On the swine flu front line

The number of pig flu cases is tipped to double every few days and GPs and emergency departments are already swamped with those showing flu-like symptoms.  How are health professionals coping?

'SO WHY didn't the pig phone go off?" It's 8am yesterday at the Austin Hospital in Heidelberg, and as the sun beats back the morning mist, the infectious disease team is already in full flight.

The team has been holding these meetings since the swine flu outbreak began — but this one is different. Late the previous night the news came through: for the first time, a hospital staff member was confirmed with the virus.

Department director Lindsay Grayson takes charge, sketching the facts on a whiteboard.

Fact: a member of a (non-clinical) department is confirmed positive for swine flu (via his GP, which is why the official "pig phone" from the Health Department didn't ring). Fact: five of the staff member's close colleagues are off sick, with flu-like symptoms.

There's an energy in the room, jokes and anecdotes pepper the business. This team is in their element: their years of expertise are being put to the test, and they're obviously excited by the challenge.

Grayson grills his deputy director, Associate Professor Paul Johnson, about the known movements of the infected staff member.

"He came out of (a hospital) meeting," Johnson says. "No, hang on, I'm assuming that. I saw him standing in the corridor outside the meeting room."

The prospect of having to quarantine members of that meeting for seven days inspires some hilarity. But the sick colleagues, who probably also have swine flu, have spent the past week in meetings with clinical unit directors — emergency, intensive care, surgery. Close contact for more than 15 minutes is usually enough to transmit the virus, which is present for more than a day before symptoms appear.

"Right," Grayson says. "Someone has to contact (the staff member) and work out exactly who they had substantial contact with."

Says Johnson: "We can plan better when we know how many contacts the person has had." (The number later turns out to be six.) And when they know how many of the other staff with flu symptoms have swine flu.

The official rules during the "contain" phase of a pandemic are to quarantine all close contacts, with or without flu symptoms. But if a lot more hospital staff go into quarantine there are serious implications. Already, healthy staff are at home with their children who were quarantined after a schoolmate got the disease. On Thursday the Austin had staff shortages in almost every medical round.

At the same time, presentations to the emergency department have reached unprecedented levels, the extra numbers almost all people with flu symptoms.

"They are not the worried well, they are the worried sick," says Grayson at his next meeting, which gathers directors of units across the hospital to assess how they're going to meet the swine flu challenge.

This meeting, run by director of operations Mark Petty, is more formal than its conversational predecessor. There's even a printed agenda. "1. Current Status", it begins, under the title "Austin Swine Flu Pandemic Plan".

Dr Fergus Kerr, director of emergency medicine, reports that the day before, his people saw 258 patients, 90 more than normal. He is worried about the staff issue and wants Grayson's advice: what is the threshold of illness at which he starts sending staff home? Sniffles? Fever? His Sunday roster is already looking tight, and he predicts it is going to be a hell of a day. The disease is spreading across the community and already-swamped GPs are almost impossible to get hold of on the weekend. The emergency department's workload could double. On the other hand, you can't have swine-flu-riddled staff wandering around a hospital.

"If they have a flu-like illness, they don't come in," Grayson says. There are nods of agreement. It's a tough call, but unarguably right.

"2. Flu clinic — Current Status". For the past few days the hospital has set up a diversion system in the emergency department. After seeing a triage nurse, those with flu symptoms who are not sick enough to need immediate treatment go to a cordoned-off corridor, are given a mask and are swabbed for testing by masked and gowned staff.

Already the clinic is seeing 70 people a day. "This is unprecedented," Kerr says. "Normal flu drives our 'winter business', but at the peak of winter we'd see 180 to 200 people a day (in the emergency department). Now we are seeing 260. This place was already at physical capacity even without these numbers."

But staff are coping. Last Sunday, after Thornbury High School closed and 40 worried families descended on the hospital without warning, they briefly set up triage desks on the forecourt outside the emergency department. Now they have the flu clinic, and they are preparing to expand it.

