The country is once again facing an outbreak of swine flu, with hundreds falling victim to the disease. According to data from the Health Ministry, since the beginning of the year, over 9,000 cases of swine flu have been reported from across the country, with 312 deaths.

The worst affected states are Rajasthan (2,941 cases, 107 deaths), Gujarat (1,431 cases, 55 deaths), Delhi (1,669 cases, 7 deaths), Punjab (335 cases, 30 deaths), MP (98 cases, 22 deaths) and Maharashtra (204 cases, 17 deaths).

However, this would represent just a fraction of the numbers. The data corresponds to the number of cases registered in hospitals and PHCs (primary health centres). The actual numbers could be several times more, with countless swine flu cases being ascribed to a passing flu.

1) With swine flu epidemics striking with regularity throughout the year, an important first step to stop the spread of the disease would be to accept that there is a problem, says Dr Nisheeth T.P., Head of Critical Care at MIOT INTERNATIONAL Hospitals, Chennai. Acceptance of an outbreak leads to public awareness and more effective measures being instituted against the disease.

2) A large part of the responsibility to contain the spread of the infection falls on us as a community. People who experience flu-like symptoms should seek appropriate medical advice. They should voluntarily quarantine themselves at home to limit the spread of the disease. Equally, schools and places of work should consider grant of leave to students and staff with potential flu symptoms, in the larger interest of the community, he says.

3) Awareness programmes on countering the spread of this highly contagious disease should be conducted at regular intervals, by both the government and private healthcare providers.

4) A provision for subsidising expensive vaccines for healthcare workers at all levels, starting with the staff in PHCs, is a necessity, especially during an epidemic. Doctors and healthcare personnel posted in remote PHCs should be alerted about the outbreak of an epidemic at the earliest.

5) Treatment with the oseltamivir tablet, commonly called Fluvir, Tamiflu and Anti-Flu, when started early, is effective against the infection. The swine flu test, which costs more than Rs 6,000 in the private sector, could also be considered for subsidy so that more people can take it.

The infection

The H1N1 virus attacks the respiratory system of the victim, making it difficult for the patient to breathe and process oxygen. The majority of such cases are cured with the prescription of the flu tablet. Some patients may require oxygen support, and in the normal course should recover in a few days with treatment.

However, if a patient's condition deteriorates and he or she develops severe lung infection called ARDS (Acute Respiratory Distress Syndrome), the patient would have to be given higher oxygen support. A further deterioration would require ventilator support, and if that is not sufficient, the patient would have to be put on the ECMO, which is an artificial lung machine.

ECMO

ECMO (Extra Corporeal Membranous Oxygenation) is the exchange of gases done outside the body by a machine. Since a patient affected by ARDS has severely impaired lung function, the ECMO facilitates oxygenation of blood and removal of carbon dioxide, outside the body. So the machine takes over the work of the lungs, which can rest and heal. This may take a week to two weeks.

ECMO has evolved from the cardio-thoracic unit. It was first used in heart surgeries as a bypass machine. With technological advancements, the ECMO unit has become smaller. It has moved from the operating room to the ICU, and is a standard treatment option in cases where the lungs or heart is failing. Besides ease of use, the complications encountered in ECMOs conducted today are far fewer in number.

However, in spite of its potential as a life-saving treatment option, there is little information about ECMO in the public domain says Dr Vijit Cherian, Head of Cardiothoracic and Vascular Surgery at MIOT INTERNATIONAL Hospital.

The cost of the procedure and reluctance within the physician community to present it as a viable option are among the challenges in popularising it. ECMO is not simply about connecting the patient to the machine, but calls for round-the-clock monitoring and a high level of care. The challenge is seeing the patient through the entire period and handling the complications that arise, a major one being bleeding.

The success rates are higher in the West because the volumes are higher. "It is only when you see success that a treatment option can be touted as a solution to the problem," says Dr Nisheeth.

India is on a learning curve in the use of ECMO. But the more people resort to it as a life-saving option, the greater will be the success.

The government, on its part, could step in to make the process accessible to a larger section of people. Poor patients from government hospitals could be referred to hospitals that have successful ECMO programmes, he said.

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