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Independents' Day

Swine flu: GPs' questions answered by the HPA

We asked you to send us the questions on swine flu you wanted the Health Protection Agency to answer. Here are the most popular- with the agency's responses.

What's the incubation period for swine flu?

The incubation period for swine flu is likely to be similar to that of seasonal flu, which is 1-4 days with a maximum of 7 days, especially for children.

Are there any specific clinical features that can help discern it from then ‘usual' British flu?

Data suggests symptoms are very similar to those of seasonal flu. Cases have presented with typical symptoms of flu-like illness: fever [?38?C] or history of fever and either flu-like illness (two or more of the following symptoms: cough, sore throat, rhinorrhea, limb/joint pain, headache) or other severe/life-threatening illness suggestive of an infectious process. Some cases in America have also presented with vomiting and diarrhoea.

The algorithm states we should take a swab 'at patient's home if possible' but this could create an enormous workload for us. Is the pragmatic approach of getting the patient to attend but immediately isolating him/her in a side room acceptable? Are there any other precautions I should take?

Ideally samples should be taken at patient's home to avoid the unnecessary exposure of other patients. Where this is not possible, patients should be swabbed in a side room applying good hygiene measures and using a surgical mask, gloves and apron.

Will labs give priority to flu swab results?

The Agency's detection capability for this virus is already excellent, using the network of regional laboratories and the Centre for Infections Virus Reference Department.

Should I continue to agree to see patients before the results come back?

Whilst waiting for the results of swabs, symptomatic patients should remain at home and self-isolate as well as following simple hygiene measures (hand washing, etc.). Although they will already be on oseltamivir treatment, if they deteriorate and need assessment for hospitalisation, GPs should of course, see the patients at home or in a side room. Again it is important to apply good hygiene measures and using recommended protective gear (surgical mask, apron and gloves).

Are the swabs the standard viral swabs as used, say, for herpes simplex? Where can we get supplies?

Standard viral transport swabs or other swabs in standard virus transport medium should be used. These can be obtained from your local health protection unit.

Can the swabs be kept overnight if a patient presents late in the day after the delivery of specimens from surgery to local lab?

Specimens should be kept in properly temperature controlled fridge, they should not be frozen. We would recommend that GPs endeavour to get the samples in during working hours as storage is more difficult during the night.

The algorithm states: 'History of fever' but patients often report having felt a bit hot or feverish. Is this ‘good enough' or should there be documented fever?

If it is not possible to document a high fever, then a clinician can make a decision to seek advice from the Health Protection Unit (HPU) based on a reliable history of the patient feeling feverish.

The footnote states that D&V have occurred in the US cases - should this be viewed as fulfilling one of the symptom criteria (fever + two symptoms)?

Yes, diarrhoea and vomiting have been seen in swine flu patients in the USA and should be considered as symptoms of possible cases. However, patients with diarrhoea and vomiting without respiratory symptoms would not fulfil the case definition for further investigation. Individual cases can be discussed with the local Health Protection Unit.

How will antivirals be distributed?

During the current pre-pandemic phase, the HPA has stocks of Tamiflu which will be made available for treatment or prophylaxis. Local arrangements should be made between GPs and the local Health Protection Unit as to how these would be provided to the patient

How should we respond to patients who request private prescriptions of antivirals, if they are travelling to a higher risk area?

In the first instance patients should be informed that all non-essential travel to higher risk areas such as Mexico is advised against at this present time. If they do decide to visit such an area they should take personal responsibility for their own safety, including ensuring they have access to adequate healthcare should they need it. They should be aware of what symptoms to look out for and consult a doctor immediately if they show signs of flu-like symptoms. At present we are advising against the use of anti-virals as a precautionary measure unless the individual has been in close contact with a person affected with swine flu. For up-to-date advice before a patient travels they should consult the Foreign and Commonwealth website.

Is there a certain threshold of cases at which the HPA will recommend the routine prescription of antivirals to contacts of suspected cases, and where will these supplies come from?

The Agency advises that post exposure prophylaxis is indicated for close contacts who were exposed to a probable or confirmed case during the period when the case was symptomatic AND the contact's last exposure occurred no more than seven days previously. HPA guidance includes information on what constitutes a close contact.

Any future recommendations on the routine prescribing of antivirals would be made by the Department of Health.

If I use an oral thermometer to check temperature, how should this subsequently be sterilised?

Thermometers should be handled and cleaned in the same way as for other common infections; no additional/ different measures are required.

What about children/babies returning from Mexico, California etc with fever? They may not be able to give an accurate history of other symptoms. And Relenza has no dose recommendation in the under 5s and Tamiflu no recommendation in those under 1.

Zanamivir is not licensed for children <5 years old and for those below this age, oseltamivir should be used in preference.

Oseltamivir suspension is available for younger children. It is unlicensed for use in the under ones but a decision to prescribe should be made on the basis of an individual risk benefit analysis by the prescribing physician.

Where can practice staff get the correct face masks and protective equipment from?

Contact your local PCT for this information.

Swine flu

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