Influenza

Mikaela Middel
Mr. Toole
May 8, 2015

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Preface

Influenza is a contagious respiratory illness caused by viruses. Symptoms can be

mild to severe and possibly at times cause death (GlobalHealth). Influenza is one of the
major causes of sickness and death around the world. Symptoms of influenza are: fever,
cough, sore throat, runny/stuffy nose, headaches, body aches, chills, fatigue, as well as
vomiting and diarrhea. Some can be infected but have no fever and just have respiratory
symptoms. Strains of the influenza virus are constantly changing and immunity to it
wears over time (Influenza, 2015).
The death toll in developing countries from influenza is significantly higher than
in industrialized countries. This is because it is less likely for vaccines and antiviral
agents to be available in developing countries. The public health and clinical
infrastructures of developing countries are inadequate to deal with a widespread health
crises like an influenza pandemic. Being inadequate is because developing countries have
limited financial and technical resources to strengthen their readiness for a future world
pandemic (Major Issues and Challenges of Influenza Pandemic Preparedness in
Developing Countries 2008).
If an influenza pandemic arises every country would be affected, although the
impact would differ between countries. Most countries have a prepared national influenza
pandemic plan in place for future pandemics but is lacking in developing countries.
Vaccine production is limited worldwide and is mainly in industrialized countries. There
are only 350 million doses of the influenza vaccine made per year and that would not be
sufficient for every country if there were to be a pandemic (Major Issues, 2008). Many

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countries (mainly developing ones) would have no choice but to confront the next
pandemic with none or very few vaccines.
Countries have started antiviral stockpiles of channel inhibitors (amantadine and
rimantadine) as well as neuraminidase inhibitors (oseltamivir and zanamivir) but these
stockpiles in developing countries are compact. The World Health Organization (WHO)
has formed global and regional stockpiles but these would be insufficient in a worldwide
pandemic. In a study done (Estimation of potential global pandemic influenza mortality)
it was estimated that in a future pandemic that out of 62 million deaths 96% of those
deaths would be in developing countries (Major Issues, 2008). Although no study can
really estimate the impact a pandemic could have, models are based off of industrialized
countries and could greatly underestimate the actual impact.

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Table of Contents
Preface

Summary of Research Methods

Background

Expert

Role of Control

10

Logic of Evil

12

Religion & Spirituality

15

Case Studies
Kuwait

18

Cuba

20

India

22

International Organizations

26

Canadian Connection

28

Solutions

30

Bibliography

32

Appendices

38

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Summary of Research Methods

This report was written from scholarly articles, guidelines, reports and websites
that were collected. These reliable sources were based on a search that included key
words such as influenza, virus, vaccine, illness, treatment, Canada, global health issues.
Searches were conducted on February 13, 2015. Publications were dated 2008 to 2015.
Results included articles, guidelines reports and websites. Some information was
excluded based on topics to broad or irrelevant. Final reference data included thirty six
references primarily from websites such as The World Health Organization.

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Background
The first influenza pandemic of 1918-1919 that killed 20 million people around
the world lead to research on viral infection. The origin of virulent strains and actions of
epidemics are still not greatly understood. For 1000s of years people have suffered from
influenza, and it is thought that humans acquired influenza when domestication of
animals began. The influenza virus itself was not isolated until 1933 (Influenza, 2004).
The pandemic of 1580 was the first documented outbreak that was thought to be
influenza. In the summer of 1580 the flu was reported in Asia Minor and northern Africa.
It was proposed that it spread from Malta to Sicily in July 1580 and then dispersed north
through the Italian peninsula before August 1580. Philip II ruled the Iberian peninsula,
Southern Italy, and several North African ports during this time, it was suggested that the
outbreak in July in the Spanish Netherlands was caused by troops that Philip II sent to the
Dutch (Influenza, 2004).
During the Eighteenth century there were numerous outbreaks, they were the most
wide spread as well as dramatic outbreaks in history. In 1729-1730 the first ever
pandemic was recorded, this pandemic caused sickness but few deaths. It was not until
October of 1732 that the flu broke out in North America and spread down New England's
coast from Boston to Southern Maine. The flu was present in Sweden during September
and then Vienna during October. By November the flu had dispersed to Hungary, Poland,
Germany, London, Plymouth, York and Durham England as well as Dublin, Ireland. In
the spring of 1781 there was verification of a wave in North America as well as North
Africa. During 1781 the flu also dispersed into the Eastern Hemisphere, there were
outbreaks in China and the British occupied India in the autumn. Then in 1782 a

