Monitoring the emergence of community transmission of influenza A/H1N1 2009 in England: a cross sectional opportunistic survey of self sampled telephone callers to NHS DirectBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3403 (Published 27 August 2009) Cite this as: BMJ 2009;339:b3403
All rapid responses
Acute respiratory viral infections in people with cystic fibrosis
(CF) are often associated with significant clinical deterioration (1).
They are thought to be synergistic with bacteria in their capacity to
cause airway inflammation and lung damage (2). For over 12 months, all
patients attending our unit have undergone routine viral throat swabs
using polymerase-chain-reaction (PCR) before starting intravenous (IV)
antibiotics. We are therefore able to assess the prevalence of A/H1N1 in
relation to other viruses as a cause of acute severe exacerbations in
patients with CF.
The first case of A/H1N1 flu virus in Leeds was confirmed on the 7th
June 2009. Since this date 187 adult patients have had pulmonary
exacerbations requiring IV antibiotics. 15 (8%) of these had a positive
viral PCR; however, only 4 of 15 (27%) tested positive for A/H1N1. One of
these was immunosuppressed post-lung transplant and presented with fevers
together with breathlessness, vomiting and headache. Eight patients were
PCR positive for rhinovirus, two for adenovirus, and one for parainfluenza
In two of the A/H1N1 cases swabs were repeated and remained positive
at four and six weeks respectively. The persistence of viral ribonucleic
acid (RNA) has been seen previously in children with asthma (3).
We conclude that only a minority of viral infections causing acute
pulmonary exacerbations necessitating IV antibiotic treatment in adults
with CF are caused by A/H1N1. A similar prevalence of viral infections is
likely to exist in the community and will have led to a significant over
prescribing of antiviral medication. What is of concern is that people who
believe that they have already had the infection may decline vaccination
when it becomes available. Delayed swabs of at risk patients needs
further investigation but could prove to be a useful tool to improve
vaccine uptake in vulnerable groups.
1) Conway SP, Simmonds EJ, Littlewood JM. Acute severe deterioration
in cystic fibrosis associated with influenza A virus infection. Thorax
1992; 47(2): 112-114.
2) Petersen NT, Hoiby N, Mordhorst CH, Lind K, Flensborg EW, Bruun B.
Respiratory infections in cystic fibrosis patients caused by virus,
chlamydia and mycoplasma - possible synergism with Pseudomonas aeruginosa.
Acta Paediatr Scand 1981; 70(5): 623-628.
3) Kling S, Donninger H, Williams Z, Vermeulen J, Weinberg E, Latiff K, et
al. Persistence of rhinovirus RNA after asthma exacerbation in children.
Clin Exp Allergy 2005; 35(5): 672-678.
Competing interests: No competing interests
Policies that have been developed for the triage of potential cases of influenza A (H1N1) in this pandemic present something of a dilemma in the management of cancer patients who receive chemotherapy in that febrile influenza episodes may mimic the symptoms and signs of neutropenic fever. If they follow the widely publicised advice to telephone the National Pandemic Flu Service (NPFS) they may not receive the rapid access to the care they need. However those who have influenza, regardless of whether they are neutropenic or not, will need to receive the antiviral drug oseltamivir promptly. Bringing them to hospital for investigation may pose a risk to staff and to other patients unless appropriate infection control measures are taken.
The following policy has been developed with the detailed advice of Professor Nick Phin and Dr Hongxin Zhao of the UK Health Protection Agency.
Advice to patients at the time of consent and during treatment: Cancer patients receiving chemotherapy who develop a febrile episode should follow the standard advice for such patients to telephone the emergency number of their treating haematology or oncology unit. They should be clearly advised not to ring the NPFS in order to avoid delay in starting antibiotics for the neutropenic cases. They will then be advised about attendance at hospital.
On arrival for assessment: Patients should be seen in a single room. The doctors and nurses attending them should use personal protective equipment and the patient should wear a surgical mask.
In addition to the usual blood count, culture of blood etc., biochemistry and a virological swab should be taken.
Other identified causes of a febrile episode with a normal or raised neutrophil count should be treated as appropriate.
Those who are not neutropenic and in whom influenza is a possible cause of their symptoms should be sent home with a course of oseltamivir which will be given at the point of contact with the hospital and with advice to self isolate and to take general respiratory and personal hygiene measures.
Neutropenic febrile patients will be admitted, infection control measures instituted, the microbiologist informed and treatment instituted according to the usual protocol with the addition of a course of oseltamivir.
