I attended this meeting with Dr Simon Tanner (Director of Public Health for London) as Vice Chair of the Patients Forum Ambulance Services (London) on July 28th, together with the Chair, Malcolm Alexander and another Forum member. We are now facing into the flu season, which will begin in late September and when the rate of infection is likely to pick up again.
Indications from the Southern Hemisphere are interesting, where Argentina has recorded the highest death rate so far. These countries are just coming to the end of the flu season and so their experience is worth studying. Data suggests that the virus is not mutating but also indicates that the seasonal flu has almost disappeared as a cause of death, to be replaced by swine flu. I still do not agree with Dr Tanner's view that public events should not be cancelled as these are likely be a significant source of infection - as we have seen with the schools over the last few months. It is also significant that Argentina's economy has already been badly hit by the pandemic, with its tourism industry having collapsed. This suggests that there will be a not insignificant impact economically in the UK, and this in a period leading up to the general election.
The question of how the NHS copes with the pandemic, and particulary how effective both drug distribution and treatment are, could also have a role in the play in the final judgement on Gordon Brown's government.
Patients’ Forum Ambulance Services (London) Ltd
PatientsForumLAS@aol.com
Meeting to discuss pandemic flu with the Director of Public Health for London- July 28th 2009
Simon Tanner, Director of Public Health
Andy Wapling, Head of Emergency Preparedness
Joseph Healy, Michael English and Malcolm Alexander
1) History of the Swine Flu Pandemic
Simon Tanner gave a brief history of the pandemic. He said that it appeared to have emerged in Mexico in April 2009 and that the virus does not cause a high level of mortality in the general population, but certain groups including pregnant women in their third trimester, people with respiratory illnesses, other chronic conditions and young people, appear to be more vulnerable to the effects of virus. He said it was more infectious amongst young people.
Simon said that the response to the current epidemic, provided public health experts with experience for dealing with a more serious epidemic should this occur, e.g. if the current virus mutated creating a ‘novel’ virus which could have a higher mortality.
We asked why it appeared that the Mexican epidemic had such a high mortality rate. Simon replied that this was probably because the rate of deaths compared to the gross infection rate was unknown, i.e. the denominator is unknown.
2) Current situation
Simon said that the spread of flu in the UK was being closely observed by the Health Protection Agency, which he described as “highly competent’ in this role. He said that the national policy had been one of containment, and had now moved on to the treatment phase. There are about 2000 new cases reported each day in London by either GPs or the Fluline. These cases are not confirmed serologically, but are either diagnosed by doctors or by the use of an algorithm by Fluline staff. Fluline started on July 26th 2009. Simon said that Fluline was in its development phase and acknowledged that it was flawed by having no language line service. We asked about the training of Fluline staff; Simon said that they received a few hours training to use an algorithm as a basis for putting questions to callers, which can identify whether their symptoms were consistent with swine flu. He said Fluline staff had onsite clinical backup. Simon added that NHS Direct would be placed under extreme pressure and therefore caller waiting time would be unacceptable, if the Fluline approach had not been adopted. He said that the system is working well so far.
There have been 16 deaths in London from swine flu so far. We asked if a peak infection rate was expected in September/October 2009 and Andy agreed that this was possible but not certain.
3) Tamiflu
Tamiflu works by halting the reproduction of the Flu virus, reduces the severity of symptoms, e.g. the incidence of pneumonia, and reduces by about one day the severity of the illness. It must be taken within two days of the onset of symptoms to be effective.
Simon said that 50-70% of people who have symptoms consistent with SF are accepting Tamiflu. He said that all those identified as having symptoms consistent with SF are being offered Tamiflu.
Simon said that there is a national stockpile of Tamiflu and the £1million GLA stockpile was now part of the national stockpile (it has been signed over by Boris Johnson to the NHS). He said that Tamiflu was stored in PCT stores. There are 125 distribution points in London at the moment and capacity to open 402 centres if necessary. In the current system a person phoning with flu symptoms who is diagnosed as having swine flu is given a number, which a friend or family member can take to the flu centre to get the supply of Tamiflu. People with symptoms are asked to collect Tamiflu within 2 days and currently the prescription for Tamiflu is not time limited. Tamiflu is funded centrally and the cost does not come from local PCT budgets. The active life of Tamiflu is 5 years.