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pandemic started in China and scattered westward. There were tens of millions of cases
and was spreading extremely rapid (Influenza, 2004).
The Spanish Flu or the pandemic of 1918 killed more rapidly than any flu of its
time and was specifically dangerous to young adults. Death rates were much more
significant in Asia, Sub-Saharan, Africa and Latin America. The mortality rates were also
greater in low income countries compared to high income countries. This was possible
because of lack of access to quality medical care, weak public health infrastructure,
housing conditions, population density, nutritional status, and pre-existing health
conditions (Major Issues, 2008). The Spanish flu killed millions of people and most was
at the central part of their life. This pandemic scoured the earth in three waves with no
certainty of where the first originated. It appeared in the United States in March of 1918,
but caught little attention due to low death rates. It also mistaken for the circulation of a
respiratory disease at that time of year. Not until the second and third waves went by that
it was noted that a great deal of the injured party were young adults. The second wave
went across North America and temporarily disrupted military camps as well as some
factories. This wave spread influenza across the majority of the world. In late August the
severity of the strain intensified. It became the most dangerous strain ever recorded.
World War I was a major role of the transmission of the virus (Influenza, 2004).
In 1957 the Asian flu or the H2N2 pandemic was reported to be in Hong Kong.
It was dispersing out towards Southeast Asia and by the end of May had gone from Hong
Kong to Japan, the Philippines, Malaya and Indonesia. Influenza was reported in
passengers as well as the crew onboard boat that had left ports from East Asia in June.
During that month it spread throughout India and the Middle East, port cities were

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affected first by influenza. Next it rapidly extended to England and the United States of
America. This particular Asian strain was the most conspicuous version internationally
for more than ten years. It was not until seven months had gone by that is was confirmed
by epidemiologists that the outbreak had begun in China. This pandemic had allowed
epidemiologists and biostatisticians to determine a way of detecting the severity of an
influenza epidemic as well as what its geographical scale would be (Influenza, 2004).
The predicted epidemic of 1976 the Swine flu failed to materialize and left
1,000,000,000 people vaccinated some with devastating health results. The precise
location of the outbreak was unknown, researchers believe the swine flu was recovered
from victims of the January outbreak in Fort Dix, New Jersey was very similar to the
strain that caused the 1918-1919 pandemic. The new strains similarities made it
impetuous to ignore the probability of a repeat epidemic. The beginnings of this event
lead to major adaptations in the public health policy. There was a nationwide
immunization program but it had little support from the federal level of government
during April and May. Without the governments support the vaccination program did
not occur until October. After vaccinating 1,000,000,000 of people the pandemic did not
occur to the scale that was predicted (Influenza, 2004).

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Expert

Frank Macfarlane Burnet was an Australian virologist. In 1918 he attended the

University of Melbourne where he studied to become a doctor and graduated with a
Bachelor of Medicine and a Bachelor of Surgery in 1922. In his final exams he ranked
second in his class. In 1926 he began research on bacteriophages, for these efforts he
received a PhD from the University of London in 1928 (Burnet, 2015).
Burnet had a major achievement in the culture and detection of the influenza virus
as well as explaining the recombination of influenza strains. He developed the method for
producing influenza vaccines that modern methods are still based on Burnets effort.
Frank Macfarlane Burnet was the first to create an influenza vaccine (Burnet, 2015).
Burnets influenza research began in the 1940s with his discovery that an
amniotic inoculation of a developing chick egg provided a method to directly isolate a
virus from a patient. Modern methods of producing vaccines are still based on his work
improving virus growing processes in hens eggs. Between 1942 and 1959 Frank
Macfarlane Burnet had produced 114 papers on the influenza virus (Burnet, 2015).
After witnessing the tragic pandemic that followed World War I, Burnet wanted
his World War II efforts to be finding a way to make citizens immune to influenza.
Burnets major contributions to influenza research were methods of isolating a virus,
immunization of influenza, phenomena of haemagglutination and elution as well as flu
virus genetics. In Frank Macfarlane Burnets lifetime he received many honours but the
most remarkable awards were the Royal medal in 1947, the Copley medal in 1959 and his
Nobel prize in medicine in 1960 (Burnet, 2015).

