There are cafés that lull us into believing that all our woes will dissolve into thin air only if we relish that extra cup of cappuccino. For Sudeshna Saxena, a 27-year-old freelance illustrator and graphic designer based in Bengaluru, an unassuming visit to her favourite café in the city turned out to be a nightmare.Make no mistake: The iced latte was all right and the croissants fresh enough. Only her hair was wet and she was sitting right under the AC vent of the café. A day later, the cold gripped her. Or, so she thought. “It was the week when it rained heavily in the city, no thanks to the cyclonic disturbance in Tamil Nadu,” she recounts. “I didn’t think it was the flu until I started waking up every day over the next 10 days with sneezing fits and a runny nose that just wouldn’t stop.”
Saxena describes the sneezing as “almost violent”, unlike anything she had experienced before. The Dolos didn’t work, the runny nose was so endless that she had to give up on tissues and instead go for copious rolls of kitchen towels. “In this period, I had brain fog for more than a week with a stiff neck, heavy head and just all-around heaviness,” she adds. “Normally, I don’t fall sick, so I didn’t have anything at home for immediate relief and it didn’t help that I’m generally reluctant to seek aid.”
The root of it all?
A resurgent influenza season, causing a ‘twindemic’ with the rising number of Covid cases, or even a ‘tripledemic’, with a third pathogen, respiratory syncytial virus, or RSV, in the mix. Across India and the world, hospitals are stressed by these parallel surges. The Atlantic has called this “the worst paediatric-care crisis in decades”. In America, in December, the Center for Disease Control (CDC) director Rochelle Walensky said in a press conference that nearly 17 out of every 100,000 people in the country have the flu and that it's “the highest we’ve seen at this time of year in a decade”. As far as India is concerned, although the National Centre for Disease Control (NCDC) hasn’t publicly issued a statement concerning the rise of flu cases, it reports that as of November 30, 2022, there were 12,881 reported cases related to the flu and 399 deaths.
Over the past few months, the surge of the tripledemic has manifested differently in our cities. While there is no direct link between Covid and flu—immunity against one does not guarantee protection against the other—the ramifications of rising cases of the two are increased hospitalisations and rising demands of medicines, pain relievers, etc. The common reason attributed to a “change in the weather” no longer holds ground at a time when cases such as Saxena’s show us that the flu this time has taken on a much stronger, darker hue.
So, what are the factors behind the sudden rise in cases, and subsequent hospitalisations this time? What really makes the past few months the worst for flu in almost a decade? Apart from localised factors such as high pollution, the primary reason attributed to the rising flu cases, according to CDC, is that people have weakened defences after not being exposed to flu and RSV because they have been working or schooling from home during the pandemic. Across the world, the rates for flu vaccinations in vulnerable populations—such as those 65 and older, children and pregnant women—are also at an all-time low.
Understanding the flu
“There has been a spike in cases related to the upper respiratory tract and existing lung infections,” says
Dr Hemalata Arora, senior consultant at internal medicine and infectious diseases at the Nanavati Hospital, Mumbai. “It’s possible that this might be the worst flu season ever because when it comes to cities like Delhi and Mumbai, it’s compounded with air pollution.”
From a technical perspective, Arora explains that the telltale signs of a particularly bad flu season include a rise in cases of pneumonia, entire families catching the flu, and children and other vulnerable groups in the population such as pregnant women and the elderly getting badly affected.
“We have to understand that the ‘tripledemic’ phrase refers to all three viruses surging in the population at once, not necessarily and not usually in the same person simultaneously,” says Dr Indu Bubna,
a pulmonologist with a private practice. “There are intermittent spikes of these viral infections coming in that first affect patients who are immunocompromised.”
The flu, put simply, is a viral infection that is spread through the air. Influenza is caused by three types of viruses called influenza types A, B and C (considered different genera), which all belong to the family Orthomyxoviridae. The disease, colloquially called ‘flu’ in humans, is generally caused by viruses A and B. Only a fraction of influenza A subtypes (H1N1, H1N2 and H3N2) are currently in general circulation among people.
Bubna says it affects the respiratory system first because that’s the most common route of the virus to enter your body. With patients having lung fibrosis, asthma and other respiratory conditions, the flu virus only adds to their woes. Depending on the virus and its many variants, viral diseases are further classified as ‘flu viruses’. In 2016, the California strain and the Michigan strain were circulating in India. “So, whenever we are talking about flu, we’re referring to the virus named influenza,” says Dr Jagruti Sanghvi, a Mumbai-based paediatrician.
