Aarti Rawal (name changed) is a 27-year-old resident of Delhi. In 2025 for the first time, Rawal took the flu vaccine on her doctor’s recommendation, “after a spell of long Covid in 2023 and 2024 messed up my health”, she said. “I’d get recurrent bronchial attacks exacerbated by winter pollution.”
When she repeated the shot in spring this year, she got her family to take it as well, even though they showed some reluctance. “They didn’t think it was necessary,” said Rawal.
Despite frequent travel within India and abroad, Rawal noticed that she was not falling sick as much as before, which, she said, “was a welcome relief”.
She has also been spared, so far, during Delhi’s present surge in influenza cases.
ISignal spoke with four doctors, all of whom affirmed Rawal’s experience in the context of the present surge of swine flu: People of all ages, including children, who have taken the flu shot have either not fallen sick, or experience milder symptoms.
Swine flu, also known as H1N1 flu based on the virus that causes it, is categorised as Influenza A, a serious form of the flu in terms of morbidity and mortality. India typically sees two influenza seasons, one from January to March and the other after the monsoon sets in.
“India’s swine flu mortality rate hovers between 2-5%,” said Anupam Prakash, director professor and head, Department of Medicine at the Lady Hardinge Medical College & Associated Hospitals, Delhi.
Swine flu morbidity and mortality can largely be reduced by vaccination. But while the influenza vaccination is readily available in India, only 1.5% adults aged 45 or older had ever taken the vaccine, according to the Longitudinal Ageing Study in India 2017-18.
India’s immunisation focus has so far been on infants, children and pregnant women. In the 12-23 month age group, the full immunisation coverage is 87.1%, although the National Immunization Schedule excludes the influenza vaccine.
But with the country’s demographic profile poised to change—the above-60 age group is estimated to compose 15% of India’s population in 2036 as against 12% in 2021—India’s health guidelines will need to adapt, Agam Vora, a chest physician based in Mumbai and joint secretary, Maharashtra state chapter of the Association of Physicians of India, told ISignal.
With a flu vaccine priced around Rs 2,000, pushing adoption among the masses would mean making it available for free at least to vulnerable categories among the less privileged, through government channels. For context, the poorest 20% households have a monthly expenditure of about Rs 12,000-18,000 for a family of five.
However, despite influenza causing around 125,000 deaths annually, about half of these in older adults and a fifth in children aged less than 5, at present, the flu vaccine is neither available for free to adult beneficiaries of say, the National Food Security Act, nor to infants.
“We presently don’t have evidence to support the inclusion of the influenza vaccine in the free government vaccination programme,” said Raj Shankar Ghosh, a public health specialist. “While debility is high, the fatality rate is still too low to justify the investment.”
But the fatality rate depends on both testing and counting deaths.
For instance, doctors whom ISignal spoke with said that in the present influenza surge, they only sent cases for testing if they needed hospitalisation. If the testing were as widespread as during the Covid-19 pandemic, when even people recovering at home were tested, the case load would significantly increase, which means the fatality rate would be lower than the 2-5% cited by experts.
But influenza may not be the direct cause of death in many cases. It is known to exacerbate comorbidities such as diabetes and heart conditions, leading to deaths. If such mortality were considered, the rate would be higher.
Vaccination key to reducing the burden of influenza
Disease burden refers to the impact of sickness on a population, measured by death, permanent and temporary disability, and financial costs.
In the case of pneumonia, for instance, Ghosh explained that the available evidence—specifically, the current fatality rate and hospitalisation burden—support making the pneumococcal vaccine free for vulnerable people.
Vulnerable people include those with non-communicable diseases, or elderly outdoor workers, transport sector workers, manual workers, said Ghosh. “Simple lung function tests such as spirometry can be used to confirm beneficiaries.”
Still, the government administers the pneumococcal vaccine for no charge only to children, not to adults.
In the instance of influenza, Ghosh said, evidence that would justify the vaccine’s inclusion in the adult immunisation schedule is still missing.
India lacks a publicly-funded seasonal influenza immunisation, partly because cost-effectiveness is yet to be established.
Yet, a study published in the April 2026 edition of Influenza and Other Respiratory Viruses, and another study published in the July 2025 edition of the Journal of Medical Economics confirmed the efficacy of introducing the seasonal influenza vaccination in two separate cohorts—adults aged 60 and above, and healthy adults aged 18-65 and pregnant women respectively. One study concluded that vaccination would “also likely reduce out-of-pocket spending for treatment, one of the focuses of the current Indian government”, and proposed private sector partnerships to make the influenza vaccination accessible.
Administering the quadrivalent flu shot to healthy adults aged 18-65 and pregnant women helped reduce the days they took leave from work because of sickness, and consequently, lower expenditure on health by about Rs 12,500 per person, as against unvaccinated people.
Flu shots need to be administered annually based on virus mutations, as we explain below. This needs sustained funding every year, unlike the Covid-19 vaccine which was a two-dose vaccine that was only needed once, or the pneumococcal vaccine that is administered twice at infancy and recommended as a booster for high-risk adults and elderly adults.
ISignal has reached out to the Ministry of Health & Family Welfare for a comment on what the government is doing to promote awareness of and the uptake of the flu vaccine. We will update this report when we receive a response.