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Role of Control

In Canada the healthcare system is controlled by the federal and provincial

government. The Canadian constitution provides levels of government with constitutional
powers and jurisdictions over the healthcare system. The drug industry also presents
power, political might and social influence over nations governments, healthcare
systems, doctors and hospitals (Canadian Federalism and Public Health Care).
The federal government is constitutionally empowered to legislate marine
hospitals, quarantines, pharmaceutical and medical device safety as well as the oversight
of food. The federal government is also responsible for the delivery of healthcare to
particular groups of people who fit into federal jurisdiction. These groups of people are
First Nations people who live on reserves, Inuit, Veterans of Canadian forces, members
of the Royal Canadian Mounted Police (RCMP), inmates in federal penitentiaries and
refugee protection claimants (Canadian Federalism).
The federal government provides provinces with billions of dollars for health
services and programs. This money however comes with conditions that the money might
need to be spent in specific services or programs as requested by the federal government.
These conditions also could include that the care delivered to patients be held to specific
federal standards and objectives. If there is a national emergency like a wide spread
epidemic of influenza the federal government would temporarily take over the duties of
the provincial government regarding health care (Peace, order and good government
section of constitutional act, 1867).

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The provincial government has the majority of legislative power under
constitution. Only the provincial government can pass laws about creation and
administration of hospitals and mental health facilities. Section 92(7) of the constitution
act 1867 states that only provinces have power over establishment, maintenance, and
management of hospitals, asylums, charities and eleemosynary institutions in and for the
province, other than marine hospitals (Department of Justice Canada, Constitution acts
1867 to 1982). The provincial government controls health insurance, distribution of
prescription drugs, dominance in laws about delivery of health care to Canadians, as well
as the training, licensing, and terms of employment for healthcare professionals.
Many countries, except the United States of America, governments have set a
limit for the cost that drug companies can charge for a drug based on its benefits. It has
been seen that the pharmaceutical industry has power, political might, and social
influence over nations governments, the healthcare system, doctors, and hospitals. The
top eleven drug companies made 711.4 billion dollars between 2003 and 2012. In 2012
alone the top 11 drug companies earned 85 billion dollars in net profits (Big Pharma
Manufacturers, 2015). The United States of America is one out of the two countries that
the industry can market to consumers directly.
The Centers for Disease and Control and Prevention, a world organization,
manages about $1.73 billion of investments from the United States government to
develop global health. Specifically $76.8 million of the United States investment is
directly sent to support global influenza activities (Global Health Funding, 2014).

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Logic of Evil
The devastations that occur within the world of influenza are not purposely
inflicted upon the innocent. There are reasons behind why certain decisions are made by
governments, drug companies, and world organizations. These reasons are the Logic of
Evil or the thought process of the powers in charge, concerning why they allow these
devastations to occur.
Developing countries have either very limited access to healthcare and services or
none at all. The major issue still remains in making certain of the availability as well as
affordability of medicines. These medicines include the essential for treating the majority
of developing countries common diseases that are present. The governments of these
developing countries are continually fighting to guarantee access to even just
fundamental medicines that could be helping to save peoples lives (Drugs and Money,
2015).
The treatment for serious infectious diseases requires advanced methods, which
are usually become much more elaborate and expensive. A major influence of treatment
and care in developing countries is the affordability. One treatment of oseltamivir costs
fifteen American dollars even at a reduced price which is still too expensive for
developing countries. In order to purchase oseltamivir for twenty five percent of the
population it would cost high income countries 0.11% of their annual health expenditure
whereas for lower income countries or developing countries it would cost 12.9% of their
annual health expenditure (Major Issues, 2008). If the country has difficulty in affording
the treatments, it is unlikely that the citizens of that country will receive the treatments
they need. Regardless of the attempts to create a better health policy and improve the