“There is seasonal influenza that manifests as the common cold and the more severe kinds such as H1N1 or swine flu. These are known as ‘severe’ because there are usually multiple organs involved here apart from just the lungs, and are spread via air droplets in the air while talking or sneezing, and fomites that are objects or materials which are likely to carry infection, such as clothes, utensils, and furniture.” She adds that it’s difficult to identify which particular flu or influenza variant is affecting an individual. One could have anything ranging from the ‘seasonal’ flu that goes away within a week to more ‘severe’ flu in the form of H1N1, RSV and even the coronavirus.
“It’s important to get yourself tested so that you’re aware of what exactly you’re infected with,” Dr Sanghvi suggests. “Often, you might not even know how immunocompromised you are and if the viral load is high because it’s a severe flu, it could be dangerous.”
In Kerala, the avian or bird flu has taken deep roots. Three weeks ago, over 6,000 birds were culled in the state’s Kottayam region. The current outbreak is not new. Between early 2013 and early 2017,916 lab-confirmed human cases of H7N9, the most common variant of bird flu, were reported to the World Health Organization (WHO). In June 2021, the bird flu strain H10N3 infected a human being, a first, in China. However, experts have always clarified that such a case occurs only when there is prolonged contact between the human and the infected bird.
Navigating the tripledemic
As the popular quote by science writer, Ed Yong, goes, “Immunology is where intuition goes to die.” Do we know for certain why that friend gets infected with Covid every third month despite being fully vaccinated? Or, why does a young patient with no comorbidities succumb to the virus? In the case of Charu Gaur, the 39-year-old founder and editor of Runway Square, a digital fashion and lifestyle portal, the flu presented itself as a mystery that persisted over three days.
“I got the flu in September 2022 where I first thought it was Covid, got tested and it wasn’t and then I had severe headaches and fever, and I got tested for dengue and it wasn’t that either,” she says. “It was only after three days and endless tests did I find out it was a severe case of flu.”
Gaur says there is a theory that most of us have let our guard down because the waning of Covid cases made us too complacent. After a heady cocktail of kadha that had ginger, basil leaves and honey, and some antibiotics, the fever subsided after six days, the weakness subsided only seven days post that, and it took three more weeks to get rid of the sore throat. The reasons? She can’t pinpoint any specific ones. “I smoke and drink, so maybe that had something to do with it? I don’t quite know.”
In the case of Aman Gurung, a 21-year-old student from Delhi, the flu lasted for two weeks. The usual telltale symptoms persisted: splitting headaches, dry cough, sweating, fever, blocked nose and sore throat. A diagnostic test confirmed that it was indeed the flu. He tried the whole platter—cough syrups, drinking warm water with organic herbs (ginger, black pepper, herbal tea), and citrus fruits rich in Vitamin C.
What explains the long gestation period of the flu this season? According to ENT surgeon Dr Hashmi Mohammad Syed, the virus of the common flu remains in the body only for a week at the most. If a patient still grapples with its symptoms or its after-effects, there is more at play than just the virus.
“The life cycle of the influenza virus is seven days, but patients end up getting secondary bacterial infections,” he explains, adding, “So they go into an inflammatory stage and end up getting infected with bronchitis that prolongs the illness. These are often known as superadded bacterial infections. Some of the post-viral inflammatory signs include nasal discharge and bronchitis.”
Experts agree that vaccines are generally effective against these flu variants. In this sense, one must get vaccinated in a structured manner, as there are two primary flu seasons, regardless of the variants: the monsoon and winter seasons. “So, it’s advisable to get vaccinated before these seasons begin so that you’re protected against these viruses,”says Arora.
According to Syed, almost every year, the vaccines keep getting updated because these viruses keep mutating and evading vaccine protection. So, it becomes crucial that one is updated about the latest influenza variants and if there are vaccines for those new variants and mutations. Such a chart is released by the Ministry of Health and Family Affairs.“When a patient comes to the OPD or clinic with common flu signs, the first approach is to treat them symptomatically and the treatment becomes rigorous only when the patient is not responding to the basic treatment,” explains Syed.
He adds that the current surge of cases due to the tripledemic can be attributed to three primary factors: the virus itself, the change in climatic conditions, and the human factor, in terms of our lifestyle choices. “The virus survives because it stays in society and it becomes less virulent over a period of time because our immune system trains itself to protect us. It’s always a cat-and-mouse game.”
Both Syed and Bubna agree that vaccines and treatment can only go so far in curbing the effects of the flu. In order to prevent these tragic spikes, experts advise major lifestyle changes, which include frequently exercising, letting the treatment take its due course, and healthy eating.
