Swine flu: Tales from the front line of pandemic Britain

A rising death toll... Conflicting advice for pregnant women... New dedicated Tamiflu depots and NHS helplines. The H1N1 virus is spreading. And for many Britons, the pandemic is already shaping everyday life
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The mother-to-be

Daisy Russell, 34, seven months pregnant with her second child

I've obviously been thinking about swine flu because it's been in the news so much, and I think the whole thing is totally overblown and likely to terrify people.

I wouldn't not go into work or take my maternity leave earlier because it would completely mess up what was happening with my colleagues. I wouldn't want to leave them in the lurch, and I wouldn't want to jeopardise the situation of the person doing my maternity cover.

I see no reason to panic. I think it is physically worse for pregnant women if they are panicky and anxious for the baby. Maybe I am less stressed out because it is my second child; maybe if I hadn't gone through it before I would be a lot more panicked, but the best thing to do is always rely on common sense.

I don't travel at rush hour, because my job is flexible; it's not a good idea to travel at rush hour anyway if you're pregnant as it gets so busy.

I'm also not so worried about the potential side effects of Tamiflu because I think there is now an option for people to employ an inhaler which, if I caught swine flu, I would probably opt for. That way the drug goes straight to your lungs and bypasses your bloodstream.

I would be more likely to follow public advice if it was about the baby – who is going to be born in September. I don't think I will do anything different, though. I won't be taking them to crowded places or taking any unnecessary risks.

Going to work every day is something you have to do and should do. But it's different, say, to going to a music festival where there are hundreds of thousands of people.

The GP

Fay Wilson, GP, Birmingham

I run an out-of-hours service dealing with swine flu when local surgeries are closed, as well as dealing with the overspill from them during the day. Initially, we had a doctor at a base with a nurse and a driver in a car travelling around the city taking swab tests; that carried on for three weeks.

At one point we got a call saying there might be a big outbreak in a local school – we were brought in to test everybody. We had to do a few hundred children and their families; it soon became clear the outbreak was not going to be contained.

We realised at this point that, instead of a home visit service, we would keep on top of demand better if we had a flu clinic. A primary care trust lent us a very good building; we now do clinical assessments as well as swabs. Some GP practices are getting 100 calls a day; others much less, and that number seems to vary as the flu spreads to different parts of the city.

We tend to focus our attention on pregnant women, healthcare workers, and children under a year old. Some people, especially the pregnant women, have concerns about the medication, so we have to be especially vigilant that we give them the right information.

I've been working extra hours to cope, at first often finishing in the middle of the night. Now I am usually away by 10.30pm, though am on call 24 hours a day. I've just had a weekend at home for the first time in two months, though thankfully my nearest and dearest is also a GP and is fantastically supportive. He's just gone off to represent both of us at a family wedding in Canada.

Amazingly, none of us at the flu centre has caught it. One person became ill but his swab tests were negative. From the start everyone was trained to be meticulous about hygiene and we use protective gloves and masks. Some people are taking Tamiflu for prevention because we are continually exposed to people with flu; others have given up and we hope we are becoming immune to it from repeated exposure. A study has been proposed to look at our immunity.

The intensive care doctor

Roddy O'Donnel, 43, paediatric intensive care consultant, Addenbrooke's Hospital, Cambridge

Flu is dangerous – it is something we fear in paediatric intensive care. If you look at whom we admit, we are talking about a very unlucky small group of children. They are the tip of the iceberg – very dramatic cases, very ill children.

As yet no one has needed ventilation at Addenbrooke's, but we have had a few cases of children with swine flu on the ward. Usually those who are very sick are not feeding or have breathing difficulties. I understand there are some who have had encephalopathy – their brain is inflamed and not working very well. That is a typical complication of flu.

We get children with flu every year – we are expecting a bad year this year. We have eight beds in the paediatric intensive care unit and we have put a proposal to management for an additional six beds – but we have not had the green light yet.

We have been planning for a pandemic for years but initially it had not been anticipated how much it might affect children. There hasn't been as much time as one would wish and there has been a scramble to boost provision round the country.

The problem we face is the huge range of equipment we need. Children range from newborns to teenagers bigger than I am – the size of everything from ventilators to feeds varies wildly. Intensive care nurses are highly skilled and motivated – we would like to recruit extra but they don't grow on trees. Nurses catch bugs too – it is inevitable some will go off sick. We may have to have nurses looking after more cases.

We serve a population of one million children in the east of England and I hope by the time winter comes we will have six extra intensive care beds for them – but it's a big ask.

We don't know how severe the pandemic will be, but if the service is completely overwhelmed we have a contingency plan to care for children in adult areas.

