Swine flu has killed 183 people in Ukraine this winter and is spreading rapidly across eastern Europe and the Middle East. At least 107 people have died in Russia after contracting the disease, 18 in Armenia and 10 in Georgia, according to government figures.

In the Middle East, 112 deaths from the virus have been reported in Iran and there are unconfirmed reports of dozens more deaths in areas of Syria and Iraq occupied by Islamic State.



Rates of severe H1N1 infection have spiked within the EU. Hospitals in eight countries have recorded an increase in the number of cases requiring intensive care over the past three weeks, according to the World Health Organisation (WHO).



“Western European countries are also reporting severe cases associated with H1N1,” said Dr Caroline Brown, programme manager for influenza at the WHO in Europe. “It’s all over the region at the moment.”



Unlike other strains of the flu virus, which are most dangerous for older people, H1N1 can be life-threatening for healthy people under the age of 65. Symptoms can appear similar to the common cold and include fever, fatigue, coughing and a sore throat – but the disease can quickly lead to pneumonia if left untreated. The US Centers for Disease Control and Prevention estimates that the 2009-10 global H1N1 pandemic caused an estimated 284,000 deaths worldwide.



Vaccination programmes and residual immunity were thought to have kept the virus under control. Experts are struggling to determine why the latest outbreak is proving so aggressive.



“The information we have so far shows the virus hasn’t changed in any significant way to make us suspect it would be causing more severe disease,” Brown said.



In Ukraine, the health ministry says 3,000 people a day are now being hospitalised with flu. More than 3.2 million people have been diagnosed since 1 October 2015 – 63% of whom are under the age of 17.



“Because of what’s happening this flu season we’re looking very carefully at this younger age group that is affected,” Brown added. “We think the data shows that most of the people severely affected have underlying conditions.”



Schools in the country are closed for a third consecutive week and all public-facing workers have been ordered to wear surgical masks in an effort to hamper transmission of the highly contagious illness.

The WHO has deployed an epidemiologist from Public Health England, Sophie Newitt, to support Kiev’s response to the outbreak, but the Ukrainian healthcare system – handicapped by war, economic crisis and years of mismanagement – is struggling to cope.

Countries where the H1N1 virus is circulating, including Ukraine, can expect an increase in the level of severe disease and death in high-risk groups, according to the WHO. The vaccine for the 2015–16 season in the northern hemisphere includes H1N1, H3N2 and B virus strains – closely related to those circulating among people. The vaccine is therefore expected to provide good protection.



But less than 1% of Ukraine’s 45 million inhabitants have been vaccinated against the flu, and potentially life-saving treatments are in short supply. State hospitals usually dispatch patients to private pharmacies to buy medicine, but, despite a recent donation from Lithuania, there is a nationwide shortage of the anti-viral drugs Tamiflu and Relenza.



“Last Sunday my sister complained that she had difficulty breathing,” said Svetlana Yatsenko, whose 44-year-old sister, Tanya Polonsky, was diagnosed with H1N1. “The clinic took x-rays and said she had pneumonia. They took her by ambulance to the hospital, where we were given a list of the drugs we had to buy, including Tamiflu. We were only able to find them on Wednesday, but by then Tanya was already in intensive care. She died shortly afterwards. She left behind her six-year-old son.”



Access to medical care is even more limited in the country’s war-torn eastern regions. Kremlin-backed rebels have banned several international aid organisations from the territory under their control and heavy fighting has destroyed much of the medical infrastructure.



Hundreds of doctors, nurses and paramedics fled the area during 22 months of fighting, which has left more than 9,000 people dead and 2.7 million displaced. Others simply left after months without pay, cut off from the government in Kiev by trenches and checkpoints.