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October 2005 - offices and public spaces are beginning
to echo with the sound of coughing. GP surgeries are beginning
to silt up with people who seek advice, antibiotics and certificates
for sore throats, coughs, and flu like illnesses. This will continue
through the winter, culminating in the annual announcements of
NHS overload due to the annual tour of the Influenza A virus as
it proceeds majestically around the globe. At the same time, public
health physicians worldwide are planning how to manage the global
epidemic that would result if the H5N1 avian flu virus manages
to mutate into a form that can pass from human to human. Their
minds are concentrated wonderfully by the knowledge that a particular
variety of Influenza A killed 6 million people in 1918, and locked
thousands more into a pathetic lifetime existence of Parkinsonian
immobility. The risk of a global pandemic of this sort is always
with us but avian H5N1 flu has upped the ante, because it carries
a 50% mortality rate. Just to be clear, this means that as things
stand, you have a 50% chance of dying if you catch it. At the
moment you have to work closely with infected birds to catch it,
but if it mutates to get the ability to pass from human to human
we will be in for a rough ride. This is not a cause for panic
or scaremongering, but it should be a cause of careful consideration
of how we respond to infectious diseases.
The SARS outbreak of 2002-3 gave us a foretaste of how we should
respond. The success of the World Health Organisation. in dealing
with SARS was due to not to high tech vaccines, but classic low
tech quarantine and isolation measures. Doctors learned to isolate
cases, to trace contacts and quarantine them. Many died, including
many doctors, nurses and healthcare workers, but in the end it
was successful. We should learn from that experience, and in particular
should develop ways of limiting the spread of the virus through
air travel. We should also develop strategies for responding to
an epidemic should it break through our airports and other communication
routes and become established in our country. This means that
we must learn new measures for dealing with common conditions
like influenza, so that when a serious outbreak occurs, isolation
techniques will be familiar to the general population.
Isolation
People get infected by mixing with people who are already infected.
Therefore, when we have an infectious viral illness we should
put ourselves out of circulation. So far as is practicable, we
should stay at home and rest. In particular, we should try not
to go to the shops, try not to go on public transport, and we
should definitely not go to work. There are sound theoretical
reasons for resting a viral illness. I explain to my patients
with flu-like illnesses that they feel tired and fatigued because
their energy is being diverted to their defence system. They should
therefore not try to divert blood away from their immune system
and back into their legs and brain by going to work. They should
give their immune system a chance to do its job properly.
Isolation (now called "social distancing") of infected
cases cannot eliminate epidemics, because sometimes the infection
is passed on by people who feel perfectly well. This is not a
reason to abandon isolation, since shedding certainly continues
after symptoms appear, and isolation can therefore reduce the
severity of the epidemic.
We have a triple line of defence against a global pandemic of
the type which currently threatens us in the form of a H5N1 mutant:
quarantine, vaccination and chemotherapy. All lines of defence
must be used. The danger is that politicians will opt for vaccination
and chemotherapy to the exclusion of isolation, because isolation
involves much social inconvenience, and will be politically unpopular,
unless it is correctly understood.
The Government's policy is set out in a 134 - page UK Flu Pandemic
Contingency Plan (March 2005). In it we find a singe paragraph
devoted to preventing transmission among the community: "
However, simple advice such as hand washing, encouraging people
suffering from the disease to stay at home and reducing unnecessary,
especially long distance, travel may achieve some slowing of the
spread of a pandemic." This coyness stems from the fact that
isolation of cases goes against an ingrained management assumption
that people should come to work when they are suffering viral
illness, and that those who stay home are malingerers until proved
otherwise.
Medical logic demands that the NHS and Health Protection Agency
should lead a concerted "Stay Home if Ill" campaign
to educate the population to recognise a flu-like upper respiratory
tract infection, learn how to manage it at home without physically
contacting a doctor, learn to stay home from work when ill, and
learn to recognise symptoms that indicate complications that need
treatment, and learn where to and how to get that treatment. They
must start this campaign now, so that people are ready with the
new strategy if a serious pandemic breaks out.
Not a Shirkers Charter
The key battle will be over changing the work ethos so that the
default position is that an ill person should stay home, rather
than struggle in to work.
All significant reforms will meet with resistance, and the key
objection that the "Stay Home if Ill" initiative is
likely to meet is that employers will argue that it will provide
an inherently lazy workforce with a Shirker's Charter. There are
several answers to this assumption. We can look at the experience
of other countries. In America, for instance some firms allow
four days off a year, to be taken at a moment's notice. They are
called "duvet days". Secondly, patients are often reluctant
to stay off work because of the financial loss incurred, as well
as the threat to job security. These factors will still counter
any abuse of the system. Third, employers need to be educated
about the workforce implications of dragging infected employees
into work. Given the fact that most offices live on recycled,
conditioned air, the products of one cough can be on every desk
in the office within the hour. Employers should be helped to understand
that an infected employee will spread infection to colleagues,
an infected employee cannot work efficiently, that an infected
employee who works will be ill for longer than one who rests,
and therefore that a "stay home if ill" policy will
result in less days lost to illness, not more.
A sensible programme of health education could therefore overcome
the objections from within commerce and industry, and indeed ,
bring them on side. The workers themselves will be happy to co-operate
with the new scheme. Less incidence of viral illness, combined
with less unnecessary consultations for viral infections will
overcome the "winter pressures" that routinely overwhelm
the NHS. This reform is one which could enjoy a rapid success.
The country will gain improved productivity, and the NHS could
gain a decreased workload, freeing up opportunities to improve
the quality of medical care that we deliver. These are all immediate
gains from this method: but the overriding gain is that it could
vastly reduce the potential impact of the global epidemic that
could result if the current avian flu virus does gain the ability
to pass from human to human. And that could potentially save many
thousands of lives in the UK alone.
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