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The calm before the storm?

Rhona Aikman describes her experiences of dealing with cases of suspected swine flu and some important lessons learned along the way ...

I came back from holiday two weeks ago just as the number of cases of H1N1 was increasing locally. The latest issue of Nursing in Practice was in my tray and I was interested to see Marilyn's editorial, Swine flu: are you ready for a pandemic?

When she wrote this there had been 78 confirmed cases in the UK and the latest figure is almost 6,000. Sadly, as I write, news reports have emerged of the death in Scotland of an elderly man from my local area, as well as a nine-year-old girl in Birmingham.

Last week, we had two to three positive cases a day in my practice, and what has become clear the over the last couple of weeks is how much time it took dealing with both the positive results and the calls from people with flu-like symptoms who needed assessment.

We are fortunate that this is a relatively quiet time, being summer, and I hope that when the number of new cases starts to fall, all those involved will meet to discuss what we can learn from recent events. This will improve arrangements before the predicted second wave this winter.

The public have been sensible on the whole; initially, we were dealing with quite a lot of calls from the worried well with no relevant contact to a case, but these have become fewer as public awareness has improved. One of the main problems we experienced was the frequent changes to guidance we received as the number of cases was increasing. Some days we were getting several faxes advising us of a change to the guidance.

It started off with GPs doing home visits to take swabs from symptomatic patients. Then, community nursing staff were deployed to take swabs and, finally, swabbing centres were set up and patients were sent there. Before these centres were established and numbers of possible cases were increasing there was a period of nearly a week where symptomatic cases were being given antivirals without swabs being taken.

It soon became clear that the majority of swabs were negative (approx 90%) and as soon as the centres were established, antivirals were only being prescribed on the basis of a positive swab. No wonder the public were confused - we were too. This is not a criticism, as the trust were having to respond to a changing situation, but it highlighted the need for good systems to be in place within the practice to ensure the whole team were kept up to date with changes.  

One large call centre locally decided to circulate its own guidance for staff and instructed asymptomatic contacts of possible cases to stay at home. Can you imagine the chaos if others had adopted this? Not only was it unnecessary, but the system was wide open to abuse. Rumour has it they were down to a skeleton staff, so hopefully they will listen to the advice from public health in the future.

The majority of cases of swine flu in my area have been children and, fortunately, no reports of serious illness are among them. Many people I have called with positive results had already begun to improve before the prescription of antiviral medication. Some parents questioned whether the medication was necessary as their child was improving. It is important they understand the rationale for treating positive cases and any close contacts; otherwise, compliance may be affected.

Ideally, antiviral medication should be started within the first two days of the onset of symptoms and the local laboratory must have been working around the clock for the last few weeks trying to turn around results, as the majority have been ready in 24 hours. With the school holidays under way in Scotland there may be a slowing down in the number of cases.

So, what can I add to the current advice? The main thing would be to ask people to reduce contacts from the onset of symptoms. This may seem obvious, but as many parents work, they have to rely on family and friends for childcare when a child is unwell. Ideally, this would be the same person if H1N1 is suspected until swab results are known. One of our cases resulted in 14 people in three different households being prescribed antivirals as close contacts.

We could also advise patients to have a thermometer at home to ensure fever is present. This might reduce the number of swabs being taken. Finally, housekeeping regarding contact details is important to prevent delays in passing on results.

Hopefully, we will not have a second wave this winter; but if we do I feel locally we will be more prepared. It now looks as though a new vaccine will be available this winter with apparently 60 million doses ordered for the UK. The next challenge will be delivering these in time ....