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Swine Influenza A/H1N1 Operational Guidance for Managers This file will provide the Executive and on call managers with necessary information and contact numbers to manage the present situation and, as appropriate, escalation. 1 Index Section 1 Section 2 Section 3 3.1 Algorithms to follow for the Management of Patients suspected or diagnosed with Swine Influenza A/H1N1 Swine Influenza Case definition S5 Algorithm - the management of returning travellers and visiting countries will follow S5 algorithm. Page 5 P5 - Post exposure prophylaxis for close contacts of probable or confirmed human case(s) of Swine Influenza A/H1N1 Page 7 ABM University NHS Trust algorithm for suspected cases of Swine Influenza in A&E laboratory testing Page 8 Page 4 Policy for the Management for patients with Swine Influenza (A/H1N1) Swine Influenza A/H1N1Policy A&E Princess of Wales Procedure for management of Swine Influenza A/H1N1 Page 39 Local Accident Centre in Neath Port Talbot Hospital procedure for management of Swine Influenza A/H1N1) Page 40 A&E Morriston (inc Singleton Minor Injuries Unit page 44) Procedure for management of Swine Influenza A/H1N1 Page 41 Page 9 Operational Management Patients requiring admission Patients requiring admission would be admitted to the areas identified in Table 1 Table 1 Morriston Singleton Neath Port Talbot Adult Ward T Ward 8 Ward C Paeds Oakwood Ward 15 Pregnant mums Neonates Ward T Ward 8* N/A Neonatal Unit Ward 15 Singleton Hospital Ward8/ Maternity N/A Princess of Wales Hospital CDU/Ward2 Paediatrics CDU/Ward2* Maternity Unit * Any pregnancy related complications then the patient needs to be discussed with the obstetric/maternity Department. 2 3.2 PPE (refer to page 49) Adequate supplies of PPE are available at the four access points of the Trust: Morriston Hospital - A&E Department; Singleton Hospital - Minor Injuries Unit; Neath Port Talbot Hospital – Local Accident Centre; Princess of Wales Hospital - A&E Department. The receiving wards will also have a limited stock of face masks which can be supplemented from the stocks available in the above areas. 3.3 Swab Kits Limited number of swab kits are available in NPHSW Swansea laboratory and can be accessed through the on call Microbiologist for the Trust. 3.4 Access to anti virals Access to all anti virals will be via the on call pharmacists on all sites who can be contacted via the site switchboard. 3.5 Transport for specimen testing Additional arrangements have been put in place over the weekend for specimen testing and if required can be contacted through the switchboard. 3.6 Ambulance Service Ambulance have been notified of the arrangements in section 3.4. Section 4 4.1 Communications On call cover arrangements Page 50 LHB (Swansea/Bridgend & NPT) Trust Bridgend and NPT Trust Swansea Consultant Microbiologist on call Infection Control Team on call 4.2 Key Contacts Page 54 4.3 Advice regarding Staff Returning from Travel to Countries with cases of Confirmed Swine Influenza A/H1N1 Page 56 4.4 Frequently Asked Questions Page 58 4.5 Swine Influenza A/H1N1 Information Leaflet – separate attachment 3 4 5 6 7 8 This is a working document and will be subject to further amendment POLICY ON THE MANAGEMENT OF PATIENTS WITH POTENTIAL/ACTUAL SWINE INFLUENZA [A/H1N1] Effective from: Review Date: Expiry date: Author: Approved by: V7 April 2009 April 2010 September 2010 Swine Influenza Task & Finish Group 1. INTRODUCTION The purpose of this policy is to advise the Trust staff in the operational management of patients who self present, or are referred to the Trust who may potentially be infected with swine influenza [A/H1N1]. In practical terms the key issues for the NHS Wales and the Trust is to ensure that returning travellers and visitors from countries affected by swine influenza or presenting with febrile respiratory illness are managed appropriately. Action is required to ensure that possible cases that present to the A&E Department are recognised and treated, appropriate infection control arrangements are in place and rapid laboratory tests are undertaken to confirm or exclude the diagnosis. If cases are confirmed it will be necessary to ensure that appropriate infection control measures are maintained and that antiviral chemoprophylaxis (Tamiflu) is provided for the patient and for contacts of confirmed cases if indicated. This is available through the pharmacy department and the out of hours pharmacy store. In most instances patients with suspected or confirmed swine influenza [A/H1N1] should not be admitted or referred to the hospitals, unless clinically essential. Patients with such symptoms should be managed within Primary Care and isolated within their own homes. This policy comes into force when a patient does get referred to the Trust or self presents at the Trust. 2. BACKGROUND What is Swine Influenza? Swine influenza is a respiratory disease of pigs caused by type A influenza viruses. Outbreaks of swine influenza happen regularly in pigs. People do not normally get swine influenza, but human infections can and do happen. Recently, cases of human infection with swine influenza [A/H1N1]] viruses have been reported in Southern California and near San Antonio, Texas. In addition, isolation of the same virus from cases in an outbreak in Mexico has indicted more widespread human-to-human transmission (Source of information www.hpa.org.uk). 