Practices must use current guidance and work with local agencies to develop plans that may reduce the impact of ’flu and save lives, say Dr Mairi Scott (left) and Tom Love
Although the precise timing of an influenza pandemic cannot be anticipated, they typically occur at intervals of a few decades, with recorded twentieth century pandemics in 1918, 1957, and 1968. A future outbreak of pandemic influenza is therefore inevitable.
Health systems need to be prepared to deal with the logistical challenges associated with an influenza pandemic. These difficulties are likely to be compounded by disruption in the wider provision of public and private services, such as schools, transport links, and commercial supply chains.
Historical patterns suggest that a pandemic will arrive in one or more waves, which may be weeks or months apart. Individual waves could last approximately 15 weeks from beginning to end, with typically 22% of all cases in the peak week.1 However, the waves may be of shorter duration with a larger number of cases at the peak, or more prolonged with a less intensive peak level of cases. The planning assumptions that have been adopted in the UK consider a clinical attack rate in the population of up to 50%, with a case fatality rate of up to 2.5%, as a reasonable worst case scenario.1 Up to 28.5% of patients may require assessment by a GP or other healthcare professional,2 and up to 4% of symptomatic patients may require hospital treatment if resources are available.1
Clinical attack rates will also apply to health professionals, and small organisations such as general practices may see absentee rates of 30–35% over the 2–3 weeks of the peak period.1,2
Preparation and planning
The World Health Organization (WHO) defines six phases in the emergence of a pandemic: Phase 4 and 5 alerts are declared when there are clusters of cases with person-to-person transmission; and a WHO Phase 6 alert is declared when there is sustained transmission among the general population.3 Within the WHO Phase 6 period, four alert levels will be declared within the UK, which correspond to distinct periods of activity (see Table 1).
Guidance for the health sector in the event of an outbreak of pandemic influenza is available within England,2 Wales,4 and Scotland,5 and is in preparation for Northern Ireland.6 A public information campaign is a key part of the national preparation for a pandemic. Information for the public will include comprehensive advice about preventing infection, self-care in the event of contracting influenza, and where to access services.
At the local level, general practices must be able to draw upon their own plans and preparation for a pandemic, but these will need to fit within a locally coordinated framework developed by the relevant PCT or Health Board. Local coordination and planning will address such issues as:2
- coordinating continuity of service across practices (and consolidation of service in the event of some practices closing)
- officially suspending non-essential activities where necessary
- communicating information on services to the local population
- ensuring consistent application of criteria for access to health services
- linking with local authority services such as social care, housing, and transport services.
Table 1: Alert levels for transmission of pandemic influenza
|WHO Phase||UK alert level||Actions|
Phase 4: small clusters with limited person-to-person transmission
Phase 5: large clusters with localised person-to-person transmission
Phase 6: increased and sustained transmission in the general population
Level 1: no cases in the UK
Public information on:
Level 2: virus isolated in the UK
Level 3: outbreaks in the UK
Level 4: widespread activity across the UK
The specifics of the patient pathway in the event of a pandemic will vary at regional level depending upon local differences in the available health workforce, geography, and the infrastructure of both primary and secondary care in the area. These patient pathways will mean that:2
- members of the public will be encouraged to remain at home if they are symptomatic
- where possible, people with influenza-like symptoms will be assessed via telephone services, and patients should make arrangements for the pick up of any necessary medicine
- people with a high risk of complications, such as the elderly and the very young, will be assessed by a GP or other appropriate healthcare professional
- where locally feasible, GPs will be able to refer patients to:
- self-care at home
- home care services
Some common elements will be implemented across the UK, for example, there will be nationally accessible telephone services for the initial assessment of people with influenza symptoms.1
Planning in general practice
General practices and associated primary care teams should develop their own action plans for a pandemic, based on the guidance available. Plans should identify areas for immediate action, areas for delayed action, and areas that will require consolidation at times of maximum activity.
