| H1N1 INFLUENZA IN CHILDREN IN THE UK |
Gareth Tudor-Williams
Pediatric Infectious Diseases Department, St Mary’s Hospital, London
This short report aims to give a perspective from a London based paediatric infectious diseases specialist working in the NHS hospital system. It does not aim to repeat any information already available on excellent websites such as the Health Protection Agency [see http://www.hpa.org.uk/] and the Department of Health [http://www.dh.gov.uk/], which provide regular updates of the situation in England and Wales, and give advice for public and practitioners.
Much planning has taken place at all levels of the NHS to prepare for pandemic influenza. However, it is only when large numbers of children start arriving in your Accident & Emergency Department that clinical teams begin to see the flaws in the plans!
In London we have experienced the first phase of high incidence of H1N1 influenza from May to July 2009. This has waned dramatically since the schools closed for the summer holiday. The outbreak has provided an invaluable opportunity to test out systems of triage and management, in preparation for what promises to be a far more dramatic epidemic in the autumn. The prediction is that there may be a need for up to 800 high dependency beds for children – especially those under 12 months of age - in London at the peak in the 3rd week in October 2009. Current capacity across the whole of London is of the order of 60 beds. Every unit is being asked to review how this capacity can be expanded. It obviously requires identification of bed spaces, but extra HDU beds are worthless if they can not be staffed.
As the epidemic escalates, numerous routine hospital activities will need to be curtailed. Staff (including doctors, nurses, physiotherapists, and other health care workers including possibly volunteers from our final year medical students) will be redeployed to acute services for the severely affected children. Maintaining a healthy workforce will be paramount. The H1N1 vaccine is unlikely to be available on a wide enough scale before October. In the meantime, staff is being fitted with FFP3 filtration masks for their own personal use, whenever they come in to contact with possible patients. Maintaining good basic hygiene and scrupulous infection control measures are being emphasized. Pregnant members of staff will not be involved in giving direct care to infected patients if possible.
Masks are but one small element of the equipment needs. Ventilators and air flow devices that will permit infants and older children to receive appropriate respiratory support need to be purchased or hired in advance. It may be possible to recommission moth-balled equipment. Oxygen supplies need to be considered, as novel areas used to nurse children may not have piped oxygen. There is very little time to embark on extensive remodeling, so temporary solutions including using portable oxygen cylinders will be required.
Diagnostic tests abound and it is important to find out what your local virology / microbiology service can offer. We favour naso-pharyngeal aspirates over throat or nose swabs, since this enables a rapid (but not highly sensitive) immunoflourescence test to be performed, and subsequent PCR and culture.
Treatment and prophylaxis with specific antivirals is causing some controversy. In our own unit that cares for a very large number of immunosuppressed children (with – for example - HIV, haematological / oncological problems, on immunosuppressive therapy for inflammatory disorders, nephrotics on steroids and a substantial number of severe asthmatics), the vast majority of those with proven H1N1 infection have had remarkably mild disease. We have had only two deaths in children with H1N1 influenza, one of whom appears to have died as a result of secondary Group A streptococcal infection. We have adopted a policy of doubling the dose of oseltamivir for children with suspected H1N1 ‘flu who are requiring high dependency care, but are unable to obtain any therapeutic drug monitoring. There has been no evidence of clinical resistance to oseltamivir so far. We give all the children broad spectrum antibiotics, as bacterial secondary infection was thought to be responsible for the vast majority of the deaths in earlier epidemics.
We have moved away from recommending oseltamivir prophylaxis for contacts, since the intervention is of unproven efficacy, there may be unwanted adverse reactions, the practice may encourage the selection of resistance, and the reality is that most of our patients will have contacts frequently in the months to come and may end up on numerous repeated cycles of prophylaxis.
We are extremely keen to understand what the risk factors for severe disease comprise, and a consortium of many of the PICU teams around the country have agreed to undertake collaborative research to answer some of the questions. For the immuno compromised children, it will be helpful to understand whether they continue to excrete replication-competent virus for prolonged periods. This is one reason for wanting to try and culture virus as well as look for its presence by PCR. It is possible that PCR will continue to pick up amplifiable genome long after the virus is rendered uninfectious.
At an anecdotal level, the first immuno-compromised patient of mine to have confirmed H1N1 'flu was on very high doses of steroids and methotrexate for severe juvenile idiopathic arthritis. He had minimal symptoms at any stage, no signs of lower respiratory tract involvement, and completely cleared the virus (as judged by both PCR and culture) after 5 days of treatment with standard doses of oseltamivir. It will be interesting to see how solid a protective immune response he has generated, when he comes across other infected children during the coming months.
As a tertiary referral unit, we are already witnessing another worrying aspect of how Health Care services are stretched, in that children are being sent away by GPs or from A&E Departments with prescriptions for oseltamivir, when in fact they have other causes for their fevers including Kawasaki disease, meningococcal septicemia or other bacterial infections.
There is a lot to learn, and no room for complacency.
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