3. PATIENT MANAGEMENT In the event of a patient / patients being referred to the Trust via the GP with suspected or confirmed swine influenza [A/H1N1] the doctor receiving the request should ascertain with the GP that admission is clinically essential and that management in Primary Care is not possible. All such patients must be referred via the A&E Department and be advised to present at the dedicated entrance. All emergency departments must identify a dedicated entrance and a dedicated equipped decontamination room. There should be posters guiding patients away 10 from the public entrance to a controlled entrance. There should be a separate mechanism for staff to be notified of the arrival. This will alert the reception staff, who will then inform the nurse in charge. The nurse in charge should proceed to the decontamination room, and enter the patient via the external doors for triage to take place, having first donned In instances where a patient / visitor has entered the main public entrance to the department, the receptionist should direct the patient to the designated area and inform the nurse in charge who will proceed to the area (having already donned PPE). Decontamination Room The decontamination room should be in a state of readiness to accept and isolate patients at any time. All patients should enter the decontamination room via the external doors (keys are available from the controlled drug cupboard in decontamination room (Site specific details needed). A trolley must be available specifically for isolated patients with the necessary equipment needed to maintain isolation precautions and other infection control procedures. This trolley is kept in the decontamination room but should be removed and placed outside the ambulance entrance door prior to any potentially infected patients entering the room. Trolley Equipment: Green plastic aprons. Gloves (S,M,L) Goggles Surgical Face Mask. FFP2 Mask FFP3 Mask X-Ray cassette Covers Swabs Full oxygen and suction equipment is available in the room and any further equipment should be taken in as required all equipment must be decontaminated using a combined detergent/disinfectant wipe (e.g Tuffie 5), prior to it’s removal from the room). 4. TRIAGE, SCREENING AND ASSESSMENT In order for potentially contagious patients to remain isolated until proven otherwise the decontamination room should be utilised for triage and assessment purposes. A full history should be taken from the patient in order to decide if they fit the criteria for isolation or if they can be treated in the main areas of the department (See Appendix 1). This must be undertaken in full discussion with duty consultant microbiologist and consultant in communicable disease control (NPHS out of hours team – Appendix 2). Swabs maybe required to be undertaken as guided by discussions within the consultant microbiologist and CCDC as outlined in Appendix 2. 11 Once criteria is established the following need to contacted and instruction awaited: Lead Consultant/On call A&E Consultant Senior Nurse Manager or A&E & Emergency Planning (in and out of hours) Infection control Bed/site manager Pharmacy Outbreak Co-ordinator- Hazel Abbot Emergency Planning Executive Lead- Karl Murry Treatment Where treatment is indicated, this should also take place in the decontamination room. Depending on clinical need, the patient should be nursed on a stretcher or treatment couch. X-ray If an x-ray is required where feasible this should be undertaken as a portable procedure within the patient isolation room. Pharmacy A limited stock of anti-viral medication (Tamiflu) is available form the emergency cupboard in Pharmacy. Contact Pharmacy/on-call pharmacist when required. 5. INFECTIVITY, SPREAD & SEVERITY OF ILLNESS Influenza is a respiratory illness characterized by fever, cough, headache, sore throat, aching muscles and joints and is spread mainly by droplets or respiratory aerosols produced when an infected person talks, coughs or sneezes. It may also be spread by hand to face contact after touching a contaminated person or surface. The virus can persist outside the body for 24-48 hours on hard services, 8-12 hours on cloth/tissue and 5 minutes on hands. A summary of influenza and complications and mode of transfer is provided in Appendix 3 The infectious period starts, typically, one day before the symptoms start and people are highly infectious thereafter for about four to five days from the onset of symptoms, and for longer in children and immuno-compromised people. The incubation period is one to three days; about 10% of people are infectious before they have symptoms. On average, one person will infect 1.4 others, but this may be a greater number in closed communities. Recovery usually occurs within seven days but complications such as bronchitis, pneumonia, pneumonia, myocardidtis and pericarditis, myositis, encephalitis and Syndrome can cause serious illness or death. Bacterial pneumonia is the most common pulmonary complication. In 1918, many victims died rapidly of viral pneumonitis. Most complications usually occur in vulnerable groups such as the elderly or the chronically ill, but pandemic viruses can have serious complications in any age 12 group. Illness is more severe than the usual seasonal influenza and may occur in all population groups. Experimental studies of influenza virus survival suggest that the virus can survive for limited periods of time in the environment, be transferred from contaminated surfaces onto hands, and is easily inactivated by commercially available alcohol hand disinfectant. Thus, contact spread is likely to be important unless controlled by careful and frequent hand washing and environmental cleaning. Pandemic influenza initially occurs in waves lasting 6-8 weeks in any one location. The planning for health care need is based on an attack rate of 25% over a 6-8 week period. During this wave approximately 60% of cases will occur during 1-2 week period. Evidence suggests that when the pandemic affects the local area there will be a period of 1-2 weeks when a large number of people will be suffering from acute influenza (modelling shows that while at a national level the peak activity may last for up to 6 weeks, at a local level it is likely to be much shorter). Demand on services locally during this peak phase will be very high. Most patients will return to normal health after 5-7 days but some will progress to develop complications: either exacerbation of pre-existing cardiac and/or respiratory symptoms, etc., or bacterial infections. Up to 10% of those who develop ‘flu may become acutely ill and will need to see a doctor. When the pandemic hits, Primary care resources must be concentrated on these acutely ill individuals, it will be important that working together with NHS colleagues and Social Services, that as many as possible should be cared for in their own home. Management of Children with Pandemic Influenza Children