We admit patients every winter from afar afield as London and Lincolnshire – it is very likely this winter that patients will have to be moved a long way from home. There are huge seasonal swings in demand.

Things are much better in paediatric intensive care than they were a decade ago, but we know each winter there are huge stresses on the system. Compared to north America you have to be much sicker to get into intensive care in the UK. Two-thirds of our children are ventilated – much higher than in the US.

I have four children, aged from 12 to three. I am worried for them because they are mine. But, also, I see children who are sicker than most. It is natural to have a high state of alertness for one's own.

The television reporter

Fergus Walsh, BBC medical correspondent

I have been preparing for a pandemic for more than six years. I was in Vietnam dealing with H5N1 [avian flu] back in 2005 and went to Turkey when there were deaths there.

So when we heard about this in late April I immediately sensed that this was what the world had feared would happen. I was at home in Berkshire when the World Health Organisation issued its warning about a new flu virus in Mexico. They said it was human-to-human transmission – which is key, that there were deaths and that they were mostly young adults. I got a call and came straight in to work.

But from the start I've tried to counsel people here at the BBC that this is a big story even if it remains mild for most, because of the sheer numbers. If you had 30 per cent of the population infected in the first wave that's roughly 18 million people. You only need a tiny percentage of those to die and a slightly bigger proportion to be hospitalised to have large numbers.

You also have the impact on society, with possibly one in eight of the workforce off sick at the peak and perhaps more looking after sick children.

You have to treat people like grown-ups and tell them exactly what's happening. One of the things I have been very strong about from the beginning is that there are huge uncertainties. We don't know how virulent it is, how it will spread, or what the death rate will be. Sometimes journalists don't like to admit there are uncertainties, but the public are perfectly capable of coping with "I just don't know" and we should do that.

In terms of not scaring people, the script is crucial. It has to be balanced and measured. When you are focusing on those who have died you do have to remind people that most cases of flu will only have mild symptoms.

A couple of weeks ago I was in Marburg, Germany, and had an H1N1 vaccine in my hand, although it wasn't ready for human use. I didn't get injected with it – although I have been immunised against H5N1 before.

I'm very clear with the team that I'm working with – and I have got a big team – that we have to do this story straight. That can mean repeating the same health messages, time after time. I would like to look back at the stories I've done, six months from now, and not cringe.

It's a particularly big and long-running story. The Chief Medical Officer said to me "This is not a sprint, it's a marathon," and I agree; this flu virus is going to be with us for years, not weeks.

To read Fergus Walsh's blog, go to: bbc.co.uk/blogs/thereporters/ ferguswalsh/

The Tamiflu depot worker

Andrew Browne, anti-viral drug collection point worker, Mile End Hospital, London

Our operation has been up and running for about three or four weeks. We started it off with a series of walk-throughs and dummy-runs to see where the pitfalls were in our various distribution processes. We had senior staff members playing patients, throwing up different problems which the workers here had to deal with. Once that was out of the way, the centre started being open from 10 in the morning until around 9.30 at night, although the workers don't generally finish until 10. I generally get here at 8.45 and leave at six; it's not so bad.

It has been very busy; there has been a constant flow of patients. At its peak it can go up to 300 or 400 people a day. All days are different; the numbers can change on a daily basis. There is no rhyme or reason to it.

We are getting people here who have been referred to us by their GP with a prescription. Then there are the people who require assessment and don't have anyone to go to, or those who need to collect the medication themselves. But we are streaming people and separating them. We are trying to keep those who are asymptomatic and flu friends from those who might have the bug themselves.

We are also meeting a lot of anxious people who are quite concerned, especially parents, who are hearing reports from the media and don't know what to expect. But generally what we see are parents who are relieved once they get the correct information and medication. There is an element of worry among the healthy, but our philosophy is that, if people are here, we are going to see them.

I am not worried about working here because I am very conscious that, if I keep washing my hands and following the basic rules of hygiene, then I am quite safe. The thing is, most of the people who are coming through are flu friends and not infectious at all.

There is a certain amount of concern from my friends and family; but I am taking a calculated risk. I am a health professional and I have done this for a long time, and I know where the dangers are with people who are infectious. We have alcohol gel all around here; and I am also encouraging people around me to wash their hands properly with it.

What I would say is that it is really important that people send their flu friends to depots such as ours if they get swine flu; they play a vital role in containing the spread. They are not at risk when they arrive – we have a one-way system so no one backtracks; everyone is moving out of a separate exit when they have been seen. The longest anyone is here is 10-15mins at a time; the risk is being minimised.