“We have so many patients coming in with the common flu who want to get treated in a day because they have a meeting to attend or a flight to catch,” says Dr Syed. “For any disease, the first treatment is rest, which seems impossible in today’s world. If they can rest for the first few days, the illness wouldn’t get prolonged. How can the body take the dual stress of fighting the virus and also attend meetings and meet deadlines? Not to mention that they are in an active stage of infection. The body gives in and then they are forced to rest for a month.”
Dr Sanghvi clarifies that there is no specific vaccine for RSV and that basic hygiene measures always come in handy. The dynamic change of vaccines, considering the changing nature of diseases, further demands keeping our basics intact. In such a scenario, there is always an attempt from scientists and the larger medical fraternity to come up with innovative and easy-to-track ways of distributing vaccines. The recent government approval for a nasal vaccine manufactured by Bharat Biotech to fight Covid in wake of the global resurgence of the virus is also a continuation of the same.
The landscape of immunity
A better part of the questions around who gets infected and who does not can also be explained by the concept of cross-reactive immunity. Here, the adaptive immunity that comes with the body fighting
a particular pathogen can often be instrumental in building protection against a wholly different variant, thus helping us prevent different flu variants without always getting targeted treatment for each. This also explains why smallpox vaccines can inoculate against monkeypox. And yet, the way cross-reactive immunity works in person A can dramatically vary from how it helps person B.
In this sense, to assume that the immunity developed by one’s body against these flu variants might shield one from the rising Covid cases, thanks to cross-reactive immunity, might be misplaced. If anything, this tripledemic of RSV, Covid and the flu has only burdened the health infrastructure.
In such a scenario, it’s always wise to go back to the basics instead of getting all caught up in remembering the names of variants and their molecular makeup. This is where an oft-ignored aspect of building one’s immunity, mental health, which helps us fight the common flu and its severe variants, must be taken seriously. While vaccine protection and a healthy lifestyle are crucial, psychiatrist Era Dutta says there is a specific branch, known as psychoneuroimmunology (PNI) that studies the relationship between immunity, the endocrine system, and the central and peripheral nervous systems.
“So, certain mental health conditions such as depression and heightened stress can lead to repeated infections and make such people more vulnerable to viruses,” she says, adding, “There are numerous studies that prove how people with stress have low antibodies and keep having the common flu.”
Joseph Joy, a 36-year-old marketing manager based in Goa, can see a clear parallel between the rise of his vulnerability to flu and the toxic conditions at his former workplace. Apart from the uncompensated overtime work, unrealistic deadlines and constant screaming matches with his manager that ate into his personal life, Joy suffered massive allergies, a constantly running nose and was always the first person in the room to get infected whenever there was a flu season.
The job lasted for more than three years and Joy remembers getting infected with countless influenza variants every three or four months. “I just didn’t have enough time to heal or rest and my body or the immune system clearly did not want to fight the viruses because it had exhausted itself dry navigating the toxicity at work.”
From a more biological perspective, Dutta explains that stress leads to the release of a chemical called cortisol, also known as the stress hormone that inhibits the flow of the White Blood Cells (WBCs) that would’ve otherwise helped tackle the virus.
Beyond the mental health, vaccine-based and lifestyle aspects of the common flu,Syed believes that global warming and rapidly fluctuating temperatures need systemic changes. “You are sleeping under the fan for a day and then without it because the temperature drops, that affects a lot of things.” In this context, the immunity system takes a backseat and the body goes on an overdrive of navigating a new world with changed drivers. According to a study published in PLOS Currents, the 2012-13 influenza season had an unusually early and severe start in the US, succeeding the record mild 2011-12 influenza season, which occurred during the fourth-warmest winter on record. “Our analysis of climate and past US influenza epidemic seasons between 1997-98 to the present indicates that warm winters tend to be followed by severe epidemics with early onset and that these patterns are seen for both influenza
A and B,” the study noted.
In India, the avian flu surge in 1997 and the swine flu spike in 2009 also coincided with rapidly hot and cold temperatures, unusual for their years. In 2015, the previous worst year for the flu with over 32,000 people infected and nearly 2,000 died, there was widespread criticism for how ill-prepared the Indian medical system was. This led to a growing demand for a national policy for influenza immunisation. In the absence of such a policy, the country is left with basic etiquette to follow doing any viral spread, vaccination and taking the onus of getting tested without assuming what the infection could be, not taking mental health for granted and not expecting a speedy recovery within 24 hours because one is
chasing a deadline.
Symptoms of bad flu
Vaccines and Variants
The flu vaccines available on prescription protect against four different flu viruses—two influenza
A viruses and two influenza B. These vaccines are specific to the tropics and come to India in two tranches, before the monsoon and winter. As per
the latest research, this is the vaccine composition
for 2021-2022:
The Healthy Route