have the highest attack rate for influenza and are the major disseminators of the virus1. Children aged 6-12 months have the highest attack rates in seasonal influenza due to the waning of maternal antibodies 2,3. Although uncomplicated influenza in children may be similar to the disease in adults there are significant age related differences in toddlers and infants. Symptoms of Influenza in Young Children There is uncertainty as to how any new influenza virus causing a pandemic will affect children – but we know that: Young children usually develop higher temperatures than adolescents and adults and often have febrile convulsions4,5 In neonates and infants unexplained fever may be the only indication of influenza4,5 Influenza is a common cause of croup, pneumonia, pharyngitis and bronchitis in young children 40% - 50% of those aged 3 years and under will present with gastrointestinal symptoms2,6 In young children otitis media and non-purulent conjunctivitis is common 20% of infants will present with neurological symptoms – some of which will be suggestive of meningitis In children aged 5 years and over the most frequent symptoms are fever, cough, headache, chills, myalgia and sneezing 13 Systemic Fever > 38oC (may fit) Respiratory Cough Non Respiratory Not playing Nasal congestion Low energy/lethargic Difficulty breathing Poor feeding Fast Breathing* Vomiting and diarrhoea Hoarse Irritability/crying excessively Earache Photobia Meningism Apnoea Fast breathing: < 2 months 2-12 months 12-5 years > 5 years = RR > 60/min = RR > 50/min = RR > 40/min = RR > 30/min Symptom checklist for children aged 4 years and under Danger Signs in Children aged 2months to 4 years: Difficulty breathing – not caused by nasal congestion Cyanosis – or sudden pallor unable to breast feed or drink continuous vomiting lethargic / seems confused convulsions has a full/sunken fontanelle photobia, stiff neck Danger Signs in Children aged < 2months: Stopped feeding well (less than ½ normal feeds) Providing Antiviral Therapy to Children 2. The hospital pharmacies should provide antiviral therapy to children for whom it is recommended following assessment at the paediatric assessment centre 3. Those five years and over who do not require hospital assessment should have the antiviral therapy distributed to their home as per the local distribution plan. Current pharmaceutical guidance recommends that those under 23kg in weight must have it prescribed by a doctor. Children on the 5th percentile would not achieve this weight until they are 11 years of age. (A decision has yet to be 14 reached on how children 5 years and over who weigh less than 23 kg will have their antiviral medication prescribed and delivered). Primary Triage Centre 5 to 17 years inclusive 4 Years and under Acute Respiratory Illness (ARI) ARI dangers signs present Refer to Outpatient Paediatric Assessment Centre ARI No co-morbidity or dangers signs Advise parent or guardian on home management and provide antiviral therapy Follow Up home visit or telephone Paediatric Triage Management of Pregnant Women with Pandemic Influenza Women with influenza in their 2nd and 3rd trimesters of pregnancy are at increased risk of hospitalization for cardio-respiratory disorders. Probably due to the increase in heart rate, stroke volume, and oxygen consumption observed in these months, as well as to decreases in lung capacity and changes in immunological function. A recent review of pneumonia in pregnancy has shown that maternal disease, including asthma and anaemia increase the risk of contracting pneumonia. Antiviral and respiratory therapies can reduce morbidity and mortality from viral pneumonia. ITU management of respiratory compromise can reduce mortality rate. Providing health care to pregnant women during a flu pandemic aim to: ensure pregnant women understand signs and symptoms of flu and measures to take to minimise exposure to the virus limit exposure of women to the pandemic virus in high risk occupations ensure systems are in place for early detection of illness and timely administration of antivirals ensure adequate observation and follow up in the community for early detection ensure obstetric services have plans in place for - Admission to “flu” areas of obstetric units where segregation from other obstetric inpatients can be assured 15 - Critical care support Operating elyth i Paediatric support The community midwife plays a central role and pregnant women should contact their midwife should symptoms of flu develop. Home assessment will be undertaken if any of these women develop symptoms compatible with influenza and antiviral therapy will be commenced if recommended by GP/Obstetrician. While symptoms persist daily home visits will be undertaken by the midwife and the general practitioner will be contacted in the first instance if the patient deteriorates. Hospital admission will be by agreement with the obstetric unit and to an agreed protocol. PATIENT HEALTH RESPONSE Pregnant Woman 2nd & 3rd Trimester Daily Monitoring from midwife by telephone Symptoms of flu develop Clinical diagnosis of influenza made Patient deteriorates and informs midwife Patient hospital admission required Home visit by midwife • • • • Home care if no other complications. Antivirals commenced. GP informed Daily follow up while symptoms persist GP home visit and hospital admission arranged if required Patient admitted to hospital under agreed protocol Care Pathway for Pregnant Women with Pandemic Influenza 6. PERSONAL PROTECTIVE EQUIPMENT (PPE) PPE should be worn to protect staff from contamination with body fluids and thus reduce the risk of transmission of pandemic influenza between patients and staff and from one patient to another (see table below). Care in the correct donning and removal of PPE is essential to avoid inadvertent contamination please refer to Appendix 3. All contaminated clothing must be removed before leaving a patient care area. Disposable or surgical masks being removed last. All PPE should comply with the relevant BSEN standards. 