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execution of the pharmaceutical sector the problem in the developing countries is still
present (Drugs, 2015).
Drug manufacturers have a great amount of independence for setting the prices
for patented medicines where there is patent legislative (Drugs, 2015). With the patent
legislative drug prices can cost much more than the actual margin price simply because
drug companies are trying to make the greatest profit possible. There is much competition
throughout the medicinal groups of drugs that have similar uses. This competition causes
companies to focus on the prices of their competitors instead of consumers need for the
product.
Developing countries often have an ineffective national purchasing system and do
not have a great market of interest to international manufacturers. They are also
recurrently inadequately educated that there are superior prices and feel that they are
required to pay any price put forward. As stated by Medecins Sans Frontieres (MSF)
numerous developing countries pay larger amounts than necessary (Drugs and Money,
2015). Paying more than what is necessary makes it difficult to buy a sufficient amount to
aid all the citizens of a developing country.
The lack of farming infrastructure in developing countries breeds disease. The
infrastructure of farming is overlooked in developing countries because of the need to
farm to sustain them. Poverty stricken governments restrictions promote unhealthy
technique (Poor Infrastructure, 2010).
The innocent are not intentionally affected during influenza pandemics, it is
simply easier for the weak to contract. Decisions made by governments, drug companies,
and world organizations all have logical reasons for support. The logical reasoning is the

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thought process of the powers in charge or the Logic of Evil, concerning why they
allow these devastations to occur.

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Religion & Spirituality

It is agreed among experts that the most effective way to prevent influenza is
through vaccine, but some people still make the decision to refrain from being
vaccinated. Some hold a strong religious belief against receiving a vaccination.
Healthcare workers such as nurses in hospitals, which refuse to be vaccinated, are
required to wear a mask by their employer for the influenza season. (Healthcare Workers
Religious Objections to Mandatory Influenza Vaccination, 2015)
Many religious groups refuse to use clinical medical care and choose to use faith
healing. Faith healing has been in existence amongst many religions for centuries. Any
non-medically based cure is considered to be faith healing. This can be psychic, or
supernatural as well as spiritual therapy. Faith healing relies on a supernatural power
often referred to as divine healing. (What Is Faith Healing, 2013)
There are different ways to execute faith healing; it can be hands on healing, the
laying on of hands, or distant healing. This can involve someone who may or may not be
an ordained individual. One may draw from the divine within oneself, and would do so
through prayers, rituals, or meditation. Pilgrimages to a religious shrine or religious place
also occur. There are no current scientific or medical evidence that can sustain the
declarations made for faith healing. The only exception is meditation, there is
scientifically proven evidence of benefits from meditation. (What Is Faith Healing, 2013)
Some pursue faith healers or individuals that profess to have an ability to heal.
Religions believe that our physical and emotional suffering is amplified when one fails to

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see any good from the illness at hand. When focused on what God can do for the illness
one stays focused on God instead of the burdensome situation. (Faith Healing, 2013)
A woman who was in two car accidents in which five of her seven siblings died
reminds herself that It was good for me to be afflicted so that I might learn Gods
decrees (Psalm 119:71). She believes that she was meant to learn from this accident and
that it was Gods plan. Healing is an act of unmerited mercy from a sovereign God. Faith
healing is not putting faith in faith itself but in the grace and mercy of Jahveh-Ropheka
God the Healer (Faith Healing, 2013).
God is fundamentally in control of all healing that takes place. Whatever the
outcome of a situation God is always with the suffering, and is aware of their every need
as well as pain. Perfection of health remains in the resurrection. (Faith Healing, 2013)
The bible teaches Christians and Roman Catholics that there are animals which
are unclean and one should not place the unclean into our bodies. Vaccines are created
from blood products as well as tissues from animals therefore vaccines are not used.
Vaccinations were created by man and are artificial made to alter immune function. For
Christians and Roman Catholics using a vaccine is similar to saying that God created man
incorrectly and an artificial vaccine is needed in order to survive. (Vaccines: A Religious
Contention, 2014)
In the Jewish religion, only kosher foods and items are used for the strictest of
Jews. Vaccines have animal blood and tissue that is not kosher. It is against the Jewish
kosher religious habit to use a vaccine that is not kosher. Similarly, most Buddhists are
vegetarian and because of the animal products in vaccines Buddhists do not use vaccines.
In the Islamic religion it is believed that Allah created out of the purest and best nature

