Important Londonwide CEO message number 9 - 7 July 2009
Advice on the management of swine flu is changing as more becomes known about the virus. This email is intended to provide:
a) An update on the management of this infection*
b) Some advice on prioritisation of services
c) An update on Londonwide LMCs public communications
Management of the infection
Based on information from our hotspot areas, the weekly pattern we are seeing if maintained this week, would seem to reflect a typical epidemic curve, i.e. it suggests that we may see substantially more people with swine flu in the coming weeks. Alternatively, we may see a drop-off in 2-3 weeks’ time when the schools break up and then a substantial recurrence in the autumn, as has been the case in a previous flu pandemic starting in the summer.
Diagnosis
Now that we are in the ‘mitigation’ phase of the swine flu epidemic, you should diagnose the condition on clinical grounds. Whilst the national algorithms issued on 2 July referred to diagnosing swine flu based on fever plus one rather than two flu-like symptoms. you should of course, use your clinical judgement: a small child probably can’t describe flu-like symptoms, and whilst, for example, diarrhoea and a slight fever can be associated with swine flu, they can also be caused by gastroenteritis (and as the main common side effects of oseltamivir are nausea and vomiting, inappropriate treatment could lead to confusion). You may therefore sometimes consider it appropriate to diagnose swine flu on the basis of fever plus two or more flu-like symptoms. Conversely, where someone has an underlying medical condition that may increase the risks of swine flu, you will probably use less strict diagnostic criteria than in someone in who is normally in good health.
Treatment and prophylaxis
Whilst the national guidance suggests that everyone with swine flu should have antivirals and not those in contact with them, the Chief Medical Officer’s letter of 2 July to all GPs provided useful clarification as far as treatment and prophylaxis are concerned.
- most swine flu infections, so far, have not been severe, but there have been hospitalisations and deaths (generally in younger people, but not always in people with significant underlying illness)
- there remains uncertainty about the behaviour of the A/H1N1 virus: you can’t easily predict whether the course of the illness will be mild or severe in any individual, hence the precautionary approach that has been advised
- experience so far suggests that those at higher risk of serious illness or death are people with underlying chronic disease; with asthma requiring drug treatment; with immunosuppression (caused by disease or treatment); and pregnant women, people aged 65 years or over, and children under 5 years old.
Please give priority for early treatment with antivirals to people in these higher-risk groups if you diagnose swine flu.
When considering treatment of people aged 5-64 years with no underlying illness, the Chief Medical Officer recommends taking a precautionary approach and offering antivirals to those with symptoms strongly suggestive of swine flu, but to use your clinical judgement: you may choose not to offer antivirals in circumstances where there are only minor or unrelated respiratory symptoms.
The Chief Medical Officer also recommends that you do not usually offer prophylaxis to contacts of people with swine flu unless, for example, a household member has serious underlying health problems or there are other special circumstances.
As we learn more about the virus, it will become possible to develop a more precise categorisation of risk groups and antiviral use will probably become more targeted.
Exclusion of people with swine flu from work or school
The original advice was that people with swine flu should be excluded for seven days. Now that more is known, it is apparent that the greatest viral load is in the first few days and the illness is, in most instances, mild, with most patients recovering within 48 hours. The guidance on exclusion from work and school has thus changed to 48 hours or until symptoms have resolved – whichever is the longer period.
Prioritisation of practice services
You do not need ‘permission’ to prioritise your services. Prioritisation is what we GPs do all the time. For example, it is perfectly acceptable for you to amend your phone messages to guide patients to specific time slots, and for your staff to be briefed on how to prioritise telephone calls. If necessary, in response to demand, you may also wish to vary consultation style or rearrange chronic disease clinics and other non-essential services in order to prioritise treating those who think they are acutely ill, be it from flu or other medical conditions. Non-essential parts of your contractual obligations may have to be deferred until time and resources reasonably permit. Commonsense is something which we as GPs have plenty of. We should use it liberally and confidently. Please use our flu@lmc.org.uk address for any concerns you have in this area.
The GPC is currently in discussion with the NHS and Department of Health on contractual measures to be deployed with regard to key elements of the contract such as QOF arrangements. We will keep you updated when we have news.
Londonwide LMCs and public communications
Since there has been hardly any information flowing to the public from the authorities, we have now commenced work on getting messages out into local media and, with your help, to your patients. Letters containing key messages have been sent to the printed media across London and we have designed a poster for you to reproduce in your surgeries. The poster can be printed in black and white as well as colour. Although many of us are being stretched to near our limits by this episode, it is important that we maintain a best-foot forward approach at this time, which will hold the profession in good stead when it comes to future dealings with the government.
*Acknowledgement to Dr Andrew Burnett, Barnet PCT DPH for this section.
Londonwide LMCs advice poster on swine flu (pdf)