16 b. Surgical masks A surgical mask should be worn for close patient contact (e.g. within 3 feet). This will provide a physical barrier and minimize contamination of facial mucosa by large particle droplets, one of the principal ways influenza is transmitted. All contaminated PPE must be removed before leaving a patient care area. Surgical masks or FFP3 respirators should be removed last, followed by thorough hand hygiene. Surgical masks should: Cover both the nose and the mouth and not be allowed to dangle around the neck after usage Not be touched once put on Be changed when they become moist Be worn once and discarded in an appropriate receptacle as clinical waste Hand hygiene must be performed after disposal is complete c. Respirators A disposable respirator providing the highest possible protection factor available (i.e. an EN149:2001 FFP3 disposable respirator) should be worn when performing procedures which have the potential to generate aerosols (see below). If an EN149:2001 FFP3 disposable respirator is not immediately available, the next highest category of respirator available should be worn (e.g. FFP2). Fit testing: As per HSE requirements, every user should be fit tested and trained in the use of the respirator. Fit is critically important and a fit check should be carried each time a respirator is worn, as follows: Select a fit tested respirator Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with elastic Adjust to fit Perform a fit check – Inhale – respirator should collapse Exhale – check for leakage around face The respirator must seal tightly to the face, or air will enter from the sides. A good fit can only be achieved if the area where the respirator seals against the skin is cleanshaven. Beards, long moustaches, and stubble may cause leaks around the respirator. Changing and disposal: If breathing becomes difficult, the respirator becomes damaged or distorted, or contaminated by body fluids, or if a proper face fit cannot be maintained, the wearer should go to a safe area and change the respirator immediately. FFP3 respirators should be replaced after each use. If, during the process of providing care, respirators become contaminated with a patient’s respiratory secretions they should be disposed of immediately. Respirators should be disposed of as clinical waste according to local infection control policy. 17 Aerosol-generating procedures: include intubation, nasopharyngeal aspiration, tracheostomy care, chest physiotherapy, bronchoscopy, nebulizer therapy. The performance of aerosol-generating procedures should be minimized as is feasible without compromising patient care. To avoid unnecessary exposures, only those staff needed to perform the procedure should be present. In addition to respirators, eye protection must be worn to prevent eye contact with infectious material during such procedures. d. Gloves Gloves are not required for the routine care of patients with pandemic influenza per se. Standard Infection Control Principles procedures, contact with sterile sites, during all activities that carry a risk of (including respiratory secretions) and contaminated instruments. require that gloves be worn for invasive non-intact skin, and mucous membranes, exposure to blood, body fluids, secretions excretions, and when handling sharp or Gloves should be removed immediately after use, disposed of as clinical waste, and hand hygiene performed. No attempt should be made to wash gloves for subsequent reuse. If glove supplies become limited during a pandemic, priorities for glove use may need to be established. In this circumstance, gloves should always be elyth ized for contact with blood and body fluids, invasive procedures, and contact with sterile sites. e. Aprons Disposable plastic aprons should be worn whenever there is a risk of personal clothes, or uniform coming into contact with a patient’s blood, body fluids, secretions (including respiratory secretions), and excretions; or during activities that involve close contact with the patient (e.g. examining the patient). Plastic aprons should be worn as single use items for one procedure, or episode of patient care, and then discarded and disposed as clinical waste. In cohorted areas, aprons need to be changed between patients. f. Gowns Gowns are not required for the routine care of patients with influenza. However gowns should be worn if extensive soiling of personal clothing or uniform with respiratory secretions is anticipated, or there is risk of extensive splashing of blood, body fluids, secretions, and excretions onto the skin of the HCW. Procedures such as intubation, and activities that involve holding the patient close (e.g. in paediatric settings), are examples of when a gown may be needed. Fluid-repellent gowns are preferable, but if non fluid-repellent gowns are used a plastic apron should be worn beneath. Gowns should: 18 Fully cover the area to be protected Be worn only once and then placed in a waste or laundry receptacle as appropriate, and hand hygiene performed immediately after removal g. Eye protection The use of eye protection should be considered when there is a risk of contamination of the eyes by splashes and droplets e.g. blood, body fluids, secretions, and excretions generated through patient care. This should be an individual risk-assessment at the time of providing care. Eye protection should always be worn during aerosol-generating procedures. Eye protection can be achieved by the use of any one of the following: Surgical mask with integrated visor Full face visors Polycarbonate safety spectacles, or equivalent. Of note, non-disposable eye protective equipment (e.g. polycarbonate safety spectacles issued as personal equipment to staff on a long-term basis) pose a potential cross-infection risk. It is important that any such items are decontaminated after soiling, using agents recommended by the manufacturer, and when leaving an influenza patient segregated area prior to performing final hand hygiene. . 19 7. PATIENTS TO BE ADMITTED If due to the clinical condition patients need to be admitted to the hospital please follow Tabel1. Table 1 Morriston Singleton Neath Port Talbot Adult Ward T Ward 8 Ward C Paeds Oakwood Ward 15 Pregnant mums Neonates Ward T Ward 8* N/A Neonatal Unit Ward 15 Singleton Hospital Ward8/ Maternity N/A Princess of Wales Hospital CDU/Ward2 Paediatrics CDU/Ward2* Maternity Unit * Any pregnancy related complications then the patient needs to be discussed with the obstetric/maternity Department. 