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Cold and flu in general practice - first aid at home

Kirsty Armstrong
SRN FPCert BSc(Hons) NPDip
Senior Lecturer/Practitioner
Faculty of Health and Social Care Sciences
St George's Hospital
Tooting, London
and
Kingston University
Nurse Practitioner
Ashville Surgery
Fulham
London
E:karmstro@hscs.sghms.ac.uk

There is scant statistical evidence on the occurrence rate and economic impact of colds in the UK population, although influenza-like illness seems to warrant more attention. In the week ending 29 September 2002, flu-like illness was still occurring only at baseline activity (Influenza and flu-like illnesses have a direct impact on NHS resources - during the 1989/90 epidemic more than 760,000 patients visited their GP with flu, and sequelae included pneumonia (70%), acute bronchitis (25%) and otitis media (25%). Triaging calls from patients with pyrexia symptoms and possible cold or flu diagnosis will not only cut down the consultation rate but also help to prevent complications in the "at-risk" groups.(3)
 
The winter epidemic
In the winter months much of our time in primary care seems to be spent dealing with colds, coughs and flu-like illnesses. Why? Well, we all huddle together in our poorly ventilated offices and homes; we spend less time outside in germ-killing ultraviolet light (and there is less light, so the effects of germ-killing ultraviolet light are reduced); we get stressed with Christmas parties and shopping; the air we breathe is colder, which may contribute to the cooling of noses, which in turn allows a higher replication rate of viruses; and we start school or college, also linked to an increased incidence of colds.

Symptoms and sequelae
Common signs and symptoms of a cold include a sore throat, sneezing and a runny nose, watery eyes, fever and malaise, a dry cough and congestion. Compare these with the more extreme symptoms of flu, which are a sudden onset of high fever, widespread myalgia, noticeable weakness and headache with anorexia (loss of appetite).
Sequelae (follow-on infections) of a cold are more common in those with chronic diseases, children (who will suffer on average five to eight infections annually), the immunocompromised individual (from treatment or illness) and the over-65s. These sequelae include: ear infections; acute exacerbation asthma/chronic obstructive airways disorder (COAD); bronchitis; chest infection/pneumonia; sinusitis; and conjunctivitis.
NHS Direct (0845 46 47) uses excellent algorithms to assess risk, and it is worth finding out whether your patient has already spoken to them.

Take a good history
A good history is vital for correct diagnosis. However, this can be done over the telephone to reduce consultation rates. Establish how long the patient has been unwell and whether or not he/she has taken any medication. Using the mnemonic PQRST (see Table 1) may be helpful.

[[NIP08_table1_48]]

Treating a cold
This depends on many of the above factors, but should generally consist of some over-the-counter (OTC) medication - a simple remedy such as paracetamol 1g to be taken 4-hourly, or 200-­400mg of ibuprofen 4-hourly (care should be taken in patients with asthma or gastrointestinal problems).(4) Complicated flu and cold remedies are useful for an urgent meeting or presentation, but have no place in the longer-term treatment of colds and flu. The patient should try to take in plenty of fluids (I suggest a pint every hour, but most patients find that hard to do), with plenty of hot drinks as these are more soothing. Rest is very important, and the patient who calls you from work demanding an emergency appointment for immediate prescription and symptom relief should be reminded of this factor. The sooner they take to their bed the better. They should expect to feel rotten for 3-5 days, and if the symptoms don't subside or actually worsen in this time, ask them to telephone you again for further evaluation.