The headteacher

Stephen Brierley, headteacher, the Deanery High School, Wigan

The Deanery is a school of 1,500 in the centre of town, and I think we were the first school in Wigan to have confirmed cases of swine flu. It started on 6 July, a fortnight before the end of term. We had two pupils fall ill first, followed by a member of staff, and then more pupils.

We followed the advice of the Wigan and Bolton Health Authority, who were very helpful. They told us not to close the school. We quickly wrote to parents to let them know. By that stage we had eight confirmed cases, including the member of staff.

In the meantime, the advice we gave was: "If you have any symptoms, please don't come into school. If you have no symptoms but have underlying health concerns, talk to your GP and it may be appropriate for you not to be in school. If, on the other hand, you have no underlying health concerns or symptoms, we expect you to be in school as usual."

The member of staff returned to work last Monday, and the original two cases were back in school before the end of term on Friday. But we certainly had a lower attendance rate than usual last week. There weren't that many confirmed diagnoses, though some pupils were prescribed Tamiflu by their GPs. Quite a few pupils were kept off school because they had symptoms and felt unwell, but didn't have a full diagnosis.

The vast majority of parents were very supportive of the line we took. The decision whether or not to close a school will make some people unhappy whatever you choose. In the case of bad weather, which is the most common reason for a closure, some people say, "A couple of flakes of snow and the school closes. How ridiculous!" But others say, "I'm not sending my child to school when there's a risk they'll slip over in the playground."

Not everyone has grasped that the virus is out there in the community. One teacher in a lower school class explained that you could get swine flu anywhere, not just at school – you could even catch it in your local Tesco. And one pupil turned to another and was overheard to say, 'Thank goodness we shop at Asda'!

This doesn't appear to be that different from the normal flu outbreaks we have every year, but people are more concerned because it has a label and lots of media coverage.

I can't see, from my own perspective as a non-medically-qualified head teacher, how closing schools would help. I would resist the idea that we need to close schools in September. The only reason our school would close would be if we were unable to get a sufficient number of teachers to guarantee the health and safety of the pupils, and we'll make every effort to ensure that doesn't happen.

The politician

Andrew Lansley, shadow Secretary of State for Health

NHS staff across the country worked hard to contain the spread of the swine flu virus. Despite their efforts, the UK now has the third highest number of reported cases of swine flu in the world, and the highest number in Europe.

But as vital weeks have passed and the number of cases has surged, I have become increasingly concerned that Government dithering over some key preparations has damaged the ability of the NHS to respond coherently to the outbreak.

It is clear that there is still far too much confusion amongst the public. A full national flu line should have been up-and-running over a month ago, and managing the distribution of drugs and information in a co-ordinated way across the country. It is clear that much of the confusion that we have seen could have been avoided if the Government had acted decisively to deliver that line on time.

I am also concerned about the Government's preparedness for the projected increase in demand for intensive care beds. The UK already has far fewer such beds than other countries in western Europe and north America.

We must hope for the best and prepare for the worst.

The child victim

Andy McSmith father of Joshua

Our 11-year-old loved the weekend away in Cumbria organised by his school. It was in the coach on the way back, on Sunday, that he started feeling drowsy and unwell. By the time he was back with us, his temperature was several degrees above normal. We put him in the parental bed, hoping it was just a reaction to the excitement and would pass. It was like having one of those old-world copper bed warmers. He claimed not to feel too bad, just tired, but he was radiating heat.

We had no idea then, and still do not know for certain, whether this was swine flu, some other flu, or just a fever, but Joshua certainly had that defining symptom – an irresistible wish to lie down – which tells you that it is time for all normal activity to stop.

Monday was definitely not one of those "Too ill for school but well enough to get up and play" mornings. He was missing his school sports day, lying curled up asleep most of the day, eating nothing. In the evening, he dragged himself downstairs to watch television for a while. That was the full extent of his day's activities.

Tuesday was the last day of term, a day when you definitely want to be there to say goodbye to the classmates you won't see until September. At 7.30am, Joshua was lying in bed claiming to be feeling better. It only required a touch on the forehead or forearm to tell he was still running a raging temperature, no matter what he said. School was out of the question.

By the middle of the day, he was worse. Half a banana was all he ate all day. He did not even have the energy to go down to watch junk television, and when a child won't watch television, you really know he's not faking. At one point, he was lying in the bed complaining that the room was floating around.

His mother and I have always believed that the best treatment for a sick child is to be tucked up in bed, administered a minimal quantity of drugs, if any, and left to let the body's natural recuperative powers do their work.

And even if we wanted to go to the doctor for diagnosis, they of course are pleading with you not to. Yesterday morning, we would have used the web to test him for the symptoms of swine flu, except that you can do this only if the patient is awake and answering questions. He was fast asleep.

