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Friday 30 September 2016
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Preparing general practice for an influenza pandemic

Patients & Services

Lindsey Davis CBE
FRCP FFPH
National Director of Pandemic Influenza Preparedness
Department of Health

Lindsey coordinates the work that is undertaken and commissioned by the Department of Health in preparation for pandemic flu. Formerly Regional Director of Public Health in the East Midlands, she holds a Special Professorship in Public Health Medicine and Epidemiology at Nottingham University

Over the past few years, public and professional concerns about the threat of an influenza pandemic have increased dramatically. Unlike most other kinds of major emergency, the numbers likely to be affected over the course of a pandemic mean hospital capacity could be rapidly overwhelmed. General practice needs to prepare accordingly, aiming to maintain essential healthcare while working with partners and primary care trusts (PCTs) to develop a combined health response to the additional demand.

Influenza – a seasonal phenomenon
Those working in general practice hardly need reminding that influenza is a viral illness that affects the UK with varying degrees of severity most winters. For many it results in a self-limiting illness, but we should bear in mind that it causes some 12,000 deaths in England and Wales each year, so improving the take-up of seasonal vaccination is still very important.

Influenza is one of the most difficult infectious diseases to control because the virus spreads easily from person to person, mainly via the respiratory route or through hand-to-face contact after touching contaminated surfaces. An individual is most infectious when symptoms first appear, but they could start shedding the virus 24–48 hours before that, so each may typically infect one or two others.

Pandemic influenza
Much of the recent concern has developed due to the emergence and spread of avian influenza or "bird flu". This is an infectious disease of birds caused by an A/H5N1 influenza virus. This virus has shown that it can also infect humans who live in close contact with poultry and cause serious (often fatal) illness, but so far there is only limited evidence that it spreads between people, and it will not necessarily be the cause of a human influenza pandemic.

The main risk is that the avian virus might change or mix with a human influenza virus to form a new variant, or that another new virus might emerge to which we have little or no natural or acquired immunity. This new or changed virus could spread quickly between humans, creating a worldwide epidemic known as a "pandemic". Patients or anyone else expressing concerns or asking for more information might find the leaflet Information for You and Your Family helpful. Supplies of these and other materials are available for surgeries and can be ordered via the Department of Health's (DH) website (see Resources).

So, is the clock ticking?
To cause a pandemic, a new variant or strain of influenza virus has to be able to infect people, transmit from person to person, cause illness in a high proportion and spread widely. Pandemics have emerged from time to time throughout history, with three in the last century.

The worst – the 1918 Spanish Flu outbreak – caused many fatalities worldwide. The others – in 1957 and 1968 – also had a serious health impact but were not as severe. The conditions that might allow another pandemic to develop are still with us. It's been almost 40 years since the last one, and other factors of modern life, such as increased travel, certainly don't help. Experts agree that there is a high probability of another occurring, although its timing and impact are impossible to  predict, so it is clearly prudent to be prepared.
 
The likely impact
As a pandemic will be caused by a new virus strain, we cannot predict its precise characteristics, impact, whom it might affect most or when it might strike. It could start in the UK, although it appears more likely that it will originate in some other part of the world, but we would probably only have a 2–4-week warning period before it arrives here.

Attempts to contain its spread – such as travel restrictions – are only likely to delay its arrival, and once in the UK it is likely to spread to all major centres of population within 1–2 weeks. We would then expect it to develop as one or more "waves", each lasting up to 15 weeks, with a gap of weeks or perhaps months between them.

Because of the numbers expected, most patients will need initial assessment and subsequent care outside hospital, so primary care will be very much at the frontline of the health response.

Planning assumptions
A pandemic would cause major international and national disruption, affecting every aspect of normal life, but it would make particularly heavy demands on health and social care.

Because we cannot be sure how serious the health impact will be – or begin to develop a specific vaccine to protect against it – until the pandemic starts, we need to develop flexible plans based on assumptions derived from an analysis of past pandemics, mathematical modelling and expert knowledge.

For health planning purposes, the most important assumptions are:

  • Up to 50% of your patients may show clinical symptoms of influenza over the course of a pandemic.
  • Up to 22% of those influenza cases can be expected to occur during the "peak week" of the pandemic wave.
  • Up to 25% of those with symptoms may develop complications.
  • Up to 32% of those with symptoms – which includes all children under seven (who may need antiviral in solution) – need to be assessed by general practice.
  • Up to 4% of those who are symptomatic may require hospital admission (if sufficient capacity is available) with a six-day average length of stay.
  • Up to 25% of those who require hospital admission may need high-dependency or intensive care, with a 10-day average length of stay.
  • Up to 2.5% of those who become symptomatic may die.
  • National decisions to confine NHS services to the provision of essential care are likely to be taken at an early- alert stage.
  • To avoid spreading infection, people who are symptomatic will be advised to stay at home and make initial contact by telephone.
  • Most symptomatic patients will need treatment with antiviral medicines.
  • No effective vaccine is likely to be available in any significant quantity for some 4–6 months.
  • The main focus of general practice is likely to be on maintaining essential healthcare, treating the complications of influenza and dealing with those at higher risk or with comorbid illnesses.
  • Up to half of your staff may be absent with illness for between seven and 10 working days at some point over the period of a pandemic.
  • Up to 15–20% of your staff may be absent due to illness in the peak weeks.
  • Additional staff absences are likely because of other illnesses, time off to care for dependants, school closures, family bereavement, fear of infection and/or practical difficulties in getting to work, and such absences need to be factored into plans.
  • Employers remain responsible for the health and safety of their staff in the workplace.

How do we go about preparing the practice itself?
Applying those percentages to the numbers of patients registered with your practice will give some indication of the size of the potential task. In common with any other organisation, the first step is to analyse the practice's activities, decide which of these are truly essential and then develop contingency plans for maintaining them over the entire period of a pandemic as far as possible.

Those contingency plans should recognise the combined effects of additional demand, higher levels of staff absences and potential shortages of essential supplies. In order to continue to provide a service to patients, practices will also need to look, for example, at:

  • Ensuring that all staff are well informed, aware and feel supported.
  • Identifying and exploring their perceptions of risk.
  • Looking at the composition of the workforce (eg, how many might be parent-workers or have other caring responsibilities).
  • Determining what minimum staffing levels might be required.
  • Exploring the potential for flexible working and supplementing staffing levels, including any training requirements.
  • Conducting joint risk assessments to determine whether working practices can be changed, physical measures applied or equipment supplied to help protect staff.
  • Developing and documenting procedures for responding to suspected influenza patients, either in the surgery or at their home.
  • Encouraging good personal hygiene habits and providing facilities for handwashing, disposal of infected material, and so on.
  • Communicating effectively with staff and patients.
  • Making best use of recovered and now immune staff.
  • Considering cross-cover between practices.

You can find useful guidance on service continuity – including a checklist – at the Royal College of General Practitioners' website (see Resources).

More general advice and a checklist on business continuity are also available from www.ukresilience.info

How does my practice contribute to the general health response?
Meeting the health- and social care demand generated during a pandemic will take the combined effort of all providers and has to be coordinated to some extent on a pan-organisational basis. PCTs are responsible for developing the local health response plans, and I would anticipate that they are consulting practices and local medical committees (LMCs) in that task.

To support that work, the DH is working with a range of other key stakeholders to find approaches that will help practices and other providers to meet the additional demand in the most effective way.

In essence, we are seeking practical ways of supplementing – not replacing – general practice, and of ensuring that the unique resource we are lucky enough to have in terms of clinical skills, experience and organisation is coordinated to the benefit of most in a pandemic scenario, while recognising and respecting its independent status.

The DH has issued guidance on what PCTs and other primary care organisations should be considering in their
contingency plans for delivering care, including access to antivirals and vaccines. The DH is inviting comments on any of the practical issues that it raises that will need further development.

The DH's website (see Resources) contains further details to inform and support your local planning.

Discussions regarding potential financial and practical impacts on practices are also taking place through the NHS Employers and the British Medical Association (BMA), and I have already given assurances that general practices will not be disadvantaged as a result of contributing to the pandemic response effort.

Use a tissue – and wash your hands
One vital thing that we can all do in advance of a pandemic is to make sure everyone understands how important personal hygiene is and gets into good habits now. This will help slow down the spread of a pandemic – and will reduce the impact of seasonal influenza and many other diseases in the meantime.

The key messages are:

  • Cover your nose and mouth when you cough or sneeze, using a tissue whenever possible.
  • Throw used tissues away promptly in the nearest bin.
  • Wash your hands with soap and water after coughing or sneezing.

What you should do now
Currently, an influenza pandemic represents one of the greatest threats to public health, which is why the NHS and the government are making planning for it such a high priority.

As well as encouraging good personal hygiene in staff, patients and the public, practice managers should be developing their internal service continuity measures and making sure their practice is fully engaged in the wider integrated planning. If your practice is not already fully engaged, don't wait to be asked – get in touch with your PCT Influenza Pandemic Coordinator.

Resources
Department of Health
www.dh.gov.uk/pandemicflu

Pandemic Flu – Important Information
for You and Your Family
www.dh.gov.uk/assetRoot/04/12/17/38/04121738.pdf

Royal College of General Practitioners
The RCGP website contains useful guidance on service continuity:
www.rcgp.org.uk/service_continuity/service_continuity_home.aspx

UK Resilience
www.ukresilience.info