Intended for healthcare professionals

Rapid response to:


A/H1N1 influenza update

BMJ 2009; 339 doi: (Published 23 July 2009) Cite this as: BMJ 2009;339:b2977

Rapid Response:

Potential for misdiagnosis

It is notoriously difficult for clinicians to distinguish viral
illness from serious bacterial infection. Many of the symptoms currently
recommended as “screening” questions for A/H1N1 such as fever, coryza,
sore throat, headache, muscle aches, vomiting and diarrhoea [1] can also
be present in early stage meningococcal disease [2]. It is unclear whether
these represent a preceding viral illness or are a prodrome of infection
with Neisseria Meningitidis [3]. SIGN recommends that meningococcal
disease cannot be excluded in children with non specific signs and
symptoms presenting within the first few hours of their illness [4].

A review of evidence for electronic decision support systems suggests
that even those operated by clinicians lack both sensitivity and
specificity [5]. As we enter the peak season for both influenza and
meningococcal disease, we believe that even experienced practitioners who
rely on telephone triage to diagnose A/H1N1 in children without a full
clinical assessment are at risk of missing serious bacterial infection
such as meningococcal disease. Furthermore, we believe that a telephone
triage system operated by call centre staff using an un-validated
electronic symptom checker is putting patients at even greater risk of

1. RCGP. Flu assessment and Authorisation of Antiviral Treatment.
Version 3-16/07/09.

2. Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey
L, et al. Clinical recognition of meningococcal disease in children and
adolescents. Lancet 2006;367:397-403

3. Dunlop K, Coyle P, Jackson P, Patterson C, Shields M. Respiratory
viruses do not trigger meningococcal disease in children Journal of
Infection (2007) 54: 454-458

4. Theilen U, Wilson L, Wilson G, Beattie J, Qureshi S, Simpson D on
behalf of the Guideline Development Group. Management of invasive
meningococcal disease in children and young people: summary of SIGN
guidelines. BMJ 2008; 336: 1367-1370

5. Bravata D, Sundaram V, K McDonald, Smith W, Szeto H, Schleinitz M,
Owens D. Evaluating Detection and Diagnostic Decision Support Systems for
Bioterrorism Response. Emerging Infectious Diseases 2004;10(1):100-108

Competing interests:
None declared

Competing interests: No competing interests

20 August 2009
Thomas W Bourke
Padiatric Research Fellow
Michael D Shields
Royal Belfast Hospital for Sick Children, Falls Rd, Belfast. BT12 6BE