Patients who deteriorate: Where patients with laboratory confirmed infection of Pandemic (H1N1) 2009 do not improve or deteriorate whilst on antiviral treatment, patients should be advised to telephone the relevant emergency telephone number as antiviral resistance appears to be more common in immunocompromised patients[2,3,4]. They will be advised to attend for reassessment. This will include a repeat blood count and cultures including a viral swab – it would be appropriate to consider sending some of the material to a laboratory capable of detecting antiviral resistance. Zanamivir by inhalation should be considered, whether neutropenic or not, after consultation with microbiologist/virologist.
 The National Pandemic Flu Service - https://www.pandemicflu.direct.gov.uk/ (accessed on 13 August 2009)
 Ison MG, Larisa V. Gubareva LV, Atmar RL, Treanor J and Hayden FG. Recovery of Drug-Resistant Influenza Virus from Immunocompromised Patients: A Case Series. J Infect Dis 2006;193:760–764.
 Hayden FG. Prevention and treatment of influenza in immunocompromised patients. Am J Med. 1997;102(3A):55-60; discussion 75-6.
 Englund J, Zerr D, Heath J, Pergam S, Kuypers J, Yager J, Boeckh M, Mattson D, Whittington N, Whimbey E, et al. Oseltamivir-Resistant Novel Influenza A (H1N1) Virus Infection in Two Immunosuppressed Patients --- Seattle, Washington, 2009. MMWR 2009; August 14, 2009 / 58 (Dispatch);1-4.
Competing interests: No competing interests
The Department of Health (DoH) document, Pandemic Flu. Managing
Demand and Capacity in Health Care Organisations  sets out guidelines
for hospitals to cope with an increasing demand for healthcare during a
pandemic. One aspect of this is triage. Despite the explicit statement in
this document that NHS organisations have a ‘legal duty to involve people
in the development of their plans….. and have a duty to consult local
overview and scrutiny committees where they are considering substantial
variations or developments in local health services’ it is difficult to
find evidence of any real local engagement in these discussions.
Many NHS Trusts in the UK now have a clinical ethics committee (CEC).
It seems reasonable to assume that these committees would be included in
any local consultation process by their Trust in relation to pandemic flu
planning. To gauge the extent to which CECs have been involved in local
planning for pandemic influenza a brief questionnaire was distributed
electronically to all CEC members of the UK Clinical Ethics Network. in
April 2009, a week before the current outbreak of H1N1 influenza.
Responses were received from 18/80 (22%) CECs. A summary of the findings
1: although all eighteen CECs who responded were aware that their
Trust had developed a specific plan for coping with pandemic flu only ten
had been formally asked to comment on it. This represents a very low level
of engagement with ethics committees on a policy that has potential
significant ethical implications for health care delivery at a local
2: CECs were prepared to play a role in the context of a pandemic
with a wide range of roles suggested including overseeing triage processes
to reviewing individual triage decisions when there was disagreement. Some
CECs thought that they would continue to provide a rapid response service
during the crisis phase as requested on individual case dilemmas while
others questioned whether this would be possible given the other workload,
urgency, and number of decisions that would need to be made.
3: In view of the DoH stipulation about local and public engagement
with the triage process it is striking that 83% of responding CECs did
not feel there had been sufficient local and national discussion regarding
what triage is, how it works and what its actual implications really are
for the public. A recent study from Derriford hospital found that using
one of the suggested means of triage from the DoH surge document for
allocating intensive care beds during a pandemic would result in up to 52%
of patients not receiving treatment who ‘normally’ would do so and that
this may still not ‘free up’ sufficient beds, necessitating further
unspecified allocation processes to be used .
It is predictable that if triage is used, patients will not receive
treatment that they may normally receive if there was not a pandemic. But
should the public have a right to know with greater clarity what ‘triage’
could mean in actual practice? As recognised by the DoH in reference to
triage, ‘there is likely to be extreme distress, anger and even a risk of
aggressive behaviour from family and friends of those in whom withdrawal
of treatment interventions must be considered’. Discussion of these
issues in advance may reduce this occurrance..
Dr Andrew Tillyard
Consultant in Intensive Care Medicine and
Clinical Academic Lead in Medical Ethics and Law at the Peninsula Medical
Dr Anne-Marie Slowther
Associate Professor Clinical Ethics, Warwick Medical School
1: Department of Health. Pandemic flu: Managing Demand and Capacity
in Health Care Organisations. (Surge ) Published 30th April 2009
2: T. Guest,1 G. Tantam,2 N. Donlin,3 K. Tantam,3 H. McMillian3 and
A. Tillyard4 An observational cohort study of triage for critical care
provision during pandemic influenza: ‘clipboard physicians’ or ‘evidenced
based medicine’? Accepted for publication in Anaesthesia.
Competing interests: No competing interests