The expectation that some form of Influenza Pandemic will devastate the world in the near future is one that I believe and have been concerned about for some years since first learning in depth about the impact of the 1917 pandemic. Then there was no understanding or treatment of the impact of influenza – we have learned a lot since but are now only realising that implementation of learning is a massive task.

General Practitioners, their nurses and their staff will suffer influenza during a pandemic. General Practitioners, their nurses and their staff will die from influenza during a pandemic. Such stark facts have their basis in history and represent the true nature of the chameleonic virus’s ability to invade, damage and move on.

It is impossible to predict

When the pandemic will strike

What form of Influenza A will cause the pandemic

What the clinical attack rate will be (ie : infectivity)

What the case fatality rate will be

Which cohort of the population will be most affected

Owing to such unpredictability, each General Practitioner, as any other employer or service provider, will need to ensure that he/she is able to cope and maintain a healthy workplace and one which can adapt to the changing needs of the patient clientele.

Influenza pandemics arise when a new genetic variety of Influenza A arises and transmits from human to human. Humans will spread the virus by respiratory droplet spread – coughing, sneezing, or close personal contact. The virus is likely to be transmissible from hand to face – hence coughing into a hand, shaking hands, then the recipient holding his hand to his face could pass the disease. Influenza is transmissible before clinical symptoms arise. Influenza invades the respiratory epithelial cells resulting in virus replication within the cell and then disruption of the cell causing release of more virus and also loss of function of the respiratory cells leading to breaches in mucosal for secondary bacterial invasion. The other symptoms of influenza arise from the immune reaction –causing muscle aches, exhaustion, and rise in body temperature. Respiratory failure and bacteraemic invasion of body organs leads to metabolic dysfunction.

Drugs used to manage influenza now include neuraminidase inhibitors – these prevent replicated viral particles leaving the epithelial cells and hence diminishing both local spread within the affected patient and also his ability to infect others – and messenger protein blockers such as amantadine which prevent the process of virus replication within the infected cell. Although Influenza A virus are all believed to be susceptible to the actions of neuraminidase inhibitors, some are resistant to amantadine.

Influenza will spread rapidly from an originating focus – initially probably locally and then very soon, as a result of the decreased travel time, within a continent and across continents simultaneously. A traveller catching influenza in China can travel to the UK within 24 hours and have close infective contact with many others – including his children – even before showing signs of influenza. In the 1917 pandemic, many travellers died before arriving home owing to the slow speed of public transport and death rate was probably lower and the speed of worldwide transmission slower.

The Health Protection Agency has produced an Influenza Pandemic Plan www.dh.gov.uk/pandemicflu

There are also a number of explanatory leaflets available through the above website which explain what the difference is between annual influenza and pandemic influenza without giving any details of explicit actions necessary to prevent spread in a pandemic or to manage the disease. The Government and HPA have been running a number of planning exercises throughout the UK to inform its management planning and a number of alert levels have been recognised which should result in specific actions being implemented and reserve stocks of antiviral drugs being distributed to local holding centres.:

Alert level 1 Cases due to pandemic virus only outside the UK

Alert level 2 New pandemic virus isolated in the UK (pandemic imminent in UK)

Alert level 3 Outbreak(s) due to new pandemic influenza in the UK

Alert level 4 Widespread pandemic activity across the UK

It will be at Alert level 2 that GPs will need to begin to implement their own pandemic plan in conjunction with the PCT within which they work. It is likely that once the first cases of pandemic influenza are confirmed within the UK, then Influenza activity will spread throughout the UK within a 14-21 day period. Patient information –both timely and appropriate – is essential to avoid inappropriate panic and inappropriate expectations of the practice. Patients will require information on at least the following areas appropriate to the practice:

1: How to obtain supplies of normal medication (eg: prescriptions faxed to pharmacies rather than collected in person at Surgery; prescription requests by email or telephone or with SAE only)

2: How medical assessment of new, non influenza, conditions will be conducted (eg: telephone triage of all patients rather than face-to-face)

3: How medical assessment of possible influenza cases will be conducted

4: How to reduce risk of contacting influenza (this should be arranged by national publicity mechanisms by the DoH)

5: How routine medical monitoring of existing conditions will be made (it will be necessary to limit such management assessments to a minimum and perhaps by conducting at a separate site or time from surgeries when possible infected cases are seen)

6: How to obtain updates on the local situation (perhaps by posters/powerpoint displays showing through surgery window or by internet site)