4) Vaccination
Simon Tanner said that once a vaccine is produced for the swine flu virus that government policy is to vaccinate the whole population. There is a contract with two vaccine manufacturers (Smith, Kline and French and Baxters). The order is for 120 million doses, i.e. two doses for each person in the UK. The intention is to start vaccination in August and sufficient vaccine has been ordered to vaccinate half the population by the end of the year. We asked about post-vaccination testing for side effects, bearing in mind that this is a new vaccine and my cause harm to some people who are given it. Simon said that the first cohort would have blood tests to make sure that the response was adequate. We did not get an answer regarding side effects.
The vaccine would first be given to priority group, but it is not yet certain which groups will be designated as priority groups.
We asked whether the vaccine would be of any use if the virus mutated and we were told that it might be of no use if there was a new pandemic caused by a mutated strain.
5) Management of services to support the community
We asked if the voluntary sector is being fully involved the response to the pandemic. Simon said that this was the responsibility of the Borough based ‘flu committee’. He said that each Borough has submitted their plans to the Strategic Health Authority and these have been audited. This audit included as assessment of the involvement of the voluntary sector in local planning. The plans also included details of the care of vulnerable group in the community.
6) Publicity
We asked if the quality of the publicity about flu will be improved, e.g. by strengthening the messages about preventing infection on the transport system. Simon said the publicity campaign was very much tied to the national campaign and costs had to be contained. He said that symptomatic people were being advised to stay at home and that a main plank of publicity was to communicate well, to reassure the public and emphasise messages about personal hygiene.
7) Quarantine
We discussed the possible need for quarantine and the curtailment of public activities. We referred to the very high level of mortality in 1918 (5-6% of the population). Simon said that curtailment of public activities was not appropriate in the UK, and that quarantine does not appear to make any significant difference to the gross number of people who become infected or change the course of the epidemic. Simon said that government strategy had to consider business continuity, but in his view the effects on the GDP should not override the need for people to remain of work to contain the spread of the epidemic.
8) Closed communities
We discussed the problems for people in mental health wards, prisons and other places where their movements might be restricted or people who live in closed communities. We agreed that this was a very significant problem that must be tackled. He said there are a number of national guidance documents for PCTs, prisons and mental health units on the Department of Health website.
Andy Walling, Head of Emergency Preparedness at NHS London, said: "We would like to reassure people that NHS London is well-prepared - all NHS organisations have plans which have been practised and checked regularly. NHS London has put in place recently audited plans on how to prepare for flu pandemic and ensure that anyone who needs help will receive it."
End
Malcolm Alexander, Joseph Healey and Michael English.
PatientsForumLAS@aol.com
Meeting to discuss pandemic flu with the Director of Public Health for London- July 28th 2009
Simon Tanner, Director of Public Health
Andy Wapling, Head of Emergency Preparedness
Joseph Healy, Michael English and Malcolm Alexander
1) History of the Swine Flu Pandemic
Simon Tanner gave a brief history of the pandemic. He said that it appeared to have emerged in Mexico in April 2009 and that the virus does not cause a high level of mortality in the general population, but certain groups including pregnant women in their third trimester, people with respiratory illnesses, other chronic conditions and young people, appear to be more vulnerable to the effects of virus. He said it was more infectious amongst young people.
Simon said that the response to the current epidemic, provided public health experts with experience for dealing with a more serious epidemic should this occur, e.g. if the current virus mutated creating a ‘novel’ virus which could have a higher mortality.
We asked why it appeared that the Mexican epidemic had such a high mortality rate. Simon replied that this was probably because the rate of deaths compared to the gross infection rate was unknown, i.e. the denominator is unknown.
2) Current situation
Simon said that the spread of flu in the UK was being closely observed by the Health Protection Agency, which he described as “highly competent’ in this role. He said that the national policy had been one of containment, and had now moved on to the treatment phase. There are about 2000 new cases reported each day in London by either GPs or the Fluline. These cases are not confirmed serologically, but are either diagnosed by doctors or by the use of an algorithm by Fluline staff. Fluline started on July 26th 2009. Simon said that Fluline was in its development phase and acknowledged that it was flawed by having no language line service. We asked about the training of Fluline staff; Simon said that they received a few hours training to use an algorithm as a basis for putting questions to callers, which can identify whether their symptoms were consistent with swine flu. He said Fluline staff had onsite clinical backup. Simon added that NHS Direct would be placed under extreme pressure and therefore caller waiting time would be unacceptable, if the Fluline approach had not been adopted. He said that the system is working well so far.