Scope of plans
It would be worthwhile considering the following points during development of action plans:
- the practice should identify a clinical lead (usually a GP) and an administrative lead (usually a practice manager). In larger practices it might be possible to identify both a lead and deputy to allow for absence from work during a pandemic
- the leads should review the literature and guidelines around pandemic influenza. National planning documents and guidelines are the starting point, but should be supplemented by information about local coordination arrangements from the PCT or other local health authorities
- the leads should consider how the following key areas will be addressed in the practice:
- roles and responsibilities both before and during the pandemic
- ethical decisions
- clinical aspects of management
- liaison with secondary care services
- infection control
- decisions about which normal clinical activities can be stopped and in what order
- decisions about how this will be communicated to other members of the team and patients
- planning for resumption of normal activities
- actions should be prioritised and set out within the time frame of pandemic alerts detailed in Table 1. Those actions that can only be addressed later should be flagged for key personnel to ensure delivery at that later stage.
Individual general practices will need to have plans for service continuity that address the safety of the staff, the maintenance of essential infrastructure, and response in the event of staff illness. Joint RCGP and BMA guidance has been developed for this.7 Such plans will have to take into account any locally coordinated continuity arrangements among general practices, pharmacies, and other community health providers.
During a pandemic, health professionals and patients will face difficult decisions. The ethical framework for policy and planning produced by the Department of Health is intended as a tool to assist clinicians and others in developing their own policies on clinical issues.8 There is no suggestion that there are right or wrong answers to these kinds of decisions: practices and primary care teams should work with this guidance to develop their own protocols.
It will be important in the case of a pandemic to record the underlying clinical and other reasons that lead to decisions, in the event of future challenge. As clinicians will be exceptionally busy, it may be helpful to create in advance a decision-making grid for clinical records.
The key guideline for clinical management has been developed by the British Infection Society (BIS), the British Thoracic Society (BTS), and the Health Protection Agency (HPA) in collaboration with the Department of Health.9 The guideline includes flow charts and tables, which can be used as a basis for local and individual practice-based protocols. In particular the section on clinical management in primary care covers most areas that individual practices should consider in their plans:9
- triage—assessment of severity of infection and whether a high-risk patient is involved
- general advice and treatment of symptoms in adults—including treating fever, resting, and drinking plenty of fluids
- management in children—treat symptoms along the same principles as for adults unless the child has high fever (>38.5°C): if aged <1 year or high risk of complications, assessment should be undertaken by a GP or at accident and emergency department; older children, under 7 years, should see a nurse or GP; children >7 years can be assessed by a member of the community health team
- when patients should re-consult and with whom—if the patient did not consult a physician in the first instance, re-consultation should involve a physician, usually a GP (see Box 1)
- investigations relevant in the community—including microbiological tests to confirm that influenza is circulating
- referral criteria for hospital care—for example, in case of influenza-related pneumonia
- the use of antivirals and antibiotics.
The appendices to the guideline include further information relevant for primary care, and should be copied and placed in all consulting rooms, key office areas, and also in each clinician’s individual bag. Of particular relevance are:
- Appendix 2: Patients at high risk of influenza-related complications—practices should use this to identify patients within their own practice who are in the high-risk group for complications. Flagging a patient’s records as high-risk will support rapid triage decisions later
- Appendix 3: Initial management of adults referred to hospital—practices should identify their own local pathways and also providers for more complex equipment, such as intravenous fluids or oxygen therapy
- Appendix 5: Initial assessment and management of children—the treatment of children requires careful consideration, as the clinical presentation of influenza can be confused by other common upper respiratory tract infections, which are normal during childhood.
Box 1: Symptoms that should prompt patients to re-consult for further medical help
|Important note: this information may be modified once a pandemic occurs|
The joint guideline from BIS, BTS, and HPA identifies repeat consultations as an important area, not only because of the increased workload, but also because of their importance in detecting the onset of clinical complications. Clear criteria for re-consulting are shown in Box 1.9
It is important that not only reception staff or those who are triaging patients are aware of these criteria, but also that patients themselves know when they should re-consult. Practices should consider how best to convey these important messages either by leaflet, notice, telephone messaging, or via web-based information.
Pneumonia is the commonest severe complication that can necessitate admission to hospital. The CRB-65 scoring system is based on one point for each of: Confusion; Respiratory rate ?30/min; low systolic (<90 mmHg) or diastolic (?60 mmHg) Blood pressure; age ?65 years (CRB-65 score;10 see Box 2). This scoring system is a useful guide and could be used when resources are scarce to allow consistency in access to secondary care. The importance of this will increase if secondary care resources reach capacity.