8. COMMUNITY ISSUES If GP’s determine that specimens are required from a patient in the community this should be organised following discussion between the Gp and the Consultant in Communicable Disease Control Out of Hours via NPHS On Call Rota. 9. TRUST WORKFORCE Occupational Health The Occupational Health Department will lead on the implementation of systems to monitor for illness and absence, implement vaccination and antiviral therapy programmes for the healthcare workforce (if specified by the WAG/NPHS), and liaise with the Infection Control Team to give general advice on the management of staff with pandemic influenza. Who should work? Staff will be at risk of acquiring Swine influenza through both community and healthcare-related exposures, and should be made aware of the symptoms of pandemic influenza. Before commencing duty all staff must report any symptoms of pandemic influenza to their line manager who will then advise accordingly. Similarly, if a member of staff develops such symptoms whilst on duty he/she must report to their line manager immediately. As a general principle, all staff who have symptoms of Swine influenza should be excluded from work to avoid infecting patients, colleagues, and others. However, in exceptional circumstances where staff shortages are extreme, line managers may allow symptomatic staff to work. Staff who feel well enough to work, and are 20 beginning to experience symptoms of Swine influenza, or are recovering and have residual symptoms, may do so provided they work in parts of the facility segregated for the care of influenza patients, and avoid contact with non-influenza patients and staff who remain well. This means for example that staff must stay in the segregated patient area of the facility throughout their shift (including rest periods). All staff who have recovered from pandemic influenza should report to their line manager before resuming clinical duties because their illness needs to be recorded, and it may also affect future deployment. These staff can care for people with influenza. Line managers, in turn, should ensure that sickness/absence is recorded, and this information is sent to the Occupational Health Department. Staff deployment Staff assigned to care for patients with Swine influenza or who work in areas of a facility segregated for patients with Swine influenza should not be assigned to care for non-influenza patients or work in non-influenza areas. Exceptions to this include: Situations where there is a limited number of staff; e.g. medical staff, Allied Health Professionals (AHP), although segregation of staff should be maintained as much as practically possible Situations when the care and management of the patient would be compromised Staff who have fully recovered from Swine influenza. In some community settings this may not be feasible. Nevertheless, consideration should be given to developing approaches comparable to hospital settings; for example, one District Nurse can be designated to see all the patients with symptoms of influenza on the morning list. In hospitals, staff from a non-influenza area can be redeployed to an area segregated for the care of influenza patients. However, once deployed a worker cannot return to their original non-influenza area for the duration of the pandemic. Staff who have recovered from pandemic influenza or have received a full course of vaccination against the strain and therefore considered unlikely to develop or transmit influenza should be elyth ized for the care of patients with Swine influenza. In exceptional circumstances, these workers can be moved within a period of duty, but this is not desirable. These workers may also be placed in units where the introduction of influenza would have serious consequences for patients (e.g. transplant units, special care baby units, renal units). These workers should not be moved within a period of duty. Bank and agency staff Bank and agency staff employed by ABM University Trust are usually utilized to complement staffing levels on a day-to-day basis across the Trust. For example, over five consecutive working days they may work in five different clinical environments. During this period this form of work allocation must be avoided. Bank and agency staff should follow the same deployment advice as permanent staff. Workers at risk for complications from pandemic influenza Healthcare workers who are at high risk for complications of Swine influenza (e.g. pregnant women, immunocompromised workers) should be considered for alternate 21 work assignment, away from direct patient care for the duration of the outbreak / pandemic, or until vaccinated. At the very least they should not provide care to patients known to have influenza, nor enter parts of the hospital segregated for the treatment of patients with influenza. General Principles During a pandemic healthcare workers can be exposed to persons with influenza both through their normal daily lives (outside of work) and in healthcare settings. Limiting transmission of pandemic influenza in the healthcare setting requires application of tried and tested principles including: Timely recognition for cases of influenza. In the current pre-pandemic period, having a high index of suspicion for possible rare cases of influenza caused by a novel strain of virus such as avian A/H5N1 is particularly critical Consistent and correct implementation of appropriate infection control precautions to limit nosocomial transmission. Standard Infection Control Principles and Droplet Precautions are applicable in most circumstances. In certain situations these control measures may need to be augmented with higher levels of respiratory protection Administrative controls, such as the segregation or cohorting of patients with pandemic influenza from those who have other medical conditions Use of auxiliary measures such as restricting ill workers and visitors from the facility and posting of pertinent signage in clear and unambiguous language Education of staff, patients, and