Friday, September 30, 2005

Quarantine that Virus

[apologies - this is a long one - 1119 words. Terrible stain on my claim to brevity. Worth serious study though. Could save your life.]

October 2005 – offices and public spaces are beginning to echo with the sound of coughing. Gp surgeries are beginning to silt up with people who seek advice, antibiotics and certificates for sore throats, coughs, and flu like illnesses. This will continue through the winter, culminating in the annual announcements of NHS overload due to the majestic annual global tour of the Influenza A virus. At the same time, public health physicians worldwide are pondering how to manage the global epidemic that would result if the H5N1 avian flu virus manages to mutate into a form that can pass from human to human. There minds are concentrated wonderfully by the knowledge that a particular variety of Influenza A killed 6 million people in 1918, and locked thousands more into a pathetic lifetime existence of Parkinsonian immobility. The risk of a global pandemic of this sort is always with us. This is not a cause for panic or scaremongering, but it should be a cause of careful consideration of how we respond to infectious diseases.
The SARS outbreak of 2002-3 gave us a foretaste of how we should respond. The success of the World Health Organisation. in dealing with SARS was due to not to high tech vaccines, but classic low tech quarantine and isolation measures. Doctors learned to isolate cases, to trace contacts and isolate them also. Many died, including many doctors, nurses and healthcare workers, but in the end it was successful. We should learn from that experience, and in particular should develop ways of limiting the spread of the virus through air travel. We should also develop strategies for responding to an epidemic should it break through our airports and other communication routes and become established in our country. This means that we must learn new measures for dealing with common conditions like influenza, so that when a serious outbreak occurs, isolation techniques will be familiar to us.
People get infected by mixing with people who are already infected. Therefore, when we have an infectious viral illness we should put ourselves out of circulation. So far as is practicable, we should stay at home and rest. In particular, we should not try not to go to the shops, try not to go on public transport, and we should definitely not go to work.
There are sound theoretical reasons for resting a viral illness. I explain to my patients with flu-like illnesses that they feel tired and fatigued because their energy is being diverted to their defence system. They should therefore not try to divert blood away from their immune and back into their legs and brain by going to work. They should give their immune system a chance to do its job properly. This argument is effective, because the people who are most likely to carry on regardless tend to be conscientious perfectionists who set themselves high standards, and want to keep on going to work.
It is sometimes argued that much viral shedding occurs before the victims know they are infected. Quarantine cannot eliminate epidemics, because sometimes the infection is passed on by people who feel perfectly well. This is true, but not a reason to abandon isolation, since shedding certainly continues after symptoms appear, and isolation can therefore reduce the severity of the epidemic.
We have a triple line of defence against a global pandemic of the type which currently threatens us in the form of a H5N1 mutant: quarantine, vaccination and chemotherapy. All lines of defence must be used. The danger is that politicians will opt for vaccination and chemotherapy to the exclusion of isolation, because isolation involves much social inconvenience, and will be politically unpopular, unless it is correctly understood. It also runs counter to an ingrained management assumption that people should come to work when they are suffering viral illness, and that those who stay home are malingerers until proved otherwise.
Nevertheless, medical logic demands that the NHS and Health Protection Agency should lead a concerted “Stay Home if Ill” campaign to educate the population to recognise a flu-like upper respiratory tract infection, learn how to manage it at home without physically contacting a doctor, learn to stay home from work when ill, and learn to recognise symptoms that indicate complications that need treatment. They must start this campaign now, so that people are ready with the new strategy if a serious pandemic breaks out.
Not a Shirkers Charter
The key battle will be over changing the work ethos so that the default position is that an ill person should stay home, rather than struggle in to work.
All significant reforms will meet with resistance, and the key objection that the “Stay Home if Ill” initiative is likely to meet is that employers will argue that it will provide an inherently lazy workforce with a Shirker’s Charter. There are several answers to this assumption. We can look at the experience of other countries. In America, for instance some firms allow four days off a year, to be taken at a moment’s notice. They are called “duvet days”. Secondly, patients are often reluctant to stay off work because of the financial loss incurred, as well as the threat to job security. These factors will still counter any abuse of the system. Third, employers need to be educated about the workforce implications of dragging infected employees into work. Given the fact that most offices live on recycled, conditioned air, the products of one cough can be on every desk in the office within the hour. They should understand that an infected colleague cannot work efficiently, that an infected worker will be ill for longer than one who rests.
A sensible programme of health education could therefore overcome the objections from within commerce and industry, and indeed , bring them on side. The workers themselves will be happy to co-operate with the new scheme. Less incidence of viral illness, combined with less unnecessary consultations for viral infections will overcome the “winter pressures” that routinely overwhelm the NHS. This reform is one which could enjoy a rapid success. The country will gain improved productivity, and the NHS could gain a decreased workload, freeing up opportunities to improve the quality of medical care that we deliver. These are all immediate gains from this method: but the overriding gain is that it could vastly reduce the potential impact of the global epidemic that could result if the current avian flu virus does gain the ability to pass from human to human. And that could potentially save many thousands of lives in the UK alone.

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