Box 2: Severity assessment used to determine the management of
influenza-related pneumonia in patients in the community (CRB-65 score)9
|CRB-65 score||Recommended action|
|0||Probably suitable for home treatment|
|1 or 2||Consider hospital referral, particularly with score 2|
|3 or 4||Urgent hospital referral|
|Any (0 to 4), in the presence of bilateral chest signs of pneumonia||Consider hospital referral|
|Score 1 point for each feature present: confusion (mental test score of ?8, or new disorientation in person, place, or time); respiratory rate ?30/min; blood pressure (systolic blood pressure <90 mmHg or diastolic ?60 mmHg); age ?65 years
Reproduced with permission from Thorax 2007; 62 (suppl 1): 1–46
National guidance on infection control is available from the Department of Health.11 A major consideration in a primary care setting is for all staff to demonstrate good practice to patients and the public. This will include providing tissues and safe disposal of tissues in the waiting areas and elsewhere in order to minimise droplet spread, and being seen to wash their hands after every patient contact, both in the consulting rooms and at a patient’s home. The policy around appropriate use and provision of personal protective equipment, such as gowns and masks, will be part of every local health authority (or board) plan.
Bereavement and deaths
Changes in legislation around certification of deaths and cremation are being considered in order to cope with a large number of deaths.2 However a vital traditional role of primary care is bereavement support. The workload implications of this, as well as the personal challenges of coping with such deaths, might mean that traditional coping mechanisms for primary care staff may be too time consuming. A mentoring or a buddying system of support might be the most time-effective way to manage this, and should be set up in advance.
Pandemic influenza will present a substantial challenge to the health system overall. Primary care services will be at the front line of a pandemic, and must be prepared to cope with a high level of demand for care, aggravated by interruptions to usual supplies and staff availability.
National and regional agencies have released guidance on the planning process for primary care. While this guidance continues to evolve in light of new information about the likely development of a pandemic, there is currently enough information for individual general practices to evolve their own local pandemic influenza plans, and to work with local agencies and other healthcare services to develop theirs.
Early preparation for a pandemic will save lives and minimise the impact on patients and on primary care staff themselves.
- Statistics predict that a global influenza pandemic is due to occur soon
- PCTs have already drawn up plans for dealing with pandemic influenza, often with little input from PBC groups
- As PBC consortia take on more responsibilities they will be expected to take an active role in such planning
- PBC clinicians could help design and agree local care pathways for practices to use in the event of a pandemic
- PBC consortia are ideally placed to coordinate a series of plans for local practice populations and build these into the PCT strategic plan
- Cabinet Office, Department of Health. Pandemic flu: A national framework for responding to an influenza pandemic. London: DH, 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080734.
- Department of Health. Pandemic influenza: guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England. London: DH, 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080757.
- Department of Health. Pandemic alert phases. www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/DH_065157.
- National Public Health Service for Wales. Health protection—Preparing Wales for a pandemic. www.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=29352.
- The Scottish Government. Pandemic Flu: A Scottish framework for responding to an influenza pandemic. Edinburgh: The Scottish Government, 2007. www.scotland.gov.uk/Publications/2007/11/21141855/0.
- Department of Health, Social Services and Public Safety. Northern Ireland interim contingency plan for health response for an influenza pandemic. www.dhsspsni.gov.uk/index/phealth/php/infectious_diseases/pandemicflu/pandemic-contingency.htm.
- BMA, RCGP. Flu pandemic preparations, service continuity planning. 2006. bma.eu/ap.nsf/Content/flupanprep.
- Cabinet Office, Department of Health. Responding to pandemic influenza—the ethical framework for policy and planning. London: DH, 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073179.
- British Infection Society, British Thoracic Society, and Health Protection Agency. Pandemic flu; clinical management of patients with an influenza-like illness during an influenza pandemic. Provisional guidelines from the British Infection Society, British Thoracic Society, and Health Protection Agency in collaboration with the Department of Health. Thorax 2007; 62 (suppl 1): 1–46.
- British Thoracic Society. Guidelines for the management of community acquired Pneumonia in adults—2004 Update. www.brit-thoracic.org.uk/ClinicalInformation/Pneumonia/PneumoniaGuidelines/tabid/136/Default.aspx
- Department of Health. Pandemic influenza: Infection control guidance. London: DH, 2007. www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/DH_085433.G