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and no alterations are needed. Jehovah's Witnesses are completely against the use of
vaccines and for some time it was banned. (Vaccines: A Religious Contention, 2014)

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Case Study: Kuwait
Kuwait is an Arab country located in Western Asia (See Appendix E). Situated is
on the edge of Eastern Arabia at the tip of the Persian Gulf. Iraq and Saudi Arabia both
share a border with Kuwait. The population is at 4.1 million people. In 2007 throughout
the country the Avian influenza was spread (Kuwait, 2015).
Avian influenza (H5N1) is a highly pathogenic virus. Human infection is rare but
can occur. After close or direct contact with infected poultry. The avian influenza has
many complications such as; pneumonia, shock, respiratory failure, altered mental state,
seizures, multiple organ failure, and death. (Al-Azemi, Medscape, 2008)
In 2007 there was an avian influenza (H5N1) outbreak in Kuwait. It is an
epidemic in poultry in Asia and has been around since 2003. The avian virus was
randomly isolated in dead birds in the Hong Kong special administrative region, in the
Peoples Republic of China. Although these birds were considered a dead end. (AlAzemi, Medscape, 2008)
February 13 of 2007 the Public Authority for Agriculture & Fisheries of Kuwait
reported a beginning outbreak in poultry. This outbreak was in the southern of Kuwait in
the Al Wafrah farm area. There were 131 confirmed influenza virus infected poultry from
twenty farms all over the country. There were high mortality rates among flocks that
were infected. Mortality rates were especially high in Al Wafrah commercial broiler
farmers as well as poultry that were raised on private farms and homes. On February 18,
2007 disease control measures were put in place. These measures controlled movement
of poultry, vaccination, disinfection of infected areas, and the culling of approximately
500,000 birds throughout the country. (Al-Azemi, Medscape, 2008)

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On February 25 of 2007 Ahmed al-Shatti who is a health ministry spokesman
confirmed that twenty infected falcons, chickens, and turkeys at the Kuwait zoo, on
farms, and at the clinic for falcons. The health ministry closed the Kuwait zoo, and all
bird markets as well as banned all bird imports and exports. There was a lot of culling of
poultry on farms done by officials. Officials also gave people who were in contact with
the infected birds antiviral medication. (Flu Scan, 2015)
The avian influenza cannot be diagnosed by clinical symptoms alone. To diagnose
the avian influenza laboratory testing is needed. This is done by swabbing either the nose
or the throat of one who is thought to be infected. The swabs are then taken to a
laboratory and tested for the avian influenza virus. Centers for disease control and
prevention recommends the use of oseltamivir, or zanamivir for treatment of the avian
influenza virus. Although there have been reports of antiviral resistance among the avian
influenza virus. Monitoring this resistance is crucial and ongoing. (Influenza Division,
2015)

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Case Study: Cuba
Cuba is a developing country found south of the United States (See Appendix D).
In April of 2009 an H1N1 virus was detected in the United Sates. WHO raised the
influenza pandemic alert from a four to a five on April 29, 2009. This alert indicated for
countries to activate their pandemic preparedness plans. The outbreak was confirmed to
be in 171 different countries around the world, and caused deaths on 139 of them (Swine
flu, 2015). The outbreak began to spread and eventually made it to Cuba (H1N1
Pandemic, 2010).
The second wave of the 2009 pandemic in the Northern hemisphere as well as
Cuba by January of 2010 had caused 14,000 deaths worldwide. Fifty-Three deaths were
deaths were reported directly in Cuba. The Cuban health facilities reported 150,000 cases
weekly of respiratory infections, including all types of influenza, colds and H1N1 cases.
Specifically H1N1 was harsh on pregnant, postpartum, and small young children. As well
H1N1 was more prominent to attack young adults compared to seniors.
Strategies to prevent another outbreak were designed for the worst case possible
and were divided into seven areas: Intersectional leadership centralized coordination,
Epidemiological surveillance and control, Public information and engagement, Active
screening of risk groups, Clinical protocols and research, Adaptation of hospitals and
other health facilities, and international cooperation ( H1N1 Influenza, 2010).
Cubas health ministry is taking precautions to prevent the illness from spreading
to the country. The government advised citizens to attempt to find medical attention as
soon as they believe they had flu like symptoms. (Influenza and other respiratory viruses,
2013)

