Published 23 July 2009, doi:10.1136/bmj.b2977
Cite this as: BMJ 2009;339:b2977

Feature

A/H1N1 influenza update

¹ Margate

As the English government launches a dedicated telephone service and website that will prescribe antivirals to take the pressure off of GPs, Adrian O’Dowd reports on the latest information on swine flu

What more do we know about A/H1N1 compared with two months ago?

Much more is now known about the virus’s transmission characteristics, what happens in the clinical setting, and its mortality and morbidity. The UK Health Protection Agency (HPA) has undertaken a project, called the first few hundred (FF100) cases surveillance system, that has collected detailed data on 350 cases of influenza and the patients’ close contacts. Results have not yet been published, but the work has allowed the agency to gather information on transmissions within households, duration of illness, and clinical picture. The data have been used by the agency’s modellers for forward planning and potential impact. The HPA says that this virus is similar to seasonal flu. Taking oseltamivir (Tamiflu) is not a pleasant experience, with side effects that include nausea, diarrhoea, and hallucinations.

According to the World Health Organization the 2009 influenza pandemic has spread internationally with unprecedented speed. In past pandemics, flu viruses have needed more than six months to spread as widely as the new H1N1 virus, which has spread in less than six weeks. However, international travel is far more common than it was in the times of the previous pandemics in 1918, 1957, and 1968, and techniques to measure it now are much more sophisticated (N Engl J Med 2009;361:279-85, doi:10.1056/NEJMra0904322).

Researchers from Imperial College London in a study published in the BMJ have called for better estimates of case fatality ratio because the methods currently being used could overestimate or underestimate the numbers (BMJ 2009;339:b2840, doi:10.1136/bmj.b2840). The study shows that the virus is not becoming more virulent.

The Department of Health and various research councils have worked together to commission research programmes on all aspects of the virus. The NHS National Institute for Health Research has put out a call for studies on flu vaccines (www.nihr.ac.uk/proposals/Lists/NIHR%20Calls%20for%20Proposals/DispForm.aspx?ID=75).

Has advice to healthcare professionals from the HPA changed since WHO announced pandemic alert 6?

The fact that the virus was spreading enough for WHO to move to a phase 6 alert in June did not change the HPA’s advice. The change of alert refers only to geographical spread of the disease and not its severity. Joint guidance issued in January by the Royal College of General Practitioners (RCGP) and the BMA recommended that general practices set up "flu centres"—cordoned-off areas in practices for people with suspected flu to try to halt the spread of the virus (www.bma.org.uk/health_promotion_ethics/influenza/panflugp/panfluguiddec08.jsp). This has not happened widely owing to a lack of physical space in many practices or the difficulty in arranging special separate appointment times for patients with flu symptoms.

A second edition of the guidance is being written and is due to be issued in a month. It will feature new chapters, including one on out of hours services. What has changed is the move from a phase of containment of the virus, which is no longer possible, to one of treatment. Swabbing in primary care is no longer necessary unless there are special reasons to do so, such as infection control or as part of surveillance schemes—for example, the RCGP "spotter" practice scheme, which collects nose and throat samples from patients with flu-like illness in 52 practices throughout the country, covering a population of 400 000 people.

What are the latest predictions on how serious this virus is?

There have been 29 deaths in the United Kingdom as of 19 July among people confirmed to have the virus, although it was not always the cause of death. The HPA has estimated that the UK had 55 000 new cases last week (range 30 000 to 85 000) in addition to the existing 9718 already confirmed previously. Figures from the RCGP show that 50.3 people per 100 000 reported flu-like illness between 29 June and 5 July, but this rose sharply by 46% to 73.4 people per 100 000 between 6 and 12 July. Globally there have been 139 566 cases and 781 deaths, according to the European Centre for Disease Prevention and Control.

The Department of Heath has issued estimates that about 12% of the healthcare workforce and 8% of the total population are likely to have the virus at any one time. England’s chief medical officer, Liam Donaldson, said that the NHS should prepare for 0.1-0.35% of infected people dying, giving a range for deaths from the first wave of 3100 if only 5% of the population fall ill, to 65 000 if 30% fall ill.