Along with seven other metropolitan hospitals, the Austin is helping set up a new option: a nearby community health centre to take a significant load off the emergency department and local GPs.

"People need to know that just because they may have swine flu, a big public hospital is not the only place they can go," Kerr says. "People are safe: in the First World, the death rate is very small. There are options in the community: we are here as back-up for the very sick."

And there will be such people. Professor Johnson has been analysing the swine flu test results, and reports that fewer than one in 10 people with flu symptoms turn out to have an influenza virus. But of those people, 70 per cent have swine flu. Already, it is the dominant flu of the season. According to his calculations, at this stage the number of people with the virus will double every two to three days, and the flu season is expected to last at least three months.

So far it has predominantly hit the young, and mildly at that. Only 3 per cent of the emergency department flu-related cases are so sick they have to be briefly admitted to a ward. But it is not clear whether this will continue. If it spreads through a nursing home, for example, the health risks may be higher.

The staff hope the official pandemic status will soon be escalated to the "sustain" phase. They are holding the line but think it is nearly time to treat and quarantine on the basis of symptoms, rather than whom someone has been in contact with.

"The plan we are running on was a plan for avian flu," Grayson says. "It was well thought out, but there are now different issues emerging."

For example, he believes they might need to review the use of the anti-viral drug Tamiflu, now the disease is out in the general community.

Tamiflu is effective, but doctors find it causes nausea in up to a third of those who take it. "Some vomit the first time they have it," Grayson says. "They think, 'I'm not taking that again.' "

Other, anonymous voices in the health system are calling for a change in swine flu policy. One such voice — not from the Austin — reports growing frustration within the sector with the Department of Human Services over what is seen as its conservative and over-cautious approach.

"There's much talk in my workplace about whether the Government's response to swine flu is influenced by the criticism it received after the bushfires," she says.

State opposition health spokeswoman Helen Shardey is also starting to voice concerns. Last week she had little to criticise. But this week she is starting to apply some pressure.

"I see the Government as being very reactive, I think they're a bit on the back foot," she says.

She is seeing delays in the tracing of swine flu contacts, in the distribution of anti-virals, in the dissemination of useful information to the public and those directly affected by swine flu.

AND she fears the worst for the impact on the already stretched hospital system. "Last year the Government blamed an 'abnormally bad' flu season for growing (surgery) waiting lists and waiting times in emergency departments," she says.

"I would be deeply concerned that the system is unable to cope with regular spikes in winter influenza — how is it capable of coping with a very large flu outbreak?"

Back at the DHS, Victoria's acting chief health officer, Rosemary Lester, is coming to the end of a hell of a week. She had been in the role only days (the chief health officer, Dr John Carnie, is overseas on leave) when swine flu hit the state.

She says she hears the concerns from across the community and the health system. And she is not apologising for making tough calls.

"We know that this (quarantine) activity is extremely disruptive," she says. "We are very grateful for the co-operation we have had. In following the 'contain' phase, we are taking a cautious approach. It's early days, so we need to."

Her overriding principle is the health of the public. And in the balance of opinions, that health is best preserved by fighting as hard, and as long as possible to slow the spread of the virus.

Another driving consideration, she says, is flexibility. Victoria's pandemic plan sets few firm rules but presents options. Her choices are determined by assessing the risk posed to the public, and carefully weighing a "proportional" response.

For instance, when the plan clicks over to the "sustain" phase, there will be considerably less strict rules on how many people must be quarantined after contact with a virus carrier.

Other options such as shutting down public transport or limiting public gatherings are unlikely to be taken up, unless the virus changes into a much more dangerous form. "As it is, the virus appears about as severe as seasonal influenza," she says. "People with chronic conditions may have a more severe outcome. But what would most worry us would be if we see more healthy people getting more severe outcomes."

She maintains a confident view. There is a surge, but the system is meeting the surge. There is a plan, and it's flexible and it's working. "Even as the numbers are getting challenging, our planning has paid off," she says.