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In 2013 based on laboratory data from EW 29-32 (See appendix A) there were
311 samples analysed 53.1% tested positive for respiratory viruses and 23.3% tested
positive for influenza. Of the samples that were positive for influenza 2.3% were
influenza B and the other 97.7% were influenza A. Out of the influenza A samples 76.7%
were H3N2 and 23.3% were H1N1. Samples that were positive for other respiratory
viruses were predominantly 18.8% RSV and 13.9% rhinovirus. (Influenza and other
respiratory viruses, 2013)

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Case Study: India
India is a highly populated country in Asia. In February 2015, there was an
influenza pandemic outbreak in India of what was believed to be the swine flu (See
Appendix A). The outbreak began to quickly spread throughout the country. Devastating
amounts of citizens have been hospitalized, and there have been many deaths. The
government has placed precautions and warnings to attempt to keep the numbers of
infected citizens lower, but many are still affected.
There was an outbreak of H1N1 swine flu, predominant in India. Health officials
say that the death toll rose to 1,731 out of approximately 30,000 contaminated with the
virus. There have been twenty one new deaths in one day. Lower temperatures and rain
that are unexpected during this time of year are what health officials are blaming. (India
Swine Flu, 2015)
Usually an outbreak would begin to slow down around this time but almost 1000
new cases have been reported in March alone. The total number of cases has exceeded
the number of cases in Indias swine flu outbreak of 2009. There have been reports of
death from the swine flu all over the country. (India Swine Flu, 2015)
In the western state of Gujarat alone there have been 387 deaths out of more than
6,100 cases, and in the north western state of Rajasthan there have been 378 deaths. In an
abundance of other states the death tolls are in the hundreds and the cases in the
thousands. (India Swine Flu, 2015)
Isolation wards in health centers would have usually closed in April but health
officials are keeping them open until the swine flu cases subside. Many different states
have began public health measures such as providing free facemasks or even treatment

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for individuals infected with the H1N1 virus. In February of 2015 one city in India
banned public gatherings in attempt to reduce the spread of the influenza virus. Apart
from all this the health minister refuses to label this as a pandemic. (India Swine Flu,
2015)
The swine flu emerged in 2009 and was thought to have come from pigs.
Scientists at Massachusetts Institute of Technology announced that the current strain of
the virus is more dangerous than the strain that caused the previous outbreaks including
the 2009 outbreak that killed more than 2,700. The Indian health ministry determined that
the virus will not be more difficult to kill. (India Swine Flu, 2015)
At first it was reported to be the same strain as the 2009 influenza pandemic but it
was confirmed that it was not identical as stated in the journal Cell Host & Microbe.
Researchers from Massachusetts Institute of Technology discovered that the current
H1N1 virus has caused at least 1200 deaths and has acquired amino acid mutations;
T200A and D225N. These mutations make it different from the pH1N1 virus. This makes
it more virulent and validates a re-evaluation of the vaccine currently in use. (Swine flu
outbreak, 2015)
Conditions in India provide a great environment for influenza reassortment. India
has billions of farmed birds and animals as well as a huge population of humans. The
huge human population is crowded in most areas making it easier for the influenza virus
to transfer and infect more and more people. (Swine flu outbreak, 2015)
Massachusetts Institute of Technology says that the H1N1 flu is more dangerous
than the Indian health officials will admit to. Mutation in the new strain allows the swine
flu to attack an infected persons respiratory cells more virulently. This contradicts the