The BMA has criticised the government for raising people’s fears unnecessarily and has emphasised that, for most people, flu A/H1N1 is not serious and can be managed with self care at home. Perspective is important: seasonal flu usually kills 8000-9000 people a year, although in 1999-2000 there were 19 000 deaths related to flu.

The national director for NHS flu resilience, Ian Dalton, says that NHS organisations should use the department’s new planning assumptions to develop their existing plans (www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102892). Practices should be ready to meet extra demand and consider the impact of staff absence.

How are current arrangements for administering oseltamivir working, and what are the new arrangements?

The success of arrangements for administering antivirals varies around the UK. The current arrangements for distributing these are decided by each primary care organisation, with some areas using community pharmacies and others using other collection points or out of hours services. Generally general practitioners (GPs) can diagnose patients by telephone using an algorithm published by the HPA or RCGP. If the doctor is satisfied that the patient is describing the symptoms of the virus, he or she issues a handwritten antiviral request form or voucher for a friend of the patient to collect before going to an antiviral collection point.

The BMA has concerns that people are getting antivirals too easily and are being needlessly medicated and that arrangements for prescribing and administering oseltamivir are too complex. The BMA thinks that it does not make sense to ask doctors to revert from using a standard prescription form (FP10).

The authorisation of antivirals is putting a lot of pressure on GPs, but the policy will change, when the National Pandemic Flu Service launches this week. GPs and other healthcare workers are expected to use their own discretion and clinical knowledge to decide whether to take antivirals themselves, the chief medical officer said.

Will the imminent National Pandemic Flu Service help GPs?

It should do if handled correctly. Despite delays, the National Pandemic Flu Service, a national telephone and internet service for England, should be launched by the end of this week. It will focus on self care, and the health secretary, Andy Burnham, said in the House of Commons this week that it will be able to prescribe antivirals by telephone and by the internet. Liam Donaldson first announced the service last week as one way to take pressure off services and to help GPs in hot spots, who are being "completely overwhelmed."

Scotland’s health telephone and internet service, NHS24, in partnership with Health Protection Scotland, set up the Scottish Flu Response Centre at the start of June. This service, staffed by about 60 people, has been well used and gives the public specific advice, information on self care, and reassurance.

The BMA’s General Practitioners Committee says that anecdotal evidence shows that GPs have been less overwhelmed as a result. People in England will be able to bypass their GP by using the National Pandemic Flu Service. If they have symptoms, answer a set of questions designed to identify the virus, and are in one of the high risk groups they will receive an authorisation code for a friend to take to a collection point to get an antiviral. The algorithm has been designed in consultation with the RCGP and the BMA. The thinking behind the service is to allow GPs to deploy their time more usefully in other areas of care.

About 2000 staff in call centres will be available, who will probably not be clinically qualified. The RCGP is happy with this, but the BMA’s Peter Holden said that the threshold for getting oseltamivir is low. If the service fails to meet demand, there are concerns that people will soon stop using it and revert to calling their GP or NHS Direct. Andy Burnham, speaking in the House of Commons on 20 July, said that the service would go live on Thursday 23 July, subject to testing. "The technology to launch the National Pandemic Flu Service has been available for some time, but with these latest HPA figures and drawing on advice from the field we have now reached a point where the service is required," he said. "It will be accompanied by a major public information campaign."

The service will not be available in Scotland, Wales, and Northern Ireland because the demand is not as high, but these countries can opt in later if they wish. In Scotland patients with flu-like symptoms have been able to call NHS24 on 08454 242 424, its specialised Scottish Flu Response Centre, or their GP, or they can get more information at NHS24’s website (www.nhs24.com/content/default.asp?page=s3_12). In Wales people are being advised to stay at home and either call NHS Direct on 0845 4647 (www.nhsdirect.wales.nhs.uk); their GP; or the swine flu information line, on 0800 1 513 513. Northern Ireland has its own helpline, 0800 0514 142 (www.nidirect.gov.uk/index/health-and-well-being/swine-flu.htm).

