Dr Gerard Panting outlines the potential course and spread of a national and global epidemic, its impact on healthcare resources, and what steps can be taken to prepare for it
- A highly infectious influenza virus is predicted to affect between 25% and 50% of the population, and health professionals will be on the front line
- Assess and treat symptomatic patients promptly—give them antiviral and other medicines if indicated
- Treat people suffering from complications
- Give the public advice and information, and begin a vaccination programme as soon as a vaccine is available
- Control spread of the infection—separate possibly infectious patients from others; ensure staff wash their hands frequently and effectively, at least once between patients, or use alcohol-based handrubs for home visits; issue fluid-repellent face masks to staff who are working with patients and surgical face masks to symptomatic patients; avoid contamination of personal clothing; send home staff who demonstrate symptoms of the infection; instigate a rigorous cleaning procedure
- Be prepared by planning the practice’s response to the pandemic, perhaps as a team-building exercise
The media may currently have lost interest in the prospect of an influenza pandemic, but it is certain that if or when it happens, all the plans for dealing with it will be scrutinised. The key question then will be, ‘Should we have done more to mitigate its impact?’
Guidance available for medical practices on pandemic influenza
There are a number of documents available that provide guidance on pandemic influenza. In May 2006, the British Medical Association (BMA) and Royal College of General Practitioners (RCGP) published interim guidance for medical practices on infection control.1 This was followed in March 2007 by a draft National Framework for responding to an influenza pandemic, published by the Department of Health.2
More recently, in October 2007, a range of infection control training materials were published by the Department of Health. These include a summary of guidance for infection control in a healthcare setting during an influenza pandemic.3
What percentage of the population could be affected?
Predictions based on previous pandemics suggest that a highly infectious influenza virus could affect between 25% and 50% of the UK population,2 and unless an effective vaccine can be manufactured and administered (a process that usually takes 6 months) in advance of the pandemic arriving here, there will be no dispensation for general practice staff.
On the contrary, as was the case with the outbreak of severe acute respiratory syndrome, healthcare professionals on the front line will be among the first casualties.
The infamous Spanish ’flu epidemic of 1918–1919 claimed an estimated 20–40 million lives, with peak mortality rates among those aged between 20 and 45 years.2 Although for the vast majority of survivors there were no residual health problems, some people suffered from complications for the rest of their lives.
The pandemics of 1957 and 1968 caused between one and four million deaths between them, with the young and old being particularly vulnerable.2
The exact scenario of any future pandemic will depend on the characteristics of the virus responsible. The Department of Health suggests that from the beginnings of the pandemic in its country of origin, the UK could expect to see its first cases in just 4–8 weeks. It would spread to all major UK population centres within a further 1–2 weeks, with cases peaking just 50 days after the first cases were diagnosed.2
What happens next would depend on whether there was a single wave of infections, in which case the epidemic would effectively be over after 15 weeks, or whether there were several waves occuring weeks, or even months, apart.
An avian influenza epidemic could be much more serious. Virus A/H5N1 has a mortality rate of over 50%. Should this virus mutate to spread from human to human, the anticipated number of deaths would rise considerably.2
Impact on health services
Although 50% of people affected by an influenza pandemic will be asymptomatic, it will present, as the Department of Health puts it, ‘a real and daunting challenge to the economic and social wellbeing of any country, as well as a serious risk to the health of its population’.2 The challenge for every UK general practice will be just as intimidating, even for those that are well prepared.
Hospital admission rates will inevitably rise. Across the UK there are approximately 160,000 hospital beds with 4000 designated for those requiring critical care. However, even if all elective work is stopped, hospital overcrowding is considered to be an inevitable consequence of an influenza epidemic, and medical supplies will also come under pressure. Existing hospital capacity may only be able to meet 20–25% of the expected demand at the peak of the pandemic, and strict criteria for admission are likely to be applied. This will put an additional strain back on to primary care.2
Under the National Framework, the aim is to reduce mortality and morbidity by implementing a range of measures. These include:2
- assessing all symptomatic patients rapidly, and treating them promptly with antiviral and other medicines if indicated
- providing effective treatment for those suffering from complications
- providing public advice and information
- introducing vaccination if and when suitable vaccines are available
- monitoring the impact, effectiveness, and adverse effects of those interventions.