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governments reports that it is the same strain as 2009 that killed 18,000. Massachusetts
Institute of Technology researchers stress the need for better surveillance and public
awareness of the virus to asses how the mutated strain is developing. (Swine flu outbreak,
2015)
Gregory Hartl, WHOs head of public relations and social media says that the
World Health Organization is monitoring the situation closely. An estimated 1,5000
people have died from the virus since December of 2014. More than 27,000 people are
thought to have already been infected in almost every state and union territory of India
from a population of more than 1.2 billion. (Swine flu outbreak, 2015)
Once someone is infected the options for treatment are limited. The Indian
government is providing a list of pharmacies and outlets that are licensed to carry
oseltamivir which is tamiflu, in thirty six states and union territories. Centers for Disease
Control and Prevention in the United States recommend tamiflu, relenza, and rapivab as
medications to treat H1N1. (Swine flu outbreak, 2015)
The health minister in the northern state of Haryana is trying to discourage people
from shaking hands to prevent the spread of the virus and keep the numbers of infected
people down. Students attending school in Ahmedabad, in the state of Gujarat wear
masks to reduce chances of contracting the swine flu (See Appendix B).Rallies are held
across the country to help raise awareness of different precautions that should be taken to
bring the spread of the swine flu to an end. (Swine flu outbreak, 2015)
The swine flu ward at Civil hospital in the western state of Gujarat India, has 500
beds and is the largest hospital in Asia. Children have lined the walls of hallways with
drawings on the importance of washing hands, eating lots of protein and avoiding public

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gatherings to help lower the risks of contracting the swine flu virus. In the flu ward of this
hospital was six year old Purvi (See appendix C). She had an IV tube in her nose and her
survival chances were uncertain along with fifteen others in the same room. (Deadly
outbreak, 2015)
Gujarat was hit the worst of all the states, sometimes there were seventy new
patients with the swine flu each day in five different swine flu wards. An observation
made based on an analysis of two strains of the virus is that it might have mutated into
something much more virulent and distinct from the 2009 strain. This new deadly strain
might affect human cells more effectively, even in the heat of the summer. (Deadly
outbreak, 2015)
Officials believe that the outbreak will begin to slowdown with rising
temperatures. A doctor in the town of Kanwat in Rajasthan which is a state in India, Amit
Varshney says that his patients do not have strong enough immune systems to fight off
the swine flu. The swine flu virus can only be detected by an expensive laboratory test
and often leads to debilitating respiratory problems. Swine flu kits are even being sold for
10,000 rupees which is equal to $160. (Deadly outbreak, 2015)

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International Organizations

The World Health Organization is a specialized agency of the United Nations that
concerns itself with international public health. WHO has a global influenza program
(GIP) which provides each member with strategic guidance, technical support and
coordination of activities essential to make their health systems more prepared against
seasonal, zoonotic and pandemic influenza threats to populations as well as individuals.
(Global Influenza Programme, 2014)
WHO is the directing and coordinating authority for health within the United
Nations system. The World Health Organization is responsible for providing leadership
on global health concerns, shaping the health research agenda, setting norms as well as
standards, articulating evidence based policy options, providing technical support to
countries and monitoring and assessing health trends. (Global Influenza Programme,
2014)
The Centers for Disease control and Prevention (CDC) has an influenza division
(ID). The mission of the ID is to improve global control and prevention of seasonal as
well as novel influenza and improve pandemic preparedness and response. In
collaboration with domestic and global partners the ID; builds surveillance and response
capacity, monitors and asses flu viruses and illness, improves vaccines and other
interventions, as well as applies research to provide science based enhancement of
prevention and control policies and programs. (Influenza Division, 2015)
The Centers for Disease Control and Prevention strive to; provide vision,
leadership, and direction for the flu division. Along with that they strive to foster external

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partnerships and cross cutting activities that support quality science and strong global
partnerships. The CDC also provides leadership and guidance in policy formulation.
Lastly the Centers for Disease Control and Prevention provide support for national and
international capacity building programs. (Influenza Division, 2015)

The CDC tries to provide technical expertise and leadership for national and
international pandemic preparedness activities. They also try to provide technical
expertise for communications, information technology, genomic sequencing, and reagent
resources. (Influenza Division, 2015)
Global Health has an office of global affairs and their goal is to increase the
global capacity to detect and respond to influenza and other emerging pandemic threats.
Global Health is in partnership with the United States government agencies, ministries of
health, multilateral and international organizations and civil society organizations to do
so. The office of global affairs role is to provide vision, leadership, advocacy, and
coordination of international activities related to influenza and other emerging pandemic
threats through policy analysis, development and coordination, program coordination,
policy implementation, and strategic planning. (GlobalHealth, 2014)