Is it worth wearing a facemask?

A systematic review in the BMJ last year showed that many simple and cheap interventions in healthcare settings, including facemasks, can help to reduce the spread of respiratory viruses, but their usefulness is limited (BMJ 2008;336:77-80, doi:10.1136/bmj.39393.510347.BE). Ordinary surgical masks become sodden in 90 minutes, so doctors would need to change masks six times a day if they wanted to wear a mask continuously. Facemasks should be used when doctors are performing high risk tasks, and supplies are limited so it is best to use them only when around affected patients.

Because the virus is now a pandemic, widespread use of facemasks by the public is highly unlikely to stop the disease spreading. Masks might give people false reassurance and lead them to ignore basic hygiene measures, such as handwashing and not reusing and disposing properly of tissues, which are far more effective at preventing spread.

How soon will a vaccine be available?

The government has signed contracts for enough vaccine for the whole UK population. Despite some reports that it may be arriving later than expected, the latest advice from the BMA, the RCGP, and the Department of Health is that it will arrive in late August or early September, albeit in small quantities initially. It will be distributed quickly to practices so that doctors can start work on priority groups, which will include the same as those vulnerable to seasonal flu, healthcare professionals, chronically ill people, and children under 5. It is anticipated that there will be 60 million doses available by the end of the year, enough to vaccinate 30 million people because each person needs two doses, with more following.

What are the likely arrangements for distribution of the vaccine?

Precise arrangements for the distribution of the vaccine are not agreed, but it will be delivered to general practices as soon as possible. GPs will lead on a national immunisation programme on the scale of the huge 1962 vaccination programme in the UK against smallpox. The BMA has compiled a database of 343 retired doctors who say that they are willing to help if needed. The General Medical Council has agreed changes to its rules so that they could quickly be granted temporary registration.

Discussions are ongoing about who should get the first vaccines when they arrive. It is highly likely that frontline clinical staff and those involved in frontline support (such as laboratory staff and porters) will be among the first to receive the vaccine as well as the priority groups, similar to those vulnerable to seasonal flu. After these, trying to select particular occupational groups is difficult. WHO’s advisory group of experts on immunisation has advised WHO to recommend that all countries should immunise their healthcare workers as a first priority.

Should pregnant healthcare workers deal with patients with swine flu?

Pregnant women have been shown to be at risk from the virus. Growing evidence shows that many practices with pregnant GPs are starting to think differently about whom these doctors should be seeing. It is up to the discretion of local practices, but the BMA has said that doctors and nurses should not put themselves into needless danger and take appropriate precautions. Pregnant healthcare staff should avoid dealing with patients with flu if possible, but this cannot be a total ban. The RCGP has advised that where it is practical and does not have an adverse impact on patients, pregnant healthcare workers should be directed away from dealing with flu patients.

Has A/H1N1 mutated? If not, how will we know if it does?

The virus has not mutated since appearing in Mexico in April. The reference laboratory at the HPA’s centre for infections carries out sequencing on samples of viruses that are sent in on a regular basis to keep track of any mutations. Similar work is happening in other countries. WHO’s four reference centres around the world (in the UK, the United States, Australia, and Japan) are carrying out similar monitoring on a global scale.

Is swine flu more likely to infect the lungs than other flu viruses?

All influenza viruses primarily attack the lungs. In a study by the University of Wisconsin-Madison published in Nature this month, researchers found that the virus yields an infection in the lungs that is more severe than would be expected from an average seasonal flu (2009 Jul 13, doi:10.1038/nature08260).

Where can I get up to date information?

See the BMJ’s microsite, at http://pandemicflu.bmj.com. The Department of Health has weekly online updates each Thursday (www.dh.gov.uk). The HPA is also posting a weekly update on Thursdays (www.hpa.org.uk). The RCGP has regular online updates (www.rcgp.org.uk).

Cite this as: BMJ 2009;339:b2977

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Competing interests: None declared.

Sources: BMA, Department of Health, HPA, RCGP, WHO, and European Centre for Disease Prevention and Control.

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