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Editor’s blog Tuesday 14 December 2010: URGENT EXCLUSIVE Swine Flu - the big issue

If the NHS falls over this winter, the cause is likely to be not policy but influenza.

Swine flu, to be exact.

I have been sent the following document: a report of a teleconference led by the Health Protection Agency.

This is obviously urgent, so would all Health Policy Insight readers please get this message to your local and regional clinical leaders as soon as possible? Thank you.

H1N1 influenza – Report of an HPA-led teleconference 10 December 2010
"The number of cases of H1N1 is increasing. Worryingly, there is a disconnect between the number of cases in the general population (13/1000 incidence, below the threshold to declare a pandemic which is 30/1000) and the impact on ICU of the severely ill. The numbers are increasing especially in the North-West and in the Midlands.

"There have been 12 flu deaths in the UK not including Scotland, 10 of which were confirmed H1N1. They ranged in age from 1 – 51 years old; none had had vaccinations. Four had cerebral palsy, one asthma, one alcoholic liver disease, one asthma, one was obese.

"Several pregnant patients have presented needing intensive care. Ten of the 14 nationally available extracorporeal membrane oxygenation (ECMO) beds are occupied by ‘flu patients, three of whom are or were pregnant.

"Although surge funding has been agreed for additional ECMO beds (at Papworth, the Brompton, Aberdeen, Leicester, Wythenshawe) this funding has not been released as yet, and the ECMO units are struggling to maintain their elective surgery as well as deal with pandemic cases.

"The fundamental messages from the HPA are these:
o be vigilant.
o start antivirals whenever there is a suspicion of flu (oseltamivir 75or 150 mg bd po).
o In patients with resistance or not tolerating NG medication, there is an IV preparation which is currently undergoing clinical trial. GSK produces it (zanamavir).
o ARDSnet ventilation especially for those with normal lung compliance
o Consider HFO for those with poor compliance
o Fluid restrict patients
o Refer for ECMO early if conventional ventilation is failing (of those ventilated >7 d pre-referral, 15% survived)
o HPA adviced has not changed with respect to infection control measures (apparently some trusts have withdrawn FFP3 masks – this is incorrect)
o The HPA will speak to the DH about re-instituting reporting through SHAs as was in place last year
o The RCoA site still has an adult practice note from last year which will be updated and the HPA will have a hot button on its homepage from early next week
o There will be advice re pregnant women after discussion with the RCOG
o In some cases, URT specimens may be negative in severe cases and LRT samples may be needed for the diagnosis.
o Point of care testing may have inadequate  sensitivity for this strain of H1N1

"There was a plea for a national statement from the DH about the issue".

I will be chasing the issues of the surge funding and a national DH statement later today.

UPDATE 1: Call made to DH at 11.10 am asking about these issues. At 17.51, the following statement was received: a spokesperson for the National Specialised Commissioning team said, "The National Specialised Commissioning Team is responsible for commissioning ECMO services in England. There is one nationally designated centre to provide ECMO services for adults, which is Glenfield Hospital in Leicester. However, demand for adult ECMO can increase during winter. For this reason, the National Specialised Commissioning Team has commissioned additional adult ECMO beds at the following Trusts: Papworth Hospital NHS Foundation Trust, the Royal Brompton & Harefield NHS Foundation Trust, University Hospitals of South Manchester NHS Foundation Trust and Newcastle upon Tyne Hospitals NHS Foundation Trust. Funding for these additional ECMO beds has been agreed and will be distributed through the normal contract process.

"We regularly review the number of ECMO beds available and there is flexibility to allow us to commission further support should the number of patients requiring ECMO increase". (For background - ECMO (Extra-Corporeal Membrane Oxygenation) is a technique that oxygenates blood outside of the body. It is a highly specialised technique which needs the input of cardiothoracic surgeons as well as intensive care specialists and ECMO-trained nurses)".

No answer there to my question about whether the agreed funding has yet been released.