It can be seen that such changes will need to put more emphasis on telephone triage and it may be appropriate for the practice to consider at Alert Level 1, or before, the need for additional telephone lines to the practice – or the use of practitioners own mobile numbers (which can always be changed at the end of the pandemic period to avoid inappropriate use thereafter). Each PCT should have an information officer who should be willing to coordinate full page advertisements on behalf of the GP practices listing the arrangements – alternatively a geographic leaflet drop using distributors or the Post Office may be appropriate. PCTs and GP representatives should be looking at these options well in advance of Alert Level 1

Pneumococcus is an invasive bacterium which commonly complicates influenza and may be responsible for organ failure and death. Maximising pneumococcal uptake is a sensible means of protecting the patient population over the age of 50 and those in other risk groups

While it is impossible to obtain sufficient supplies of olsetamivir or zanamivir for practitioner prophylaxis for the expected initial 8 week pandemic wave, there is another antiviral - amantadine – which can be used as prophylaxis for face-to-face practitioners for the period of pandemic wave. Amantadine works to decrease the replication rate of influenza A virus and has relatively few side effects at the prophylactic dose of 100mg daily. The practice, having determined how best to maintain a service throughout the pandemic period, should purchase a 56 capsule supply for each practitioner or staff member willing to take the drug and who will have significant face to face contact with patients.

Early detection of pandemic strains of influenza will be necessary to inform the country as soon as possible about pandemic influenza. Effective nasal swabbing is an art and a short teaching session from a local infection control nurse may be helpful in teaching practitioners how to swab at low risk to themselves and to give everyone confidence and encouragement in swabbing patients who present with Influenza-like symptoms

In order to meet requirements as an employer it is necessary to protect employees from infection. This can be best done by limiting exposure utilising non face-to-face contact as much as possible… there should theoretically be no need for non clinical staff to be exposed in the workplace by appropriate use of telephone, mail, fax and internet/email. Even within the Surgery premises, the receptionists can be replaced in the emergency situation by touch-screens, intercoms and physical screening. Those who do need to have face to face contact with those possibly infected with influenza (which could be anyone presenting during the pandemic period) should have adequate and full personal protection equipment:

Face shield to prevent droplet spread from patient to conjunctivae

FFP3 respirator masks changed when wet (each should last 4-6 hours)

Disposable full gown with sleeves

Gloves

As there is likely to be a demand on these items as a pandemic approaches, the practice should consider stocking supplies of these personal protection items in sufficient quantities for at least one eight week period. There are various stockists such as: www.surviveall.co.uk

One of the most likely sources of spread of influenza will be the Doctors’ Waiting Room with sniffing children and coughing/spluttering adults shouting down their mobile telephones or sneezing into the air conditioner. While surgical masks are unlikely to prevent anyone catching influenza, they will provide a moderate limitation to the spread of infection. A policy of only allowing people to enter the premises if they wear a mask and keep it on throughout, depositing it afterwards in a clnical waste bin outside the surgery may be appropriate. Also insisting on the use of a viricidal hand wash before entering the surgery may be appropriate. An estimate of the likely requirements for masks and hand wash needs to be made and a supply stocked.

It is likely, if the effects of a pandemic mimic those of previous high morbidity attacks, that transport services will be affected as drivers go sick, and supermarkets limit their supplies or opening hours. Keeping an eight week rolling stock of essential surgery supplies – consumables, drugs, staff refreshments, prescription paper etc – would be a sensible precaution

How will the practice cope during a pandemic – will staff come to work or stay at home..if the latter, can they be employed to work from home using available technology? What if doctors and nurses go sick – has the PCT a plan to "share" or "centralise" services? How will those aspects of primary care listed above – maintenance of repeat prescriptions; non-influenza consultations; influenza consultations; routine hypertension monitoring; cervical cytology – be maintained if at all? Information streams will be necessary as the situation changes – will patients know where to find information?

Will computer software suppliers be able to maintain software support – what plans have they got in place? What happens if there is disruption to power or water – will the practice have a means of adapting? Will fuel supplies be available for continuing home visits or getting to work – will it be necessary to staff the practice for different hours in order to decrease patient-patient contact?

A business continuity plan should consider many issues such as those above and should also look at the ways that the practice will be able to return to normal – at what point will it feel safe to re-open the premises normally in the knowledge that the pandemic will return in a later wave of infection.

Weblinks:

Flu backgrounder www.dotpharmacy.co.uk/upflu.html

Department of Health information www.dh.gov.uk

Chief Medical Officer www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalOfficer/fs/en

Bird Flu information site: www.bird-flu.me.uk/

Health Protection Agency: www.hpa.org.uk/infections/topics_az/avianinfluenza/menu.htm

Protective equipment: www.survivall.co.uk