than other types of flu. If this is kept wrapped in mystery and statistics then you will have people rushing to buy Tamiflu, even though the drug is known to have some serious side-effects. All in all, pharamaceutical companies are not complaining.

Update: Dr. N. S. Deodhar, Pune, India (formerly Additional Director General Health Services, Ministry of Health & Family Welfare, Director, All India Institute of Hygiene & Public Health, Ex-member: over 185 important national and international committees, who offers Consultancy services to 30 parties/clients, e.g., World Health Organization; UNICEF,

author of over 250 publications and research papers, including 10 books and several international awards) has this to say about swine flu’s death rate:

Death rate after H1N1 flu is low.We are oblivious of the facts. Deaths due to Swine flu are being blown out of proportion by media trying to create hysteria among lay people. Mortality of Swine flu is less than 0.1 % of those affected, that means may be one in 1,000 affected is likely to suffer the life loss. If one considers that real number of affected persons is several times of the reported cases, true mortality due to flu is much lower than 0.1 %. Affected children from the private schools and economically better of patients are reported, what about the children from Municipal Schools and slum dwellers?
Almost all cases of flu get naturally cured in couple of days as the infection is self-limiting. However, flu like illness should not be neglected…
We need to take care of children and elderly who are at high risk as they have less immunity and do not let them exposed to infection, e.g., by not going to crowded places or visit hospital…
This is also true of others at high risk, e.g., persons over 45 years of age, those who are diabetic, have high blood pressure or cardio-vascular disease, have asthma or other diseases of the lung…
Tamiflu is the antiviral drug that is being used, especially for H1N1 cases showing signs of seriousness. Efficacy of this drug has not been tested by clinical trials. As is the case with most of the antiviral drugs, none of them is curative and may be useful if administered during the early stage of infection. The cost of treatment with Tamiflu is Rs. 5,000=00. It is doubtful if Tamiflu is of any real benefit to the patients. In children Tamiflu may cause adverse side-effects..

I have the full text of Dr. Deodhar’s comments on swine flu if anyone is interested, I can send it my email. However I have extracted the important points here.

Another important update (17th Aug 2009) :

Steps to take to prevent H1N1 or Swine Flu or any other flu from making you ill/ Prevention of swine flu and seasonal flu:
This is not an official government advice, especially the part about face masks or N95, but it is advise from a doctor.

Most N95 respirators are designed to filter 95% particulates of 0.3µ, while the size of H1N1 virus is about 0.1µ. Hence, dependence on N95 to protect against H1N1 is like protecting against rain with an
umbrella made of mosquito net.

Tamiflu does not kill but prevents H1N1 from further proliferation till the virus limits itself in about 1-2 weeks (its natural cycle). H1N1, like other Influenza A viruses, only infects the upper respiratory tract and proliferates (only) there. The only portals of entry are the nostrils and mouth/ throat. In a global epidemic of this nature, it’s almost impossible not coming into contact with H1N1 in spite of all precautions. Contact with H1N1 is not so much of a problem as proliferation is.

While you are still healthy and not showing any symptoms of H1N1 infection, in order to prevent proliferation, aggravation of symptoms and development of secondary infections, some very simple steps – not fully highlighted in most official communications – can be

practiced (instead of focusing on how to stock N95 or Tamiflu):

1. Frequent hand-washing (well highlighted in all official communications).

2. “Hands-off-the-face” approach. Resist all temptations to touch any part of face (unless you want to eat, bathe or slap).

3. Gargle twice a day with warm salt water (use Listerine if you don’t trust salt). H1N1 takes 2-3 days after initial infection in the throat/ nasal cavity to proliferate and show characteristic symptoms. Simple gargling prevents proliferation. In a way, gargling with salt water has the same effect on a healthy individual that Tamiflu has on an infected one. Don’t underestimate this simple, inexpensive and powerful preventative method.

4. Similar to 3 above, clean your nostrils at least once every day with warm salt water. Not everybody may be good at Jala Neti or Sutra Neti (very good Yoga asanas to clean nasal cavities), but blowing the nose hard once a day and swabbing both nostrils with cotton buds dipped in warm salt water is very effective in bringing down viral population.

5. Boost your natural immunity with foods that are rich in Vitamin C (Amla and other citrus fruits). If you have to supplement with Vitamin C tablets, make sure that it also has Zinc to boost absorption.

6. Drink as much of warm liquids as you can. Drinking warm liquids has the same effect as gargling, but in the reverse direction. They wash off proliferating viruses from the throat into the stomach where they cannot survive, proliferate or do any harm.

All these are simple ways to prevent, within means of most households, and certainly much less painful than to wait in long queues outside public hospitals.

Happy breathing!

(First photograph from the Hindu and the second one is taken by me at Chennai airport and the third at Mumbai airport)

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(From tomorrow for a week I will be traveling and will thus not be posting on my blog and may not answer comments. In other words I am taking a short break.)