2026 flu status: H1N1 cases up, H3N2 cases down, symptoms more severe
The Indian Council of Medical Research influenza dashboard reports higher numbers of swine flu or H1N1 cases across India in 2026 as compared to the previous year. However, the overall number of flu cases is similar to previous years.
Specialists ISignal spoke to ratified this, saying the overall number of flu cases they were seeing in the clinical setting was similar to previous years. They attributed the higher swine flu test outcomes to greater awareness, readily available laboratory facilities and more testing.
Sub-clinical infection—with minimal or no outward symptoms—is widespread, explained Prakash, adding that “the more you test, the more positive cases you will identify”.
However, Prakash said the intensity of symptoms flu patients were presenting was definitely more severe this year. “Patients are experiencing severe body ache from the onset itself and high fever (103-104 degrees F), besides the usual flu symptoms,” he said.
The Ministry of Health and Family Welfare has listed fever, cough, sore throat, runny or stuffed nose, and breathing difficulties as the typical symptoms of swine flu.
Aakashneel Bhattacharya, an infectious diseases specialist practising in Gurgaon, spoke of seeing “patients in their thirties, so weak, that they needed support from their vehicle to his clinic”.
“Swine flu is debilitating irrespective of the patient’s age,” he said.
Bhattacharya has also seen a lingering dry cough in patients after the fever is resolved.
Among infants and children, patients have presented with the sudden onset of sore throat, cough, cold, myalgia (body ache), high fever (103-104 degrees F), and febrile seizures triggered by the fever, according to Supraja Chandrasekar, director of paediatric services at DHEE Hospital, Bengaluru.
“Prescription medicine such as an antiviral is used if the symptoms are severe, or don’t respond to the usual medications, like fever not responding to paracetamol or an NSAID, or if the child is unable to retain fluids (vomiting), or the coughing is severe especially through the night, or the child is looking dull,” she said. “And paediatric patients with breathing difficulties such as breathing too fast or wheezing or needing nebulisation or febrile seizures are best hospitalised.”
Specialists across medical disciplines recommend the influenza vaccine
While scientific evidence for the inclusion of the influenza vaccine in the government adult immunisation schedule is missing, doctor associations have included it in their recommendations.
On August 24, the Association of Physicians of India presented to the Governor of Maharashtra a comprehensive framework for adult immunisation in India developed by the Indian Medical Association (IMA) in association with 23 societies representing different medical specialists, such as Cardiology Society of India, Chest Council of India, Federation of Obstetric & Gynaecological Societies of India, Geriatric Society of India, Indian Society of Nephrology, Indian Society of Oncology, Research Society for Study of Diabetes in India, Indian Academy of Geriatrics, etc.
“Usually, every specialist recommends vaccines based on their perspective, [so] we wanted to create a guideline that wouldn’t confuse patients with multiple health conditions,” said Vora, joint secretary of the Maharashtra state chapter of the Association of Physicians of India.
The framework, Unified Consensus on Adult Immunization 2026, recommends the flu vaccine for at-risk individuals such as those with non-communicable diseases, high-risk individuals with compromised immunity due to diseases like cancer or chronic kidney disease, those whose lifestyle compromises their immunity such as smokers or alcohol consumers, people who expect to travel or attend mass gatherings, and those above 50 years of age because that coincides with the setting in of immune senescence, the gradual age-related decline of the immune system.
A step further, Vora questioned the immunity of every person living in polluted cities. With research showing that pollution lowers immunity, and can even cause diabetes, he said residents of metros and large cities have compromised immunity. So, he recommends the influenza vaccine to adults across the board.
For children, the Indian Academy of Paediatrics guideline suggests that children from the age of six months to five years must take the flu shot annually.
The flu affects people of all ages, and children are especially vulnerable.
“After the age of five, the vaccine is optional, and recommended only to high-risk cases, such as children with asthma, or heart diseases, or on long term steroids, etc.,” explained Chandrasekhar.
WHO annual flu vaccine recommendations take cognisance of virus mutations
A decision about which flu vaccine to take is best left to a physician. Since 1973, the World Health Organization (WHO) has been recommending the appropriate composition of the influenza vaccine based on the WHO Global Influenza Surveillance and Response System’s review of circulating strains, separately for the Northern Hemisphere and Southern Hemisphere, in February and September respectively.
Essentially, because viruses periodically mutate, the vaccine must cover the latest strains.
Popular vaccines protect against the most prevalent three or four variants, and are consequently called trivalent or quadrivalent respectively.
Pharmaceutical majors in India offer both the intra-muscular vaccine made for the Northern Hemisphere and Southern Hemisphere. “Considering the pre-monsoon months are the best time of the year for Indians to get the flu shot, for the strongest protection during the humid monsoon when influenza peaks, we can opt for the latest Northern Hemisphere vaccine,” said Chandrasekhar.
A nasal spray variant is also available but Bhattacharya said the intra-muscular version is preferable.
The flu vaccine is manufactured every year, and those getting vaccinated must ensure the latest strain is used.
“Avoid backlog vaccines of the previous year,” cautioned Chandrasekar.