At 16.45, the following CAS Alert was sent out by DH:
Central Alerting System: Treatment Guidelines For Patients With Influenza 2010/2011


Category: Non urgent (cascade within 48 hours)
Issue date: 14-Dec-2010

Reference: CEM/CMO/2010/18

From: Chief Medical Officer - Department of Health

Action by recipients:
CMO Urgent Messages - Recipients on Public Health Link
NHS Foundation Trusts (England) - Medical Director
Primary Care Trusts (England) - Medical Director
NHS Trusts (England) - Medical Director
Strategic Health Authorities (England) - Director of Public Health

For information to:
NHS Foundation Trusts (England) - Chief Executive
Consultants in Communicable Diseases
Primary Care Trusts (England) - Director of Public Health
Primary Care Trusts (England) - PEC Chairman
Primary Care Trusts (England) - Chief Executive
Regional Directors of Public Health
Strategic Health Authoritie! s (England) - Chief Executive
Territorial CMOs in Ireland, Scotland & Wales
NHS Trusts (England) - Chief Executive

Title: Treatment Guidelines For Patients With Influenza 2010/2011


Gateway Reference Number: 15295

Please Cascade Within 48 Hours To:
Medical Directors of Acute Trusts
Chief Pharmacists of Acute Trusts
A&E Directors
Intensive Care Unit Directors
Critical Care Directors

For information:
All GPsCommunity Pharmacists

14 December 2010

Dear Colleague

Professor David Salisbury wrote last week on the use of antivirals for individuals suspected to have influenza, particularly in the context of primary care.

The purpose of this letter is to update you on appropriate guidelines for treatment in secondary care and other settings.Please see the attached letter for full details or download at: https://www.cas.dh.gov.uk/Home.aspx

Your sincerely


To: Medical Directors of Acute Trusts
Chief Pharmacists of Acute Trusts
A&E Directors
Intensive Care Unit Directors
Critical Care Directors

Date: 14 December 2010

Copy: RCP
Royal Pharmaceutical Society
British Thoracic Society
All GPs

Dear Colleague

Treatment guidelines for patients with influenza 2010/2011.

Professor David Salisbury wrote last week on the use of antivirals for individuals suspected to have influenza, particularly in the context of primary care. This can found at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_122572

The purpose of this letter is to update you on appropriate guidelines for treatment in secondary care and other settings.

Over the last few days, we have been alerted by the Health Protection Agency (HPA) and other sources that the incidence of severe illness due to influenza infection requiring access to critical care services has increased. At the 7th of December 2010, sixteen confirmed cases in 18-35 year olds are in hospital (all due to H1N1 infection), with a number of probable cases currently under investigation. Many, but not all, of those cases have underlying conditions including pregnancy. Eleven of twelve cases currently receiving ECMO treatment are confirmed or probable swine flu (H1N1) cases. Since the beginning of September, eleven deaths associated with influenza infection have been reported in the UK. Ten cases are associated with A(H1N1) 2009 infection and one with influenza B. Ages ranged from four to 51 years including four cases under 10 years.

Based on the reports from colleagues treating such patients about the similarities of the clinical presentations to last year’s A (H1N1) 2009 cases, I recommend that last year's Clinical Management Guidelines should be followed for patients admitted to hospital with symptoms suggestive of H1N1(2009) influenza.

These can be found at http://www.dh.gov.uk/en/Publichealth/Flu/Swinefluguidance/index.htm

Please note that infection control guidelines can be found at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_110899.pdf

These guidelines provide advice on the management of Influenza A H1N1 (2009) in adults, children and pregnant women. An update on the treatment of children has been provided on behalf of the Royal College of Paediatrics & Child Health, which states:

“At present and while influenza activity is above seasonal threshold, all sick children being admitted or considered for admission to hospital with influenza like illness or its complications can be considered for prompt initiation of oseltamivir and concurrent broad spectrum antibiotics. Children in the recognised co-morbid risk groups or with severe disease (HDU/PICU admissions) should start oseltamivir without delay. Antiviral therapy can be stopped if proven to be influenza negative by appropriate investigations i.e. PCR negative nasal swabs/NPA plus PCR negative ETA/BAL if ventilated.

In young children (<=5yrs), particularly infants (<1yr old), it is very difficult to distinguish influenza and its complications from other respiratory viral infections and other treatable diseases. Infants should always be reviewed by a health care professional (usually a GP) if presenting in the community or by a suitable experienced clinician if presenting to hospital.”

Infants admitted with bronchiolitis may have any one or more respiratory viruses including Influenza A H1N1(2009). A positive near-patient RSV test does not exclude other respiratory pathogens. Clinicians should have a low threshold for starting oseltamivir and antibiotics if there are atypical features, severe or progressive disease whilst awaiting further results.
Attached is a short briefing note (Annex A) on management of influenza-like illness in adults and children admitted to secondary care that you and colleagues may find helpful.