visitors about the transmission and prevention of influenza that is understandable and applicable Treatment of patients and staff with antivirals which can reduce infectiousness and the duration of illness Vaccination of patients and staff, when developed Under COSHH Regulations all employers, including the NHS, are required to undertake local risk assessments to inform decisions on choice of control measures. The COSHH guidance can be viewed as a generic assessment designed to ensure that infection control measures across the NHS are implemented in a consistent manner. It reflects published evidence on influenza transmission and control, and the exceptional circumstances of a pandemic, where there may be: Potential for a large number of patients Greater number of HCWs potentially exposed to the pandemic virus; and where the Availability of control measures may vary. The local COSHH risk assessment will identify any local circumstances, which should also be taken into account. Hand hygiene Hand hygiene is the single most important practice to reduce transmission of infectious agents in healthcare settings, and is an essential element of Standard Infection Control Principles. During outbreaks of pandemic influenza strict adherence to hand hygiene recommendations should be enforced. 22 The term ‘hand hygiene’ includes hand washing with soap and water and thorough drying, and the use of alcohol-based products (i.e. gels or foams) containing an emollient that do not require the use of water. If hands are visibly soiled or contaminated (for example, contaminated with respiratory secretions), they should be washed with soap and water and dried. When decontaminating hands using an alcohol rub, hands should be free of dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. Hands should be decontaminated before and after all patient contact with an infected patient or their bed area, removal of protective clothing, and cleaning of equipment. Following hand washing, hands should be dried thoroughly using paper towels that are then discarded in the nearest waste receptacle. Waste bins with foot-operated lids should be used whenever possible. In addition to the placement of alcohol rub at the point of use (e.g. patient’s beds/exam rooms and lockers), consideration should also be given to extend/reinforce the distribution of personal carried alcohol rub to certain groups of transient/migratory staff (e.g. medical staff in hospitals, and community staff performing home visits). All staff, patients and visitors entering and leaving areas where care is delivered should perform hand hygiene with either soap and water followed by drying, or alcohol hand rub. Management of the coughing and sneezing patient Patients, as well as staff, and visitors, should be encouraged to minimise potential influenza transmission through good hygienic measures as follows: Cover nose and mouth with disposable single-use tissues when sneezing, coughing, wiping and blowing noses Dispose of used tissues in nearest waste bin Wash hands after coughing, sneezing, using tissues, or contact with respiratory secretions and contaminated objects Keep hands away from the mucous membranes of the eyes and nose Certain patients (e.g. the elderly, children) may need assistance with containment of respiratory secretions; those who are immobile will need a receptacle (e.g. a plastic bag) readily at hand for immediate disposal of tissues and a supply of hand wipes and tissues. Patient masking: Where possible, in common waiting areas or during transport (e.g. from the community to an acute hospital, or from one area of the hospital to another), coughing/sneezing patients should wear surgical masks to assist in the containment of respiratory secretions and to reduce environmental contamination. 10. ENVIRONMENTAL ASPECTS Clinical and non-clinical waste No special handling procedures beyond those for Standard Infection Control Principles are recommended for clinical and non-clinical waste that may be contaminated with influenza virus. Waste generated within the clinical setting should be managed safely and effectively, with attention paid to disposal of items that have 23 been contaminated with secretions/sputum (e.g. paper tissues) in addition to other routine and domestic waste management. Liquid waste such as urine and faeces can be safely disposed of into the sewerage system. All waste collection bags should be tied and sealed before removal from the patient area. Gloves should be worn when handling ALL waste and hand hygiene performed after removal of gloves. Linen and laundry Linen used during the patient’s care should be managed safely as per Standard Infection Control principles. Linen should be categorised as ‘Used’ or ‘Infected’. Both ‘Used’ and ‘Infected’ linen must be handled, transported and processed in a manner that prevents skin and mucous membrane exposures to staff, contamination of their clothing and the environment, and infection of other patients. Linen should be placed in appropriate receptacles immediately after use and bagged at the point of use Linen bags must be tied and sealed before removal from the influenza patient care area Gloves and aprons should be worn for handling all contaminated linen Hand hygiene should be performed after removing gloves that have been in contact with soiled linen and laundry Hospitals: Bed curtains should be changed following patient discharge. Community care: Paper sheeting is a good alternative for use on patient examination couches, and should be changed after each patient. Laundry workers: Guidance on laundry worker protection is described in HSG(95)18 – Hospital Laundry arrangements for used and infected linen. Staff should be fully trained in all laundry operations, including hand hygiene and the correct use of protective clothing. Staff uniforms The appropriate use of PPE will protect uniforms from contamination in most circumstances. During an outbreak / pandemic, staff should not travel to and from work, or between hospital residences and place of duty in uniform. Hospital laundry services should be used to launder uniforms if they are available. If there are no laundry facilities available then uniforms should be laundered in a domestic washing machine in water as hot as the fabric will tolerate, then ironed or tumbled-dried. Uniforms should be transported home in a sealed plastic bag, washed separately from other linen, in a load not more than half the machine capacity, in order to ensure adequate rinsing and dilution. 