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Pandemic influenza planning: are you prepared?

Mairi Scott and Tom Love look at the management of a flu pandemic in primary care, identify a number of issues that need to be addressed in preparing for such an event, and suggest some resources which can be drawn upon for developing pandemic plans

Mairi Scott
Director Professional Development Academy, University of Dundee

Tom Love
Lecturer in Health Economics, University of Dundee

Pandemic influenza is a regular phenomenon. Pandemics happen at unpredictable intervals that typically last several decades although, occasionally, they can occur more frequently. In the 20th century, influenza pandemics were recorded in 1918, 1957 and 1968, in each case causing serious morbidity and mortality.

A pandemic has the potential to cause considerable suffering to individuals and disruption to society. The specific challenges associated with a pandemic depend both upon the clinical characteristics of the disease, which can vary considerably between different events, and the way in which health systems and society more generally are organised. Elements that were vulnerable to disruption in 1918, such as labour-intensive manual communications systems, may be less prone to interruption in the electronically sophisticated 21st century. Conversely, some modern mechanisms, such as just-in-time delivery systems, may be more vulnerable to the disruption of a pandemic than was the case in previous eras.

Epidemiological modelling suggests that a pandemic is likely to arrive in one or more waves, each of which may be separated by weeks or months. A typical wave may last up to 15 weeks with approximately 22% of all cases occurring in the peak week, but this is only a guideline; in reality, a wave could be longer with a less severe peak, or could be shorter with a greater proportion of cases in a concentrated peak period.

Given that the precise nature of a pandemic is uncertain, UK planning authorities have adopted standard assumptions for the purposes of making preparations. These consider a clinical attack rate in the population of up to 50%, with a case fatality rate of up to 2.5% as a reasonable worst-case scenario. Up to 27.5% of patients may require assessment by a GP or other healthcare professional, and up to 4% of symptomatic patients may require hospital treatment, if resources are available.1

Clinical attack rates will also apply to health professionals, and small organisations such as general practices may see absentee rates of 30–35% over the two to three weeks around the peak period. The highest level of absenteeism is inherently likely to occur at the time of highest demand for care from the public.2

Patient pathway
The specifics of the patient pathway in the event of a pandemic will vary from region to region depending on local differences in the available health workforce, geography and the infrastructure of both primary and secondary care in the area. However, some common elements will be implemented across the UK.

At a national level there will be accessible telephone services for the initial assessment of people with influenza symptoms. The key points are summarised in Box 1, but the main premise is that first contact with the health service will be through telephone assessment, preventing primary care from being overwhelmed with a large number of uncomplicated cases. This will also keep primary care expertise for those cases where there is a higher risk of complication, such as the elderly or the very young. Where a patient can be adequately assessed by the telephone service, arrangements will be made for the pick-up or delivery of medication if appropriate, and there will be no need for the direct involvement of the local primary care team.

[[Box 1 flu]]

Preparation
The World Health Organization (WHO) defines six phases in the emergence of a pandemic. WHO phase four and five alerts are declared when there are clusters of cases with person-to-person transmission, and a WHO phase six alert is declared when there is sustained transmission in the general population. Within the WHO phase six period, four alert levels will be declared within the UK, which corresponds to distinct periods of activity (see Table 1).

[[Tab 1 flu]]

Guidance for the health sector in the event of pandemic influenza is available within England, Wales, Scotland and Northern Ireland.2–5 A public information campaign is a key part of the national preparation for a pandemic. Information for the public will include comprehensive advice about preventing infection, self-care in the event of contracting influenza, and where to access services.

At a local level, general practices must be able to draw upon their own plans and preparation for a pandemic, but these will need to fit within a locally coordinated framework developed by the relevant primary care trust or health board. Local coordination and planning from the regional health body will address issues such as coordinating continuity of service across practices (and consolidation of service in the event of some practices closing); officially suspending nonessential activities where necessary; communicating information on services to the local population; ensuring consistent application of criteria for access to health services; and linking with local authority services such as social care, housing and transport services.

