Swine flu comes home: a GP’s tale

So there we were, early Wednesday afternoon, preparations under way for the evening surgeries, when the phones started to ring off the hook. Almost simultaneously we got an email from the PCT telling us that 143 children from the local primary and infant schools were sick with an as yet unidentified viral illness. Some were being swabbed for swine flu and we were to have a low threshold to swab any child we saw, especially as small children with swine flu don’t always fit the diagnostic algorithm we’d been asked to use until now. And yes, before you tell me, I know I’m meant to call it H1N1 but no one out in the community actually does.

Anyway, by now parents were beginning to phone in for advice and their anxiety levels were high. Our receptionists all had copies of the HPA advice but nothing had prepared them for either the volume of calls, or the near panic displayed by some of the parents of these very young children, and they were already starting to show the strain and needed help. We decided that a GP would call back all concerned parents and by the end of a very long surgery we’d dealt with a large number of patients and their families and were just about beginning to understand how all of those protocols worked in practice.

Going home that night it was clear to me that the next day would be much worse. Having finished my surgery at almost 8pm it was also clear that we needed a better system in place to cope. One that didn’t involve fitting these telephone consultations- involving up to 6 patients per call plus all the associated prescriptions and notification paperwork- in amongst the normal offerings of a busy surgery. What was needed was a dedicated telephone flu clinic with expertise in how to manage these cases and their contacts being rapidly acquired. And so began the first of my flu clinics.

The first thing that having a dedicated clinic did was take the pressure off of the receptionists who no longer felt overwhelmed. Calls were returned within 20 minutes and this alone, I suspect, helped reassure parents that the health system was up and working and would be there if needed. On this, the first full day of our local outbreak, we had been advised to treat all probable cases and all household or close contacts. By the second day we were asked to treat only high risk household contacts.

All of the children I’ve been involved with so far have had relatively mild symptoms: a fever of 38 or 39, being subdued, eating less, a cough, a runny nose, a sore throat, all improving significantly within 2 days. But I’ve also had high risk patients who haven’t been so well: a grandfather with asthma, wheezing and coughing up green phlegm, who needed antibiotics and a steroid inhaler in addition to his tamiflu; a mother with cardiac problems who was feeling very unwell with her flu symptoms; a sibling with chronic health problems who needed prophylaxis; a pregnant mother of a probable case in two minds about whether to take the relenza that by day 2 was being recommended for pregnant contacts or cases.

As a doctor it’s been a steep and interesting learning curve in which I’ve gone from just about understanding, in theory, how this is all supposed to work, from knowing, from experience, how to deliver good swine flu care from switchboard to consulting room, with assessing contacts and educating and reassuring being key tasks. There has also been an interesting line of thought emerging from both patients and health care professionals, the suggestion that it’s better to get this now, before it (maybe) mutates to something more virilent.

If you’ve got it already, like half the little ones from our neighborhood, and all is well, then I’d agree. But for other people, especially those who are high risk, I think that argument breaks down. This isn’t like chicken pox-ie get it when you’re young and it’s sure to be milder- because we don’t know how any one person will react. Of course it might be mild, is likely to be mild, but then again it might not, especially if you’ve got asthma or one of the other preexisting conditions that make you more vulnerable. And if you can manage not to get it for a few more months we should, hopefully, have a vaccine which will go first to those same high risk individuals. Hence giving tamiflu to not very ill children, not for them so much as for those around them who might not be so fortunate. And to their high risk contacts for the same reason.

Early days, time will tell and all that. Interesting how little is on the news anymore. Is it just that the story got old, or that the media heeded calls not to whip up panic, or that more important things have knocked swine flu off the news agenda? I suspect our local experience is being quietly repeated all around the country and that we’re all finding our own way to  respond to our patients’ needs for help and reassurance. Hence my decision to share my experiences with you. Just in case today or tomorrow is your first day and you’re wondering what to do next.