24 Consideration may be given to the use of theatre type blues for staff who do not usually wear a uniform. Crockery and utensils No special precautions, beyond those for Standard Infection Control Principles, are recommended for dishes and eating utensils used by a patient with influenza. Wash dishes and eating utensils in a dishwasher with a hot rinse. Do not hand wash these items. There is no need to use disposable plates and cutlery. Environmental cleaning and disinfection Patient cohorted areas and clinical rooms should be cleaned daily at a minimum. Cleaning schedules may vary by setting: Hospitals: as a minimum, daily and after patient discharge Clinical rooms: as a minimum, daily (preferably at the end or the beginning of the day) and in-between influenza and non-influenza sessions if the same clinical room is used Frequently touched surfaces (e.g., medical equipment, door knobs): at least twice daily and when known to be contaminated with secretions, excretions or body fluids. Freshly prepared neutral detergent and hot water should be used. Damp rather than dry dusting should be performed to avoid generating dust particles. During wet cleaning a routine should be adopted that does not redistribute micro-organisms. This may be accomplished by cleaning less heavily contaminated areas first and by changing cleaning solutions and cloths frequently. The use of vacuum cleaners should be avoided. Dedicated or single-use/disposable equipment should be used. Non-disposable equipment, including mop heads, should be laundered after use. Any spillage or contamination of the environment with secretions, excretions or body fluids should be treated in line with the local spillage policy. Domestic staff should be allocated to specific areas, and not moved between influenza and non-influenza areas. They must be trained in the correct methods of wearing PPE and the precautions to be taken when cleaning cohorted areas. Domestic staff should wear gloves and aprons; in addition a surgical mask should be worn when cleaning in the immediate patient environment in cohorted areas. Patient care equipment Effective cleaning of patient care equipment is an essential prerequisite to both disinfection and sterilisation. Standard practices for handling and reprocessing used and soiled patient-care equipment, including re-usable medical devices, should be followed for both influenza and non-influenza areas of hospital and primary care settings: 25 Prevent exposure of the skin and mucous membranes and contamination of clothing and the environment. Gloves should be worn when handling and transporting used patient-care equipment Clean heavily soiled equipment with neutral detergent and hot water before removing from the patient’s room or consulting room Reusable equipment (e.g. stethoscopes, patient couch in treatment and consulting rooms) must be scrupulously decontaminated between each patient; equipment that is visibly soiled should be cleaned promptly. If applicable, follow local and manufacturers recommendations for cleaning and disinfection, or sterilization of reusable patient-care equipment Wipe external surfaces of portable equipment for performing x-rays and other procedures in the patient’s room with neutral detergent and hot water upon removal from the patient’s room or consulting room. Whenever possible, non-critical patient equipment should be dedicated for use by pandemic influenza patients only. Use of equipment that re-circulates air (e.g. fans) should be avoided. Furnishings Remove all non-essential furniture, especially soft furnishings from reception and waiting areas in hospitals and community settings, and treatment rooms (including A&E, and day rooms/lounges). The remaining furniture should be easy to clean and should not conceal or retain dirt and moisture. Toys, books, newspapers, and magazines should be removed from the waiting area. 11. PANDEMIC FLU Pandemic influenza occurs when a new influenza, a virus subtype emerges which is markedly different from recently circulating subtypes and strains, and is able to: Infect humans (rather than, or in addition to, animals and birds) Spread efficiently from person to person (because a high proportion of the population is susceptible as most people will have little or no immunity to the new virus because they will not have been infected or vaccinated with or ot a similar virus before) Cause significant clinical illness is a high proportion of those infected. The likely timing and burden of illness in the UK is summarised below. The scale, severity of illness, and consequences of pandemic influenza exceed those of the most severe winter influenza epidemics. 1. Mortality in the UK is likely to exceed 50,000 deaths. This compares with an estimated 12,000 deaths each year in the UK from inter-pandemic (seasonal) influenza, mainly in elderly people. 2. Excess mortality is likely to occur in the elderly, younger adults and children. 3. Modelling suggests that it may take 2-4 weeks for the virus to reach the UK after a case has occurred in Asia. 4. Once cases occur in the UK influenza activity will be widespread within a few weeks. 5. There may be more than one epidemic wave (with an interval of several months), and a second wave may be more severe than the first. 