Joshua sings in his local church choir, and today he and his older sisters are supposed to be heading off by coach and plane to Berlin to perform in churches there. It would be an experience that he would remember for the rest of his life. And by the way, for us it would mean the rare and precious luxury of a childless long weekend, which we had planned to spend away from London. I fear it is not going to happen.

The WHO flu expert

Dr Alan Hay, director, World Health Organisation World Influenza Centre, at the National Institute for Medical Research, Mill Hill, London

We receive samples of flu viruses sent from all over the world – about 3,000 a year. In the early weeks of the pandemic last April and May we were working 18-hour days to identify the strains. We are one of four monitoring centres round the world – the others are in Atlanta, Melbourne and Tokyo – and it was very important to get the information on the first cases to the countries as early as possible. We were working into the night and at weekends.

Now most countries have the capacity to identify the viruses using kits with the necessary reagents supplied by the Center for Disease Control in Atlanta.

Our focus now is very much on monitoring the virus for any changes and for resistance to anti-viral drugs – very important for the use of Tamiflu. We also look for unusual flu viruses that could threaten the population, like H5N1 avian flu that appeared some years ago. But it is not just H5N1 – in 2003 there was a major outbreak of H7N7 in poultry in the Netherlands and 90 people were infected. That's the kind of thing you need to keep an eye on.

The influenza virus is always changing – this was realised soon after it was discovered in the 1930s. The four global monitoring centres were established in 1948 because it was recognised that the composition of the flu vaccine, which had just been developed, would have to be changed to match the changes in the virus. The network is much the same today.

Twice a year we advise WHO on the most appropriate strains to include in the vaccine – in February for the northern hemisphere and in September for the southern hemisphere. We have two months till next September to work out what will be the best vaccine for the southern hemisphere next winter [from March 2010].

The global flu network has been doing its job for many decades but what changed things was the emergence of H5N1 avian flu in Hong Kong in 1997. Avian flu has caught the imagination because of its high pathogenicity – it has a mortality rate in humans of over 50 per cent [there have been 436 cases and 232 deaths in humans worldwide]. Laboratory capacity was increased to detect novel viruses and stockpiles of Tamiflu built up so we had something to treat it with before we could develop a vaccine.

Now we are interested in H1N1 swine flu and we are trying to anticipate what the situation will be in 12 months – will it replace seasonal flu or circulate alongside it? We can't predict how virulent the H1N1 virus will turn out to be – studies have shown it is more virulent in animals.

I have four grandchildren, aged one to three. I am concerned for them. I would hope that, if they catch this virus, they are among those who are mildly affected. But you can't be sure. Flu isn't something you mess with.

YOUR QUESTIONS ANSWERED

How do I know whether I have swine flu?

The sudden onset of fever (temperature over 38C/100.4F) and a sudden cough are typical symptoms. Other symptoms may include a headache, tiredness, aches and pains, diarrhoea, a sore throat, sneezing and loss of appetite. Some people will be only mildly affected, while in others the illness will be more severe.

What should I do if infected?

Stay at home. The defining symptom of flu is an irresistible desire to lie down, so it shouldn't be difficult. To protect the rest of the family, use a handkerchief to catch coughs and sneezes, wash your hands often – and clean surfaces such as door handles.

Should I take Tamiflu?

If you are otherwise healthy, you probably do not need antiviral drugs (Tamiflu and Relenza) for yourself. However, if you live with anyone in the high risk groups – elderly, pregnant, children, or anyone with a chronic condition such as asthma or heart trouble – it may be worth getting antiviral drugs for them, to take prophylactically while you are infectious .

What about vaccination?

A vaccine is on the way but it is not available yet. The Government has ordered 132 million doses, enough for two shots each for the entire population. But limits on the speed of production mean half of us won't get it before next year, which could be too late if there is an epidemic this winter. First supplies are due by the end of August and vulnerable groups, expected to include children and healthcare workers, will be first in the queue.

How long am I infectious and when should I go back to work?

Most people recover in a week, even without antiviral medication. The fever should resolve in 3-4 days but a cough may persist for quite a time. You should not return to work while still feverish but there is no need to wait till the cough disappears.

Once you have had swine flu, are you immune to it?

Yes, regardless of how mild or severe your symptoms. But if the virus changes significantly then your immunity will be correspondingly reduced. Seasonal flu mutates every year and swine flu is expected to do the same. What we don't yet know is whether any mutation it undergoes will make it more or less severe.

Where can I get more advice?

See www.nhs.uk

By Jeremy Laurance, health editor

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