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Gastro patient back at work in a takeaway

Three GPs, including Dr Joanna Harris (pictured), share their approach to a practice problem

Three GPs, including Dr Joanna Harris (pictured), share their approach to a practice problem

Case history

You have just seen a young woman the day before with a campylobacter gastroenteritis and told her not to work in her business which is a food take away service. That night your son comes home and tells you that he has been in that take away (he said the food was delicious) and the patient recognised him as your son. She asks your son to pass on the message that she is much better and back to work. What action should you take?

View from Dr Declan Fox
'I won't go off half-cocked - there could be a simple explanation'
In these days of government-orchestrated abuse of GPs and increasing litigation, my first thought is---Am I liable for any customer infections here?

No doubt I have recorded my usual advice in the file, that she should not return to work until she has had at least one clear stool sample so I am probably protected even if this does lead to an outbreak of Broad Street pump proportions. I really need to check my notes tonight.

There seems to be no hope of mistaken identity here and it does not sound as if she deliberately ignored my advice. She may have misheard what I said. Some 60s guru said, ‘if they haven't heard it then you haven't said it' so I have to assume some moral responsibility for this, although hopefully no legal responsibility.

Of course it is probably not as bad as it appears at first. Clinically she is well, the stool sample on which I based my advice was taken at least four days ago and chances are she is no longer excreting significant amounts of campylobacter. Even if she was, normal hygiene would greatly reduce the risks to her customers. CDC advice is that outbreaks are actually uncommon and that some infected people have no symptoms at all.

I shall have to phone the takeaway and talk to her. There could well be some simple explanation for this so I won't go off half-cocked but more likely, she will tell me she felt very well and thought it was OK to return. I shall have to advise her—again!--of the standard procedures.

Whether she agrees to go home or not, I shall have to discuss this with my local communicable diseases expert. This could be a public health consultant or a microbiologist and they will advise whether drastic measures are necessary or not. Closing down the takeaway? Calling all customers served by her? Calling all customers who came in during her hours on duty? Advising them all to have stool samples checked? Probably none of this will be necessary but I shall leave the experts to decide while I make my next call to my medical defence body.

Dr Declan Fox is a GP in Newtownstewart, Co Tyrone

View from Dr Joanna Harris

'Should I breach confidentiality in the interests of public health?'

This dilemma raises the question of whether it is sometimes necessary to break patient confidentiality in the interests of public health. On the face of it this looks rather concerning. Your patient has a known infectious disease, campylobacter, often spread by the faecal–oral route and as a food handler she is not only preparing takeaways for the public at large but your own son is at risk! A phone call to the environmental health officer could have the takeaway swiftly shut down and she may even have her food handling licence revoked.

However on mature reflection this may not be necessary. The advice for food handlers is that they should have been free from diarrhoea for 48 hours before returning to work. It is not necessary to obtain microbiological clearance, in this case a negative stool sample.

A stool sample report at our local laboratory takes approximately five working days to come back. The fact that you already know this is campylobacter suggests that you saw her originally the previous week with gastroenteritis and at that stage advised her not to work, while awaiting the results of the stool sample. The visit the previous day would be to confirm the result. You may possibly want to start an antibiotic such as erythromycin although in many cases the diarrhoea will ease spontaneously after two-five days without antibiotics. The important thing is not to take drugs such as loperamide which slow the passage of the stool and can prolong the infection. Her symptoms in fact may have already settled.

At this stage you would of course notify the authorities on the appropriate form under the Public Health Act 1988 since food poisoning is a notifiable disease. You could then remind her she needs to be free from diarrhoea for 48 hours and arrange to see her again only if the symptoms do not settle.

If you are at all unsure whether your recommendations were clear, a quick phone call to the patient could confirm whether she has taken your advice. And as for your son, no need to break patient confidentiality here but be on the lookout for any worrying symptoms!

Dr Joanna Harris Harris is a part-time partner at a practice in Ealing, West London

View from Dr Des Spence

'I won't contact environmental health - I am no stool pigeon'
Firstly, rush my son to the nearest hospital and get him admitted for IV fluids and monitoring. Then seek out the nearest no-win-no-fee philanthropist lawyer and claim compensation for the psychological, physical and metaphysical trauma that he has suffered, I have suffered and my unborn grandchildren have suffered. This is the standard modern management plan isn't it?

