Letter from Dr Peter Bailey
I have followed with interest the work of the
Science and Technology Committee as it has investigated the response
to the threat of pandemic influenza.
My practice has around 5,000 patients, and there
is a staff team of around 20 including doctors, nurses and administrators.
We have kept ourselves fully informed about the emerging pandemic
of avian influenza and have studied the history and epidemiology
of previous pandemics in humans.
The Health Protection Agency's revised advice
in the event of pandemic influenza guesses at an attack rate of
25 per cent and a case fatality rate of 0.37 per cent, giving
an excess mortality of 53,700 for the UK as a whole. In view of
the 50 per cent death rate for cases of avian influenza in the
few humans known to have contracted the disease, this could be
a serious underestimate. In 1918, the pandemic was caused by a
virus of avian origin and had a case fatality rate of 2 per cent.
It would seem prudent to base our plans for dealing with the next
pandemic on a pessimistic assumption rather than rely on the most
optimistic figures taken from the mildest of recent pandemics.
Using an attack rate of 30 per cent and a case
fatality rate of 3 per cent the UK would see over 17 million cases
of influenza and there would be over half a million deaths.
My practice would expect to see 45 excess deaths
during the pandemic. The work load of the practice would rise
to unsustainable levels. The Chief Medical Officer's advice of
having two separate waiting areas and two separate treatment teams,
one dealing with influenza cases and one dealing with the
rest" is unworkable.
Among our own clinical team, attack rates are
likely to be higher because of constant exposure to the virus.
It would seem reasonable to use a figure of double the population
average. This would suggest that at least half of the doctors
and nurses and administrative staff would become unwell. There
is a greater than 1:4 probability that the practice would experience
the death of a team member.
It seems to me that there are many pressing
questions that are not answered by the plans that have been prepared
- What model is proposed for calculating
the number of doses of antivirals to be provided to each practice?
- When will stocks be made available
to the practices?
- How will stocks be distributed?
- How should stocks be protected?
- Who should be given treatment courses
(signs, symptoms, duration of illness, risk exposures etc)?
- What arrangements have been made
for out of hours access, given that treatment should be started
within 48 hours according to the data sheet for oseltamivir?
- Have any plans been made to treat
front line Primary Care staff with prophylactic antivirals during
the course of the pandemic?
- How many additional doses of antivirals
will be distributed for prophylaxis and who will be eligible for
- Will non-essential staff be expected
to come to work?
- Who will determine who is non-essential"?
- How should Primary Care teams respond
to demands for prophylactic treatment in families in which cases
- What is the status of existing H5N1
- Are there any plans for protecting
Primary Care teams using existing vaccines?
And perhaps the most important question of all:
- What behavioural responses to perceived
risk are expected in doctors, nurses, ancillary staff and the
- Volunteering for overtime without pay;
- Voluntary quarantine by infected cases;
- Family support strengthened.
- Abandonment of influenza victims;
- Absenteeism in all sectors but especially
- Civil disorder and breakdown of infrastructure
(utilities, transport, food supplies, education, broadcasting,
law enforcement, mortuary and cremation facilities);
- Violence against Primary Care staff and
- Theft from treatment centres.
All these questions require sensible answers
and Primary Care teams must be fully engaged in any solutions
that are proposed.