Planning in primary care
General practices and associated primary care teams should develop their own action plans for a pandemic based on the guidance available. Plans can identify areas for immediate action, delayed action and those that will require consolidation at times of maximum activity. We recommend that, at the level of a general practice, the following planning steps should
take place:

  • The practice should identify a clinical lead and an administrative lead (usually a practice manager). In larger practices it might be possible to identify both a lead and deputy to allow for absence from work during a pandemic. Specialist expertise should support the delegation of specific areas, eg, practice nurses should lead on infection control, practice pharmacists on handling of stock, etc.
  • Leads should review the literature and guidelines around pandemic influenza. National planning documents and guidelines are the starting point, but should be supplemented by information about local coordination arrangements from the primary care trust or other local health authorities.
  • The leads should consider how these key areas will be addressed in the practice:
    - Roles and responsibilities both before and during the pandemic.
    - Ethical decisions.
    - Clinical aspects of management.
    - Liaison with secondary care services.
    - Infection control.
    - Decisions about which normal clinical activities can be stopped and in what order.
    - Decisions about how this will be communicated to other members of the team and patients.
    - Planning for resumption of normal activities.

Actions should be prioritised and set out within the time frame of pandemic alerts detailed in Table 1. Those that can only be addressed later should have key personnel responsible for delivery at that stage identified.

Continuity of service will be a key issue for individual general practices to address in their plans. General practice will need to contend with levels of absenteeism arising both directly from illness among staff, and indirectly from illness among family members and events such as school closures. Service continuity plans should address the safety of the staff, the maintenance of essential infrastructure, and response in the event of staff illness. Such plans will have to take into account any locally coordinated continuity arrangements among general practices, pharmacies and other community health providers. Joint Royal College of General Practitioners (RCGP) and British Medical Association (BMA) guidance on service continuity has been developed as a starting point for individual practices.6

Ethical issues
During a pandemic, health professionals and patients will face difficult decisions. Given the availability of local healthcare resources, some patients may have to be denied treatment, or advised to make their own arrangements for care. The ethical framework for policy and planning produced by the Department of Health is intended as a tool to assist clinicians and others in developing their own policies on clinical issues.7 There is no suggestion that there are right or wrong answers to these kinds of decisions; practices and primary care teams should work with this guidance to develop their own protocols.

During a pandemic it will be important to record the underlying clinical and other reasons that lead to decisions for use in the future. As clinicians will be exceptionally busy, it may be helpful to create a decision-making grid for clinical records.

Traditionally, primary care plays an important role in bereavement support. The workload implications of this, as well as the personal challenges of coping with such deaths, might mean that traditional coping mechanisms may be too time consuming or ineffective. A mentoring or a buddy system of support might be the most time-effective way to manage this and should be prepared in advance.

Clinical management
The key guideline for management of pandemic influenza has been developed by the British Infection Society, the British Thoracic Society and the Health Protection agency in collaboration with the Department of Health, and is published in Thorax.8 The guideline includes flow charts and tables that can be used as a basis for local and individual practice-based protocols. In particular, the section on primary care; part 1, section 5 to 8, covers most areas that individual practices should consider in their plans:
1. Triage.
2. General advice and treatment in adults.
3. Treatment in children.
4. When patients should re-consult and
    with whom.
5. Investigations relevant in the community
6. Referral criteria for hospital care
7. The use of antivirals and antibiotics.

While it is intended that the majority of uncomplicated cases will be managed via the telephone assessment service, some people may present directly to primary care settings. It will be important to reinforce the importance of the telephone service as the first line of contact and triage for prospective patients, as this mechanism will be crucial in preventing frontline primary care services from being overwhelmed by demand. Patients who are not members of high-risk groups and who have no features suggesting severe disease or complications may not require face-to-face consultations.

Management decisions for patients with influenza should be based primarily on:

  • An assessment of illness severity.
  • Identification of whether the individual is in an "at-risk" group.
  • Current advice from Department of Health/local public health officials based on the epidemiology of the pandemic.