A long time ago I realised that taking stool specimens caused more trouble than it was worth. Viruses like the norwalk virus are the most common cause of GI upset but transmission is poorly understood, and stool specimens are always negative. As for the bacterial causes such as campylobacter and salmonella, these are treated symptomatically and expectantly just like the viral causes. Also, a stool result takes a week to come back, when the patient is invariably better. A positive bacterial result merely stirs anxiety and builds pressure to treat with inappropriate antibiotics. Remember also that diarrhoea illness is endemic and only a tiny fraction reach doctors most patients having sought a OTC preparation from the chemist. So, my golden rule is never take specimens unless the illness has been going for a week or so. Remember no investigation is better than mindless investigation – leave that to the hospitals.

So what risk does our campylobacter food handler present? Campyloabcter is within the food chain with origins in animal reservoirs. Most infection is via undercooked meats and meat products. Therefore, a food handler observing good hygiene such as hand washing and gloves would protect against spread. Our patient presents a low overall risk to the general pubic and therefore, I would not contact environmental health– I am no stool pigeon.

Phone the patient the next day and remind her that about the risk of transmission.

Throwing in a couple of choice phrases like ‘public liability' and ‘environmental health officers' normally does the trick. I would document my discussion and advice in her notes – end of story. The only other thing I need to do is remind myself to stop working so hard and spend more time teaching my son to cook. I hate takeaways.

Des Spence is a GP in Glasgow

Learning checklist

What does this incident teach us?

Management of gastro-enteritis

- Usually a self limiting illness which requires no investigation.

- Advice should include:

Hygiene-hand washing, surface disinfecting and prompt washing of any soiled items

- Isolation-usually advised during the period of symptoms.

- Maintaining fluid balance- by drinking glucose containing drinks or soups. (There is no evidence to support starvation.)

- Drug therapy-usually avoided –antibiotics if patient still symptomatic when stool sample positive-more often they have got better by then.

- There is evidence for empirical treatment of severe diarrhoea with ciprofloxacin but benefits have to be weighed against risks of side effects.

Anti-motility agents such as loperamide can provide symptom relief and may shorten duration of illness but should be avoided if fever and blood accompany the diarrhoea

Food Workers

- There is no need to obtain clear stool samples before they return to work.

- They and health workers should be advised to refrain from work for 48 hours after the resolution of symptoms.

- Only hepatitis A and typhoid/paratyphoid infections require different advice

- Ask your local microbiologist for advice about these infections.

How much do patients remember from consultations?

- Patients only remember about 50% of what you tell them. They may understand even less and they might also disregard your advice if it does not fit in with their health beliefs.

- It is important to find out what they know (or think they know) correct any misunderstandings and add advice at a level appropriate to their understanding.

- Written information can sometimes help.

Breaching confidentiality

- In this dilemma, the question is whether the risk posed to the public is sufficiently serious to outweigh the important principle of maintaining patient confidentiality.

- Remember that you should have already notified the public health service regarding this condition, having completed a notifiable disease form and claimed the generous fee!

- The chip shop owner also has a responsibility to report this illness to public health.

- Medical defence bodies have experience of many ethical dilemmas and can be very helpful in offering advice.

Other circumstances where confidentiality can be breached

- Sharing information with other health professionals involved in the patient's care has always been regarded as acceptable. - - -However deciding exactly who information can be shared with and how much detail is necessary for good clinical care is important. Is it appropriate to send a full patient summary with a referral?

How will the electronic care record affect patient confidentiality and their trust in it's protection?

- Sharing information with parents of children is clearly permitted. Care givers and families of patients who are not competent can also be given information where it is felt that this is in the patient's best interests.

- There is a legal framework for breaching confidentiality to a coroner's court, for child protection, to a complaints committee, to the DVLA and where serious criminality suspected.

There are statutory obligations to disclose information about notifiable diseases, terminations, IVF treatments and organ transplantation.

Dr Richard Stokell is a GP trainer in Birkenhead, Merseyside

Dr Des Spence Dr Des Spence Dr Declan Fox Dr Declan Fox Dr Joanna Harris Dr Joanna Harris

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