What Canadian doctors need to know about swine flu

National and international health officials have ratcheted up the warning levels about the A/H1N1 swine influenza. The World Health Organization raised its influenza pandemic alert from phase 3 ("Predominantly animal infections; few human infections") to phase 4 ("Sustained human to human transmission"). "The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable," said WHO director-general Dr Margaret Chan in a statement.

Update, Wednesday, April 29: The WHO announced today that the swine flu is expected to become a pandemic and raised its alert level to phase 5 on the scale of 1 to 6, which indicates the early stages of a pandemic with "widespread human infection." "All countries should immediately activate their pandemic preparedness plans. Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia," said Dr Chan in a statement. "At this stage, effective and essential measures include heightened surveillance, early detection and treatment of cases, and infection control in all health facilities."

On Tuesday alone the number of laboratory-confirmed cases of swine flu in Canada rose from six to 13, with more under investigation. Cases have now been confirmed in BC, Nova Scotia, Ontario and Alberta. The chief public health officer warned that the disease is likely to kill some Canadians. "We will likely see more cases, we will likely see more severe illnesses and we will likely, unfortunately, see some deaths as well," Dr David Butler-Jones told reporters in Ottawa. "We hope not, but it is a normal part of an influenza outbreak."

To prevent the spread of the disease, people who suspect they might be infected have been warned to see a doctor immediately. Are physicians prepared to deal with suspected cases of swine flu? Several provinces have already published instructions online to guide physicians in dealing with a patient suspected of carrying the swine flu virus.

Ontario has produced the most comprehensive set of guidelines for physicians. After an initial notice to doctors last Thursday, the province's Ministry of Health and Long Term Care published three notices on Sunday. "Management of Patients Presenting with Influenza-Like illness (ILI) in the Ambulatory Care Setting" (PDF) emphasizes the importance of following good infection control and hand hygiene practices, and encourages doctors to post a sign (PDF) to remind patients to be aware that they could spread respiratory illnesses if they have the flu. Patients who present with flu-like symptoms should be given masks, asked to use alcohol hand cleansers and separated from other patients and staff if possible.

If patients with flu-like symptoms have travelled to Mexico recently, they should be examined by clinicians wearing fitted N95 respirators, eye protection, and gloves and a gown "when there is a risk of contamination with respiratory secretions."

The Ontario guidelines recommend following the BC Centre for Disease Control's suggestions (PDF) for treatment of this year's influenza strains. First-line treatment should be zanamivir, not oseltamivir, despite the fact that swine flu has been shown to be sensitive to oseltamivir. (That recommendation may change if more cases appear in Canada.) Treatment must be started within 48 hours of the time symptoms appeared, the guidelines say.

A huge part of any infectious diseases response is reporting and surveillance. To that end, the Ontario guidelines ask doctors to report suspected cases to public health officials: "Clinicians are advised to report individual cases of ILI with a travel history to an affected area to their local public health unit." (The only affected area so far is Mexico.)

Quebec also strongly advises that all patients who have flu-like symptoms wear a mask and be particularly vigilant about maintaining good hand hygiene practices, particularly in healthcare facilities. The Ministry of Health and Social Services recommendations (PDF) also agree with Ontario's suggestion to doctors to wear eye protection, a mask and gloves when examining patients with flu-like symptoms. The patient should be quarantined. These precautions should last for a minimum of seven days since the symptoms first appeared, the Quebec guidelines say, though that time period may have to be extended for children and immunocompromised patients.

Quebec's Ministry of Health and Social Services also released a copy of its guidelines on how to operate a hospital during an influenza pandemic, as a precauation. The document is available here (PDF), in French only.

Nova Scotia published a very basic set of questions and answers for health professionals, available here (PDF). The document estimates the virus's incubation period at two to nine days and encourages travellers to Mexico to get this year's flu vaccine before they leave (though it's not yet known whether there is cross-protection against the swine flu).

Canadian doctors may find it useful to keep handy a copy of the Canadian Pandemic Influenza Plan for the Health Sector. Annex G, "Clinical Care Guidelines and Tools," provides an extensive, thorough explanation of many of the practical things you may need to know.

The full document is available here (PDF).

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