Assuming that the UK is not the country of origin of the pandemic, the majority of the population will be alerted to the possibility of contracting influenza, and, therefore, consultation rates for respiratory tract infections of all sorts are likely to rise significantly, resulting in considerable pressure on practices. The GPs will need to focus on certain groups of patients. These will be those who:
- are suffering from complications of influenza
- are less than 7 years of age
- have relevant pre-existing medical conditions (such as diabetes, asthma) and immunosuppressed patients (e.g. those taking steroids)
- are identified in ‘at risk’ groups and are not responding to treatment, such as the very young, the elderly, and those patients with underlying diseases (heart or chest disease)
- need higher levels of care, as in the groups above, but cannot be admitted to hospital.2
The use of antiviral medicines is an integral part of current planning. Although oseltamivir may only reduce symptoms of influenza by one day, plans are in place to provide antiviral medications widely, in order to reduce the impact on individuals and decrease the overall clinical attack rate, hopefully by as much as one-third. Ideally, patients should be treated within 12 hours of the first symptoms appearing, but certainly within 24 hours of first reporting the symptoms. However, treatment given up to 48 hours after signs of the illness have become evident may still have an impact.2
Patients who are symptomatic should be advised not to attend the GP’s surgery, and alternative pathways will need to be established to provide rapid access to available antiviral treatment around the clock. Those patients will then be expected to manage their own illness at home but, nevertheless, some patients will come to the surgery. Once there, they should be separated from everybody else as soon as possible, and staff who become unwell at work must go home straightaway.2
Controlling the spread of infection
A number of infection control precautions have been suggested by the joint BMA/RCGP guideline and by the Department of Health.1,3 All GPs will be discouraged from wearing ties and will be encouraged to choose work clothes that will reduce the spread of infection. Attention to hand hygiene will be the single most important practice required to reduce the transmission of infection. Frequent handwashing, at least once between each patient, is good practice in any case, but becomes particularly important where patients may have influenza. As an alternative, alcohol-based handrubs can be used, particularly for those undertaking home visits.1,3
Disposal of potentially infective material, including tissues, will be another issue. Patients should be encouraged to cover their nose during sneezing, and symptomatic patients who do attend the practice should be given a surgical face mask to wear.1,3
Staff working within a 1-metre distance of patients known or thought to be ill with influenza should wear a fluid-repellent surgical face mask, which can be changed when moving to areas where patients are cared for who do not have the illness, or when the mask becomes moist.1,3 Gloves are not strictly needed for care of patients with pandemic influenza but, nevertheless, their use is advised if sufficient supplies are available.1,3
It is also recommended that aprons should be worn when examining influenza patients, in order to reduce the risk of contamination of personal clothing. Ideally, these aprons should be used once and then discarded, but if supplies are limited, one apron may be used for a whole session when examining these patients.1
Eye protection would be necessary when undertaking procedures where there was a risk of splashing onto the face, even though ocular inoculation is not regarded as a major transmission route.1,3
Influenza viruses can survive on hard surfaces for several hours, but are quickly destroyed using standard detergents and disinfectants. All practices will, therefore, need to instigate an enhanced cleaning programme for all clinical areas, with particular attention being paid to frequently touched surfaces, such as doorknobs. Waiting rooms should be stripped of magazines and toys until the pandemic is over in order to avoid interpatient transfer.1,3
Being prepared is the key, and planning the practice’s response to the pandemic would be a useful exercise—perhaps as part of a team-building event. This is really a question of adapting the guideline to suit the individual practice and using the exercise as a means of ensuring that everyone knows what would happen and how, so that practice staff do not have to make it up or adapt it as they go along. Every practice should nominate a pandemic influenza practice lead, who should be responsible for planning the practice’s strategy and ensuring preparations are kept under regular review.
|Department of Health, Health Protection Agency. Pandemic Flu—a summary of guidance for infection control in healthcare settings. London: DH, 2007—
Department of Health, Health Protection Agency. Guidelines for Pandemic Influenza : Infection Control in Hospitals and primary care settings. London: DH, 2005—
Infection control training video and posters are now available on the DH website—www.dh.gov.uk/en/PandemicFlu/DH_078752
The pandemic flu plan from the local PCO/Health Board
Check on DH website for any updates on: www.dh.gov.uk/en/PandemicFlu/index.htm
World Health Organization’s revised guidelines on the pharmacological management of humans infected with avian influenza—www.who.int/csr/disease/avian_influenza/guidelines/en/
- Royal College of General Practitioners and the British Medical Association. Pandemic Flu: Interim guidance—Infection control for general medical practices. London: RCGP and the BMA, 2006.
- Cabinet Office and Department of Health. Pandemic influenza. A national framework for responding to an influenza pandemic. Draft for Comment. London: DH, 2007.
- Department of Health, Health Protection Agency. Pandemic Flu—a summary of guidance for infection control in healthcare settings. London: DH, 2007.G