Guest Editorial

As the Foundation of Health Care, Family Physicians Need to Plan Now for Pandemic Flu

By Doug Campos-Outcalt, M.D., M.P.A.
Posted: 9/29/2009, 2:55 p.m.

Although the official start of the 2009-10 flu season is pegged at Oct. 4, the long-anticipated novel influenza A (H1N1) pandemic influenza is here now. For the week of Sept. 13-19, the CDC reported that 26 states had geographically widespread influenza activity; 11 states had regional influenza activity; and 12 states, the District of Columbia and Puerto Rico had local influenza activity.

Doug Campos-Outcalt, M.D., M.P.A.

Visits to doctors for influenza-like illness have been higher than expected for the past six weeks. Nationwide, 4.6 percent of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network were attributed to influenza-like illness -- well above the national baseline of 2.4 percent. Many of these visits were related to H1N1 infection rather than to seasonal flu.

Obviously, H1N1 has arrived in physician's offices around the country, and family physicians need to respond.

As FPs, we will face multiple challenges during this period, and we should strive to prevent infection among our patients and staff members and morbidity and mortality among those who are infected. We also need to continue to provide care for all our patients while dealing with this influenza surge. And high on our list of priorities is the necessity to make sure our clinics are not spreading H1N1 to all of our patients. To that end, there are a number of steps we can take.

Immunize ourselves and our staff members. This should include vaccine against both seasonal and pandemic influenza. All health care workers should be immunized and will receive priority for vaccine. Any staff member who refuses vaccination is a risk to him- or herself, patients, and the clinic. Consider furloughing staff members who, after counseling, continue to refuse immunization, or move them into nonpatient-contact work.
Wear personal protective equipment, or PPE. Ensure that all physicians and staff members in the practice wear PPE when examining or treating patients who may be infected. Protective eyewear, gloves and masks should be worn whenever there is a risk of exposure to infectious fluids. This includes procedures that can induce coughing.
Adhere to good infection control practices. Hand washing and sanitation, along with frequent cleaning of countertops, equipment and examination table surfaces, should become routine.
Separate infectious patients from others in space and time. Consider reserving time at the end of the day for patients with influenza-like illness. In the waiting area, separate potentially infectious patients from other patients. Inform patients about appropriate respiratory hygiene practices, and ensure tissues and hand sanitizers are available.
Consider chemoprophylaxis for staff members who receive a strong exposure (e.g., a cough in the face). This option should be considered until staff members are immunized, which will be two weeks after the receiving the H1N1 vaccine.
Require sick staff members to stay at home. Take a look at your sick-leave policy, and consider revising it temporarily.
Be a source of information. You should provide advice to sick patients on how to avoid spreading the infection to other members of their households.
Consider providing antiviral chemoprevention. You might want to provide prescriptions for antiviral chemoprevention for household members at risk of complications from influenza.

It's important to note that providing timely care for sick patients will be critical. For those who are at high risk for complications, antiviral treatment is most effective if it is started before 48 hours of onset of symptoms. Also, for family members of infected individuals who are themselves at high risk of complications from influenza, the sooner chemoprophylaxis is started, the better.

To address the timeliness factor when your practice may be overwhelmed with patients, consider developing telephone triage protocols for your staff members. These protocols should allow staff to rapidly place patients into one of four categories:

those worried about potential exposure,
those who are ill but who do not need medical attention,
those who are ill and who can be cared for in the outpatient setting, and
those who need to seek hospital or emergency care urgently.

The protocols should include appropriate advice for individuals in each of the four categories. Remember, not all patients who should receive antiviral medications need to be seen in person.

For us FPs to be maximally effective in our role as the foundation of the health care system, it is critical that we stay current on the evolving pandemic epidemiology and on public health recommendations regarding vaccine prioritization, disease reporting, specimen collection, and treatment and chemoprophylaxis. Watch for communications from state and local health departments, as well as from the CDC.

In addition, the CDC and AAFP Web sites offer much advice and many useful tools for dealing with the pandemic flu. These sites also list current recommendations for each of the points emphasized here. The time to read this information and to plan is now, before H1N1 overwhelms your practice.

Doug Campos-Outcalt, M.D., M.P.A., is the AAFP's liaison to the CDC's Advisory Committee on Immunization Practices. He also is the associate head of the department of family and community medicine at the University of Arizona College of Medicine, Phoenix.