There have been 16 deaths in London from swine flu so far. We asked if a peak infection rate was expected in September/October 2009 and Andy agreed that this was possible but not certain.
3) Tamiflu
Tamiflu works by halting the reproduction of the Flu virus, reduces the severity of symptoms, e.g. the incidence of pneumonia, and reduces by about one day the severity of the illness. It must be taken within two days of the onset of symptoms to be effective.
Simon said that 50-70% of people who have symptoms consistent with SF are accepting Tamiflu. He said that all those identified as having symptoms consistent with SF are being offered Tamiflu.
Simon said that there is a national stockpile of Tamiflu and the £1million GLA stockpile was now part of the national stockpile (it has been signed over by Boris Johnson to the NHS). He said that Tamiflu was stored in PCT stores. There are 125 distribution points in London at the moment and capacity to open 402 centres if necessary. In the current system a person phoning with flu symptoms who is diagnosed as having swine flu is given a number, which a friend or family member can take to the flu centre to get the supply of Tamiflu. People with symptoms are asked to collect Tamiflu within 2 days and currently the prescription for Tamiflu is not time limited. Tamiflu is funded centrally and the cost does not come from local PCT budgets. The active life of Tamiflu is 5 years.
4) Vaccination
Simon Tanner said that once a vaccine is produced for the swine flu virus that government policy is to vaccinate the whole population. There is a contract with two vaccine manufacturers (Smith, Kline and French and Baxters). The order is for 120 million doses, i.e. two doses for each person in the UK. The intention is to start vaccination in August and sufficient vaccine has been ordered to vaccinate half the population by the end of the year. We asked about post-vaccination testing for side effects, bearing in mind that this is a new vaccine and my cause harm to some people who are given it. Simon said that the first cohort would have blood tests to make sure that the response was adequate. We did not get an answer regarding side effects.
The vaccine would first be given to priority group, but it is not yet certain which groups will be designated as priority groups.
We asked whether the vaccine would be of any use if the virus mutated and we were told that it might be of no use if there was a new pandemic caused by a mutated strain.
5) Management of services to support the community
We asked if the voluntary sector is being fully involved the response to the pandemic. Simon said that this was the responsibility of the Borough based ‘flu committee’. He said that each Borough has submitted their plans to the Strategic Health Authority and these have been audited. This audit included as assessment of the involvement of the voluntary sector in local planning. The plans also included details of the care of vulnerable group in the community.
6) Publicity
We asked if the quality of the publicity about flu will be improved, e.g. by strengthening the messages about preventing infection on the transport system. Simon said the publicity campaign was very much tied to the national campaign and costs had to be contained. He said that symptomatic people were being advised to stay at home and that a main plank of publicity was to communicate well, to reassure the public and emphasise messages about personal hygiene.
7) Quarantine
We discussed the possible need for quarantine and the curtailment of public activities. We referred to the very high level of mortality in 1918 (5-6% of the population). Simon said that curtailment of public activities was not appropriate in the UK, and that quarantine does not appear to make any significant difference to the gross number of people who become infected or change the course of the epidemic. Simon said that government strategy had to consider business continuity, but in his view the effects on the GDP should not override the need for people to remain of work to contain the spread of the epidemic.
8) Closed communities
We discussed the problems for people in mental health wards, prisons and other places where their movements might be restricted or people who live in closed communities. We agreed that this was a very significant problem that must be tackled. He said there are a number of national guidance documents for PCTs, prisons and mental health units on the Department of Health website.
Andy Walling, Head of Emergency Preparedness at NHS London, said: "We would like to reassure people that NHS London is well-prepared - all NHS organisations have plans which have been practised and checked regularly. NHS London has put in place recently audited plans on how to prepare for flu pandemic and ensure that anyone who needs help will receive it."
End
Malcolm Alexander, Joseph Healey and Michael English.
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