Other treatments
Clinical Evidence Concise lists some beneficial and harmful treatments for the common cold.(5) Treatments that have unknown effectiveness include echinacea (there are so many different types it is difficult to compare just one with placebo), steam inhalation, and zinc gluconate or acetate lozenges. Antibiotics and decongestants are deemed to be ineffective or harmful.(6) A large dose of vitamin C (1g) at the onset may reduce the length and severity of the cold, but research into the prolonged use of vitamin C in colds is equivocal.(2)

Future prevention of infection
Infective agents that cause cold include over 200 viruses (with 100 rhinoviruses) and several bacteria, but rhinoviruses are usually to blame - 30-40% of colds are caused by respiratory syncytial virus (RSV).(1) Transmission is mostly through hand-to-hand contact with subsequent passage to the nostrils and eyes, rather than droplet transmission in the air - so careful handwashing and minimal touching to the face may help to reduce transmission.(8)

True flu
Those who have had true influenza will never again confuse it with a bad cold. Symptoms include sudden onset of fever, myalgia (aching joints and muscles), and sometimes loss of appetite and diarrhoea. Severity of fever (>38°C) is greater than for a cold - patients can expect 7-10 days of fever and being bedridden. Influenza is mainly transmitted by droplet infection, so sit well back in your chair when they visit you!
The adage that common things occur commonly and rare things occur rarely means that even if you and the patient feel that this may be flu, if there are unusual symptoms (eg, urinary) or a relevant history (recent return from a tropical area), take advice from a more experienced colleague. This also applies to the sick child with neck stiffness, rash or other unusual symptoms not synchronous with cold or flu symptoms.
Treatment of influenza will vary depending on the patient. You can recommend paracetamol or ibuprofen and steam inhalations with menthol for the congestion, saline drops for the stuffed noses of babies (from the pharmacy), occasionally chlorpheniramine maleate (Piriton; Stafford- Miller) from the pharmacy to help with sleep, and other complementary treatments, as long as they do not interfere with current medications.
Laboratory tests for flu are arduous, and symptoms can usually give a better picture. Be aware of the cluster of cases in communities when considering flu as a diagnosis - my experience is that if you see one in a morning clinic you will see five or six. This is how flu epidemic statistics are calculated - more than 400 in 100,000 primary-care consultations for flu-like illness constitute an epidemic.
For "high-risk" patients (eg, those with asthma, COAD, chest problems and other chronic diseases), anti-viral treatment may be an option. But prevention is better than cure, and the influenza vaccine should be our first choice (this year it contains Moscow-, New Caledonia- and Hong Kong-like virus!). NICE guidelines recommend zanamavir (Relenza; Glaxo Wellcome) for use in patients with chronic disease in whom treatment can be started within 48 hours.(7) Amantadine has strict prophylactic prescribing guidelines.(8)

Summary
A total of 10-15% of your patients may develop flu annually, so an action plan for your workplace that is adhered to by all may help to reduce consultation rates, standardise your advice and smooth the way forward into the flu zone. In 1989/1990 and 1993 respectively, 29,000 and 13,000 deaths were attributed to flu, and we are due an epidemic, hence the push for vaccination in the at-risk groups. Current work on studying the virus includes exhuming a body and extracting the viral DNA from the 1918 epidemic. The flu vaccine is very cost-effective in the at-risk groups - less so in healthy, young adults6 - a carefully planned flu vaccination campaign may leave you more time and energy to enjoy Christmas!

References

  1. PHLS. Weekly influenza report. Avail-able from URL: http://www.phls.co.uk
  2. Lorber B. The common cold. J Gen Int Med 1996;11:229-36.
  3. Fleming D. The impact of three influenza epidemics on primary care in England and Wales. Pharmacoeconomics 1996;9 Suppl:38-45.
  4. Johnson G, Hill-Smith I, Ellis C, editors. The minor illness manual. Oxford: Radcliffe Medical Press; 2000.
  5. Clinical evidence concise. London: BMJ Publishing Group; 2002;7:265-7.
  6. Arroll B, Kenealy T. Antibiotics for the common cold (Cochrane Review). In: The Cochrane Library 2002; Issue 3. Oxford: Update Software. Also available from URL: http://www.cochrane.org.uk
  7. Goldmann D. Transmission of viral respiratory infections in the home. Pediatr Infect Dis J 2000;19:S97-102.
  8. NICE. New guidance - zanamivir (Relenza) for influenza. London: NICE; 2001.

Resources
Public Health Laboratory Service
W:www.phls.co.uk
Department of Health
W:www.doh.gov.uk