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Pandemic Panic

From the plague of Athens in 430 BC to the current outbreak of Ebola in West Africa, pandemics have long gripped the imagination of the public and led to panic. 

But what are they - and are they really likely to post a threat to the UK? Pandemics are usually described as infectious diseases whose spread means they are affecting a wide area - often more than one continent. The most dangerous pandemics tend to be those with person-to-person spread rather than ones where direct contact with animals is needed to catch the disease. There have been pandemics throughout recorded history - in some cases causing massive loss of life, such as the Black Death in Europe in the 1400s, thought to have killed between 30% and 60% of the continent's population. Spanish Flu after the First World War killed between 50 million and 100 million people worldwide.  

“The risk of pandemics is always with us and always has been,” explains Rose Gallagher, professional lead for infection control and prevention at the Royal College of Nursing (RCN). 

The impacts have stretched far beyond those affected and the health service, and have often been associated with civil disorder and unrest, as well as long-lasting economic effects. 

The diseases behind many pandemics are now names from the past or are no longer a threat to health. Bubonic plague still infects people regularly - 40 people have died from it in Madagascar recently - but it can now be treated with antibiotics. However, it can develop into pneumonic plague which is harder to treat, can be spread human-to-human and requires the use of personal protective equipment.   

Other diseases can be avoided through vaccination. Smallpox has been eradicated through mass vaccination. Epidemics of polio were common last century but it has now been virtually wiped out with cases only remaining in Pakistan, Afghanistan and Nigeria - all areas where vaccination campaigns have been met with hostility. The development of better water and sanitation systems have also been important in reducing the burden of infectious diseases such as cholera and typhoid fever (the possible cause of the plague of Athens). And better healthcare will help people survive diseases which would have killed them in the past. 

But the risk of a pandemic remains. Recent years have seen concerns over diseases such as severe acute respiratory syndrome (SARS), Middle East acute respiratory syndrome (MERS), new strains of avian, bird and swine flu, and most recently Ebola. Often these diseases are passed from animals to people who live in close contact with them. 

What has changed is the ability of pandemic diseases to reach us quickly. “This has to be about the global perspective,” says Gallagher. “The flu after the First World War spread across the world in 18 months to two years. But today the way that we live means that the potential for the spread of the disease is much quicker.”

The widespread availability of air travel in particular has meant that as humans have become world travellers, so have diseases. There is also the possibility of diseases spreading rapidly in densely-packed urban environments with inadequate health systems such as Nairobi, Cairo and Mumbai. 

Gallagher points out we are in a good position to deal with a possible pandemic. Worldwide, there is surveillance and monitoring of infections which look likely to cause problems, allowing healthcare systems to plan for any outbreak and, in the case of flu, vaccinations to be developed that are effective against the latest strain. Much of the focus of this work is areas where humans and animals live closely together - such as parts of South Asia. 

However, it is the diseases which can then be spread from person to person which cause most concern - and which infectious disease specialists are keen to spot early. In many cases transmission does not happen easily, or at all - the H5N1 flu virus, for example, was deadly but did not spread readily between humans. But the natural process of mutation could lead to a virus becoming more frequently spread between people. Some scientists suggested the H5N1 would only need five mutations of its genetic structure to become transmissible between humans. 

The World Health Organization (WHO) has a global influenza preparedness plan and the UK has its own plan, covering everything from communications to guidance for coroners. Local councils also have their own emergency preparedness plans, which are likely to cover health emergencies. In Kent, for example, there is a pandemic flu plan, drawn up by the local resilience forum, which covers everything from public disorder to voluntary quarantine for those affected. 

However, Ebola has shown how hard it is to galvanise governments to tackle a disease which breaks out in countries far away - even when early action could prevent it spreading worldwide. 

Unfortunately diseases which predominately affect poorer people rarely attract the level of research seen into diseases of affluence. WHO director general Margaret Chan said recently: “Ebola emerged nearly four decades ago. Why are clinicians still empty-handed with no vaccine and no cure? Because Ebola has historically been confined to poor African nations.”

But while Ebola and other relatively unknown diseases may grab the headlines, Gallagher's main concern is the more mundane flu. “People underestimate the impact of flu and it spreads very readily,” she says.

She advocates simple strategies to reduce its impact. “Vaccination helps to protect both the person vaccinated and the wider community,” she says. But people also need to be encouraged to wash their hands regularly and to avoid spread to others through coughing or sneezing into handkerchiefs. A healthy lifestyle can avoid the long-term conditions which make people more vulnerable to complications from flu. And if flu breaks out, patients need to be encouraged to seek help in the most appropriate way - which may be through telephone advice. This sort of patient education and interventions may be a long way from the picture of pandemics often portrayed in films or the media: but may be by far the most effective response. 


Ebola in primary care

Ebola is unlikely to infect people in the UK in significant numbers although it is expected there will be a few cases among those who have travelled to West Africa. Public Health England (PHE) has issued guidance for primary care staff if they have concerns about a patient. If a patient calls a surgery and has been in an Ebola-stricken area within the last 21 days and feels unwell, or has had a temperature of over 37.5 degrees in the last 24 hours, they should be advised not to attend and the surgery should seek advice on who should see them. It is likely they will be taken to A&E and dealt with there. If, however, such a patient presents in primary care they should be immediately isolated and any clinical assessment should not involve physical contact. If they meet the criteria for a suspected Ebola case, a consultant microbiologist or similar should be immediately contacted for advice and onward referral. The room used by the patient may need decontamination. 

Staff safety should be paramount in any situation. PHE stresses the importance of planning clinical activity as soon as a patient is identified as a suspect case - for example, not just telling them to go to A&E, but ensuring A&E and ambulance services know in advance they are dealing with a potential case. 

More advice is available on the PHE website, and the RCN has also established a virtual Ebola reference group which will contribute to guidance. See page 39 of this issue of Nursing in Practice for more information on the latest Ebola recommendations.