The pandemic continues to spread throughout all corners of the world, with Serbia and Iraq getting their first cases yesterday. In the UK the West Midlands still lead the way in new cases with 115 confirmed there yesterday. The actual prevalence in this area and other flu “hotspots” is probably much higher as guidelines on swabbing suspected cases have now changed. This was confirmed yesterday by Maureen Baker of the RCGP:

Places with sustained community transmission will be designated as “hotspots”; … Once identified, the following measures will be put in place:
– Swine flu cases will be verified through clinical diagnosis rather than laboratory testing and swabbing
– Antiviral treatment will continue to be offered to all symptomatic cases
– The prophylactic use of antiviral treatment and contact tracing of symptomatic patients will cease [more about this below]

This change is not before time for some GPs, some of whom have been given conflicting information about where to send their swabs: if one letter says send them to the local lab and another says sent them to the tertiary care centre what do you do? In one London PCT, community nurses who were responsible for swabbing were told at the end of last week that the GPs were to take over this role. Unfortunately nobody thought to tell the GPs, no doubt leading to one or two angry “you’re supposed to do it” – “no you are” arguments.

The message on the change of swab policy in these areas may quickly get around GPs but what about the rest of us? I’ve heard of one stroppy discharge letter from A&E complaining of a patient being prescribed tamiflu by the GP despite not being swabbed. With advice and policy changing on a daily basis, are hospitals and surgeries having regular influenza briefings? Or is it every man for himself?

Tamiflu: the altruistic drug

The other interesting change in guideline for doctors in influenza hotspots is regarding prophylactic use of Tamiflu. As mentioned above, in designated “hotspots”:

the prophylactic use of antiviral treatment and contact tracing of symptomatic patients will cease.

Many of my doctor friends don’t think much of Tamiflu – “it doesn’t do anything anyway” is a fairly typical remark. That might be a bit rash, but what is the point of prophylaxis with Tamiflu? A rapid response in this week’s BMJ discusses this and asks if we haven’t been misleading the public.

I am a public health consultant who is expected to prescribe antiviral medications for such mass prophylaxis. I am prepared to do so but only when I am satisfied that people have been truly informed and the likely benefits outweigh the likely risks … When pupils at Welford Road School, Birmingham, were given HPA supervised mass prophylaxis (May 2009) it was very apparent that parents believed that they were getting a special “treatment” that would benefit the child. So great was this faith in Tamiflu that many requested Tamiflu for other asymptomatic family members.

I wonder how many doctors understand the real reason for prophylaxis? Is it really a lack of transparency that some people who are given prophylaxis have the wrong idea?

Stationary policies

NHS London showed that things may not be moving as quickly as we had thought with their unfortunate misspelling of the word “stationery”.

For legal reasons around the status of FP10s, GPs should move to other solutions for providing antivirals … This can include using an FP10 that has been clearly annotated “convenient stationary”

The latest Londonwide LMCs email couldn’t resist pointing this out, but unfortunately they made their own typo.

… annotating the words ‘Convenient Stationery’ (not that NHS London spells this with an A for some peculiar reason), and swab only if you are in an area…

Never mind.

Choose your own swine flu adventure

Anyone who used to enjoy reading those “choose your own adventure” books will enjoy the swine flu symptom checker. You go through a series of questions like:

In the last 7 days have you visited a country at high risk for swine flu, been in close contact with someone with swine flu?

Before you get to the swine flu stuff you have to negotiate a number of safety net questions like: are you “unusually drowsy or confused”? Plugging in my own history (of a slight sore throat, no recent contact with swine flu) led me to a page of advice on sore throat, which fortunately can be treated “safely at home”. Phew.

Tom Nolan is the clinical community editor of doc2doc, the BMJ’s professional networking community.