Infection control and personal protection
Guidance on infection control is available from the Department of Health.9 Staff in a primary care setting will need to demonstrate good practice to patients and the public. This will include providing tissues, and the means for their safe disposal, in the waiting areas to minimise droplet spread and visible handwashing after every patient contact, both in the consulting rooms and in patients' homes.

NHS Education for Scotland (NES), in partnership with Health Protection Scotland, has developed an educational programme provide information on hand hygiene and the use of Personal Protective Equipment (PPE).10

The policy around appropriate use and provision of personal protective equipment, such as gowns and masks, will be part of every local health authority (or board) plan. It is likely that some personal protective equipment will be made available to practices from central repositories, and staff should be familiar with the safe and effective use of such equipment, including the frequency of use and replacement, correct fitting and removal, and disposal practices. Depending upon how future infection control policies are developed, it may be necessary to instruct family members of patients at home in the use of such equipment.

Discussion
A pandemic will bring challenges for many parts of society, but primary healthcare will be at the frontline of managing high demand for services while struggling against limited resources and absenteeism. Individual workers will be faced with complex dilemmas about the best organisation of care at a local level, and the most humane way to manage limited resources.

Maintaining the safety of the workforce with effective personal protection and infection control will be a key factor in ensuring that primary care can do the most effective job possible on behalf of patients.

The specific timing of a pandemic is not predictable, and may emerge with little warning. Planning for such an event should take place as soon as possible, drawing on some of the resources made available by government and professional agencies.

References
1. Department of Health (DH). Pandemic flu: A national framework for responding to an influenza pandemic. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. Department of Health. Pandemic influenza: guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
3. National Public Health Service for Wales. Preparing Wales for a Pandemic. Available from: http://www.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=29352
4. Scottish Government. Pandemic Flu: A Scottish framework for responding to an influenza pandemic. 2007. Available from: http://www.scotland.gov.uk/Publications/2007/11/21141855/0
5. Department of Health, Social Services and Public Safety (DHSSPS). Northern Ireland Contingency Plan for Health Response for an Influenza Pandemic. DHSSPS; 2008. Available from: http://www.dhsspsni.gov.uk/index/phealth/php/infectious_diseases/pandemi...
6. British Medical Association (BMA), Royal College of General Practitioners (RCGP). Flu pandemic preparations, service continuity planning. London: BMA; 2006. Available from: http://bma.eu/ap.nsf/Content/flupanprep
7. Department of Health. The ethical framework for the response to pandemic influenza. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
8. British Infection Society, British Thoracic Society, Health Protection Agency. Pandemic flu: clinical management of patients with an influenza-like illness during an influenza pandemic. Provisional guidelines from the British Infection Society, British Thoracic Society, and Health Protection Agency in collaboration with the Department of Health. Thorax 2007; 62(Suppl 1):1-46.
9. Department of Health (DH). Pandemic influenza: guidance for infection control in hospitals and primary care settings. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/DH_085433
10. NHS Education for Scotland (NES). Pandemic flu Infection control measures. Available from: http://www.scotland.gov.uk/Topics/Health/health/AvianInfluenza/PandemicF...

Resources
A great deal of information to help with preparation is available from government agencies on the internet. Health departments are charged with preparing frameworks for the four countries that make up the UK, and professional bodies are also involved with preparing materials to help health professionals prepare for a pandemic. Primary care trusts and health boards will have plans that address specific issues in different localities; the public health and the emergency planning personnel of your local trust are likely to be the people with responsibility for this.

UK Department of Health
W: http://www.dh.gov.uk/en/publichealth/flu/pandemicflu/index.htm

Health Protection Scotland
W: http://www.hps.scot.nhs.uk/resp/pandemicinfluenzaplanning.aspx

National Public Health Service For Wales
W: http://www.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=29352

Department of Health, Social Services and
Public Safety (Northern Ireland)
W: http://www.dhsspsni.gov.uk/index/phealth/php/infectious_diseases/pandemi...

Royal College of General Practitioners
W: http://www.rcgp.org.uk/clinical_and_research/pandemic_planning.aspx