  • Ted Hutchinson

    An estimated 675,000 Americans died from the A/H1N1 pandemic influenza in the United States in 1918-1919.
    Many of these deaths were from ensueing bacterial pneumonia rather than directly from the viral infection. The United States Public Health Service conducted surveys in twelve cities and rural areas of the country in late 1918 to early 1919 to determine the case-fatality rate in each city or area. Case-fatality rates varied from 0.78 deaths/100 cases in San Antonio, Texas to 3.14 deaths/100 cases in New London, Connecticut. The strong variation with location suggested that solar ultraviolet-B (UVB) irradiance, through production of vitamin D, reduced the risk of death following infection by this pandemic influenza.

    To investigate this possibility, the case-fatality rate data were compared statistically with solar UVB doses in July and January. Strong correlations with UVB doses were found for both indices.

    There are two mechanisms whereby vitamin D can reduce the risk of death once the pandemic influenza virus infection took hold: reduced production of proinflammatory cytokines and reduced risk of bacterial pneumonia. The hormonal metabolite of vitamin D, 1,25-dihydroxyvitamin D, reduces the production of cytokines from T-helper 1 type (proinflammatory). 1,25-dihydroxyvitamin D also induces the production of human cathelicidin, LL-37, which has both antimicrobial and antiendotoxin properties. LL-37 has been found effective in reducing the risk of several types of bacteria, and is also thought to reduce the risk of respiratory viral infections including seasonal influenza.

    Whether this finding is relevant to the current A/H1N1 influenza virus outbreak is unknown but should be evaluated.

    “The authors propose a very interesting hypothesis based on intriguing observations that vitamin D deficiency and influenza infection share a similar pattern in incidence during the year. Recent work by several groups have demonstrated that vitamin D induced anti-microbial peptides that may be important for the immune defense against pathogens such as virus. As we are entering the fall and winter season, it may be worth considering addressing vitamin D status in individuals at risk for influenza infection.”

    Here is the abstract of the paper

    The possible roles of solar ultraviolet-B radiation and vitamin D in reducing case-fatality rates from the 1918–1919 influenza pandemic in the United StatesDeaths during the 1918–1919 influenza pandemic have been linked to both the influenza virus and secondary bacterial lung infections. Case fatality rates and percentage of influenza cases complicated by pneumonia were available from survey data for twelve United States locations in the 1918–1919 pandemic. This study analyzes case fatality rates and cases complicated by pneumonia with respect to estimated summertime and wintertime solar ultraviolet-B (UVB) doses as indicators of population mean vitamin D status. Substantial correlations were found for associations of July UVB dose with case fatality rates (r = -0.72, p = 0.009) and rates of pneumonia as a complication of influenza (r = -0.77, p = 0.005). Similar results were found for wintertime UVB. Vitamin D upregulates production of human cathelicidin, LL-37, which has both antimicrobial and antiendotoxin activities. Vitamin D also reduces the production of proinflammatory cytokines, which could also explain some of the benefit of vitamin D since H1N1 infection gives rise to a cytokine storm. The potential role of vitamin D status in reducing secondary bacterial infections and loss of life in pandemic influence requires further evaluation.

    While 5000iu/daily/D3 is a reasonable substitute for 20~30minutes fully body midday non burning sun exposure it is still worth trying to get as much skin exposed to sunlight as possible because Skin is unique among organs in that it is capable of manufacturing biologically active 1,25D in the presence of UVB light from start to finish, although local production of 1,25D from circulating 25D in other tissues is a substantial source of vitamin D’s biological activity in the body.

  • Wayne Jenkins

    I was fascinated to read about medical humanities, claiming benefits, patients stories etc, i thought to myself what a flourishing new field of humanities. Then I noticed that all of these submissions are by Debra Kirkland. Her surname stood out because Kirkland is the only Welsh training horse to win the UK’s grand national (the biggest horse race in the calender) 1930’s perhaps, where I live. Anyway does Ms. Kirkland have any time to actually see patients or is her time spent mostly blogging?

  • Sorry to frustrate your equestrian instincts but my name is Kirklin so, alas, no sporting claim to fame, no matter how tangential. I would say more but I’ve got to rush now- patients to see don’t you know.