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Canadian Connection

The Public Health agency of Canada has in place the Canadian Pandemic
Influenza Plan for the Health sector (Common menu bar links, 2014). In April of 2009 a
new strain of influenza was discovered as a version of H1N1. This strain quickly spread
throughout several countries. June 11, of 2009 the World Health Organization announced
that the H1N1 outbreak was considered a pandemic. The first cases in Canada were
confirmed on April 23, of 2009. By June 11, 2009 the H1N1 pandemic was declared to
have spread all over the country to all provinces and territories. On August tenth of 2011
the pandemic was declared to have come to an end by the World Health Organization.
(Canadas Response, 2010)
Canada went through two waves of the H1N1 virus in 2009. The first wave was in
the spring and the second followed it in the fall. The peak of the outbreak was in early
June 2009 and in November 2009. The first wave was the bigger of the two. There was a
total of 40,185 laboratory confirmed cases that were reported to PHAC. During the
pandemic there were 8678 hospitalized patients. Of the patients admitted to the hospital
1437 which is 16.9% were admitted to the intensive care unit. From those in the Intensive
care until 60% needed ventilation. In the whole pandemic there were 428 deaths from
H1N1 in Canada. The mortality rate was approximately 1.3 per 100,000 of the
population. (Canadas Response, 2010)
The 2009 pandemic in Canada marked the first pandemic of the twenty first
century. It was also the first pandemic with a vaccine as well as antiviral medication. It
was also the first opportunity for the global community to use the pandemic response

Middel 29
plans. The response plans had been created and updated over the past two decades.
(Canadas Response, 2010)
The number of hospitalizations was far greater than the original estimated
number. The H1N1 virus was the leading reason for hospitalization during the peak of the
second wave. The Ontario emergency departments were greatly impacted by the patients
with flu like symptoms in the fall of 2009. During the outbreak the H1N1 virus cost the
acute care system close to 200 million, which is not including all the physician fees.
(Canadas Response, 2010)
Patients admitted to hospitals came in much greater numbers than in a baseline flu
year. Hospitalized patients were more likely to be pregnant/postpartum or to have asthma
and other chronic lung disease than in a baseline flu season. H1N1 patients were also
more likely to need hospitalization and ventilation than typical flu patients. (Canadas
Response, 2010)

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Solutions

If one feels seriously ill, one should always visit a health care provider. Only a
health care provider can know for sure if conditions require medicinal treatment or if bed
rest and fluids are that is needed (Fightflu, 2015). Public health leaders say that the best
way to control the spread of influenza is the use of vaccines. (Vaccine Development,
2013)
The development of new vaccines, increased vaccine production and regionally
appropriate strategies for vaccine use are essential to be able to meet the global
populations needs during seasonal as well as pandemic outbreaks. PATH is doing what
they can to respond to these needs by implementing multiple strategies to expand flu
vaccine solutions that will be optimal for the developing world. (Vaccine Development,
2013)
Accelerating the development of new influenza vaccines that can be accessible as
well as affordable for people in low resource countries in the flu outbreaks. As well as
helping emerging country manufacturers produce flu vaccines for pandemic preparedness
is what PATH is trying to accomplish. Doing this would make the fight against influenza
stronger. (Vaccine Development, 2013)
Influenza vaccine has become much of a routine in developed countries. Although
in developing countries there are many barriers to the affordability as well as the
availability making vaccines inaccessible to the developing world. (Vaccine
Development, 2013)

Middel 31
Alternate vaccine strategies are needed that can break down these barriers and
bring effective protection to underserved populations. PATH is trying to develop new flu
vaccines that can be accessible, affordable, and available to people in low resource
countries during the flu outbreaks. PATH strives to create clinical studies in low resource
countries. These studies are designed to inform future flu vaccine development efforts as
well as public health decisions on flu vaccine use in the developing world. (Vaccine
Development, 2013)

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Appendices
Appendix A:
Map of India.

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Appendix B:
Indian students wear masks for
protection against swine flu, as
they attend class at a school in
Ahmedabad, in the state of
Gujarat, March 2, 2015.

Appendix C:
Purvi, a 6-year-old patient in the
swine-flu ward of Civil Hospital,
Ahmedabad.Zahir Janmohamed

Appendix D:

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Cubas Location on the Earth.

Appendix E:
World map with Kuwaits location.