GPs sent “useless” guidance on coping with possible human cases of bird flu

BMJ 2007; 334 doi: (Published 08 February 2007) Cite this as: BMJ 2007;334:275
  1. Susan Mayor
  1. 1London

    GPs near the outbreak of H5N1 avian influenza at a turkey farm in Suffolk, in the east of England, have found the information they have been sent on how to deal with people presenting with symptoms “useless.” A key diagnostic algorithm is difficult to find and the guidance makes no provision for recommended infection control measures, such as the provision for surgical masks.

    In a letter sent to GPs in the area last Monday, the Health Protection Agency (HPA) explained that all the people potentially exposed to H5N1 in the outbreak had “been requested to contact their GP in the event that they experience fever and/or respiratory symptoms.”

    The letter told GPs to assess patients according to a flow chart on the agency's website ( This advises that people with fever ≥38°C; history of fever and respiratory symptoms (cough or shortness of breath); or other severe life threatening illness and who have had close contact with live or dead poultry in an area affected by avian influenza H5N1 should be reported to the local health protection unit immediately.

    The flow chart advises that a patient meeting these criteria should ideally be seen in their home, and both GP and patient should wear a surgical mask. The patient should be transferred to hospital if warranted by their clinical severity. They should start oseltamivir (Tamiflu) as soon as possible and be tested to confirm the viral strain, with samples treated as “high risk.”

    Ian Hume, a GP in Diss, Norfolk, and chairman of the local medical committee, said, “This is useless. Practices generally ask patients to come into the surgery. I would be jolly miffed if by the time I realised that a patient fitted the criteria [for possibly being infected with H5N1] they had been sitting in front of me in the surgery for some time.” He added that GPs had no surgical masks. “And we have no idea where Tamiflu would come from.”

    Dr Hume was disappointed that the letter from the agency was not faxed to GPs in the affected area until the middle of Monday morning. “I expected that it would have been waiting for me first thing in the morning.” He said that earlier notification of procedures would have been useful. He also thought that the flow chart to which the agency's letter referred was difficult to find on the agency's website.

    After taking several minutes trying to find the flow chart, Dr Hume said, “As a busy GP, I'd have given up by now,” despite guidance from BMJ staff, who had spent some time searching the site earlier. “It seems difficult to find this information. I would have expected it to be clear considering the potential seriousness of the situation. Why didn't the HPA fax the flow chart out directly to GPs as paper copies?”

    The Suffolk office of the Norfolk, Suffolk, and Cambridgeshire Health Protection Unit has been providing antiviral prophylaxis and seasonal flu vaccination to people potentially exposed because they work at the infected premises. The virus has so far been detected in only one shed out of 22 at the turkey farm, and 100 of the 2000 staff who work there had been given oseltamivir, by the time the BMJ went to press on Tuesday.

    A spokeswoman for the Health Protection Agency said that the letter faxed to GPs advised them to contact their local health protection unit in the first instance. During an outbreak of avian flu, oseltamivir and surgical masks would be supplied by these units. The main aim of the guidance was to ensure that GPs did not feel isolated. “HPUs [health protection units] are on hand and equipped with information and resources to help GPs,” she said.

    Jonathan Van Tam, consultant epidemiologist at the influenza, respiratory viruses, and pandemic flu office of the agency, said, “It is always accepted that you see the patient wherever possible, in the home or surgery. The virus is known to transmit through prolonged, close exposure. The supply of personal protective equipment is a PCT [primary care trust] issue.”

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