I understand that there are sufficient stocks of antivirals available for ordering, particularly oseltamivir in capsule form. Additional supplies of suspension for paediatric use are expected this week. Hospital chief pharmacists should ensure they have adequate available stocks of oseltamivir and zanamivir.

I want colleagues to make all endeavours to ensure that patients in influenza risk groups, including pregnant women, and health care workers, have received seasonal influenza vaccine which contains appropriate antigens against Influenza A H1N1 (2009) and Influenza B.

Yours sincerely,

Chief Medical Officer (Interim)
Chief Medical Officer (Interim)

Annex A
Management of influenza-like illness in adults and children admitted to secondary care: recommendations for winter 2010-11

• H1N1 (2009) influenza virus is one of the viruses circulating during the current influenza season.
• Up to half of adults with influenza-like illness in General practice are likely to be infected with an influenza virus.
• This H1N1 virus continues to cause severe disease in a minority of younger adults and in children.
• There has been a sharp increase in the numbers of patients admitted to intensive care due to H1N1 infection requiring special support for severe hypoxaemia: this has placed increased pressure on critical care services, significantly over and above expected seasonal pressures.
• While half of patients requiring respiratory support have had recognised co-morbidities which increase the risk for severe influenza, half have had no recognised co-morbidities.
• Several pregnant women have already been admitted for advanced respiratory support and have had early deliveries, either to support their treatment, or spontaneously.
• Patients with high BMIs are also represented among the severely ill.

Some key features of pneumonia due to H1N1 influenza infection
• Commonest in adults below age 55 years and in children.
• Also occurs in patients of all ages with co-morbidities which increase the risk for severe influenza.
• Pregnant women are at high risk.
• Bilateral chest X-ray changes are typically present (but can be subtle and non-specific).
• The white blood-cell count is often low or normal.
• Patients are initially alert (unless there is another reason for confusion).

Warning signs of severe H1N1 respiratory illness (predictive of poorer outcome)
• Dyspnoea.
• Requiring oxygen supplementation.
• High heart rate in adults.
• Altered conscious level.
• Raised C-reactive protein > 100 mg/l.

Antiviral therapy in children and adults admitted to hospital
• Treatment with oseltamivir should be started on clinical grounds whilst awaiting test results.
• For pregnant women, the European Medicines Agency advises that either oseltamivir or zanamivir are equally safe; in Britain, the inhaled medicine, zanamivir, has been used because of lower systemic drug levels during inhalation treatment.
• Oseltamivir dosing should follow advice in the national guidelines.
• In severe illness, antiviral treatment may be commenced after more than 48 hours of illness.
• Consideration should be given to extending the duration of antiviral treatment in critically ill children and adults.
• Oseltamivir reaches blood levels effective against H1N1 when given in standard dosage by nasogastric tube, even in severely ill patients in an intensive care setting; for severely ill patients in intensive care, double doses have been used, and combinations of antiviral medicines have been considered.
• Liaise with local infectious diseases specialists, respiratory physicians or clinical virologists if considering a possible need for alternative antiviral treatment.

Note on oseltamivir dosages for children under the age of one year
The European Medicines Agency has recommended appropriate oseltamivir dosages , as follows:
• Newborns up to one month of age: 2 mg/kg twice a day.
• Children over one month and up to 3 months of age: 2.5 mg/kg twice a day.
• Children over 3 months and under one year of age: 3 mg/kg twice a day

Antibiotics for children and adults presenting to secondary care
• Adults and children, with features of influenza complicated by lower respiratory tract signs, severe painful pustular tonsillitis/sore throat, severe painful cervical lymphadenopathy, and significant acute suppurative otitis media, should be offered empiric antibiotic therapy, whether or not they are admitted to hospital.
• Antibiotic treatment should be given according to the usual guidelines for the treatment of community-acquired respiratory infections, exacerbations of chronic obstructive pulmonary disease or community-acquired pneumonia, as appropriate.
• In influenza infection, there is a small additional risk of Staphylococcus aureus secondary bacterial infection: for severely ill patients, this can be addressed by using co-amoxiclav, doxycycline or levofloxacin in place of usual first-line treatment.