6. Cumulative clinical and serological attack rates across all waves together may 26 be in the order of 25% and 50% respectively. Surveillance of influenza has improved markedly since the last pandemic of 1968. Modelling studies using transmission characteristics based on the 1968 pandemic and air traffic data from 2002 indicate that the approximate delay between a first case in Hong Kong and a first case in the UK would be less than a month. In terms of the spread within the UK, it will probably take only 2-3 weeks from the initial introduction until activity is widespread and a further 3 weeks (6 weeks from initial UK cases) until activity peaks. It is expected that the first wave of the pandemic will last 15 weeks and follow the predicted case per thousand, as illustrated in the graph below. The graph indicates a short lead in time with a rapid climb the maximum within 6 weeks of onset. Subsequent waves of pandemic influenza will occur in waves weeks or months apart. The planning assumption is that 25% of the population will be affected although this operational plan also considers the NHS response required should 50% of the population become affected (Cabinet Office Refreshed Guidance Feb. 2006). Pandemic Impact Hospital admissions for acute respiratory and related conditions are likely to increase by at least 25%. At the peak of the pandemic this could be 19,000 new patients each week nationally requiring hospitalization. A short, sharp epidemic would put greater strains on services than one that is more sustained at a lower level. In general, emphasis should be given to out-of-hospital care, saving hospital beds for only the most severe cases. Absence from work Normal sickness rates are around two percent, but previous pandemics indicate that 10% or more of the population may lose working days. Based on the estimated clinical attack rates, 25% of workers will take time off during the pandemic (possibly five to eight working days). Workers’ needs to care for others, and difficulties (or fear of) traveling to work mean that absenteeism may be higher. Modeling suggests that absenteeism due to the pandemic peaks at 3.5% of the workforce by week 14. This would double the normal absenteeism in a private sector company and equate to a two-thirds increase in the public sector. Health care workers are likely to have a higher sickness absence rate than other population groups because they have a higher risk of exposure. In Liverpool in 1957, 12-19% of nurses were absent during the first four weeks of the pandemic. In one hospital nearly a third were absent at the peak. NHS sickness rates are usually around four to six percent. Potential Impact on Services Workforce: Staff sickness or even death and workforce depletion Disruption to supplies and utilities, including foodstuffs Existing patients acquiring influenza Business continuity Communications with staff, patients and clients Complexity of added infection control measures Managing demand for vaccine/antivirals Need to draft in ‘volunteers’ (indemnity/CRB checks etc) 27 Domestic pressures on staff if schools close or members of the family are ill Acute Care: Higher A&E attendance Pressure on HDU/ITU beds Infection control processes Bed- blocking because of reduced community capacity Intermediate care: Pressure on admissions Difficulty admitting patients to secondary care Higher transmission among residential institutions Primary care: Illness and death at home Difficulties in arranging hospital admissions/increase in early discharges Staff sickness – especially in single handed practices Social care: Sickness in clients/carers High transmission in residential homes/daycare Children whose parents are too ill to care for them Others: Pressure on mortuary facilities, delays in registration, burials and cremations Long-term effects on the national and world economies and societal structures Logistical problems due to interruption of supplies, utilities and transport in communities, including foodstuffs 12. INTERNATIONAL & NATIONAL PHASES The World Health Organisation [WHO] has defined phases in the evolution of an influenza pandemic which allow a step-wise escalating approach to preparedness planning and response leading up to declaration of the onset of a pandemic. Once a pandemic has been declared, UK action will depend on whether cases have been identified in the UK, and how extensively it has spread. For UK purposes, additional UK alert levels are included within the WHO pandemic phase. The WHO phases, which were revised in April 2005, describe the progression of an influenza pandemic from the first emergence of a novel influenza virus, to a wide international spread. This is a global classification based on the overall international situation and is now used internationally for planning purposes: INTER-PANDEMIC PERIOD No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may PHASE 1 be presenting animals. If present in animals, the risk to human infection or disease is considered low. No new influenza virus subtypes have been detected in humans. PHASE 2 However, a circulating animal influenza virus subtype poses a substantial risk to human disease. PANDEMIC ALERT PERIOD Human infection(s) with a new subtype, but no new human-toPHASE 3 human spread, or at most rare instances of spread to a close contact. 28 Small cluster(s) with limited human-to-human transmission but PHASE 4 spread is highly localised, suggesting that the virus is not well adapted to humans. Large cluster(s) but human-to-human spread still localised, suggesting that the virus is becoming increasingly better adapted PHASE 5 to humans, but may not yet be fully transmissible (substantial pandemic risk). PANDEMIC PERIOD Pandemic phase – increased and sustained transmission in the general population. Past experience suggests that a second, and possibly further, PHASE 6 waves of illness caused by the new virus are likely 3-9 months after the first wave has subsided. The second wave may be, or more, intense than the first. POST PANDEMIC PERIOD – return to inter-pandemic period Transition between phases may be rapid and the distinction blurred. The crucial interval is between WHO Phases 5 and 6, which will determine to a large extent whether a vaccine can be developed in time for the first wave of illness in the UK. The WHO plan recognises additional national subdivisions for Phase 2 onwards, according to whether a country is affected itself, had extensive travel/trade links with an affected country, or is not affected. 13. THE ROLE OF THE HEALTH PROTECTION TEAM Infectivity, spread and severity of illness Influenza is spread mainly by droplets or respiratory aerosols produced when an infected person talks, coughs or sneezes. It may also be spread by hand to face contact after touching a contaminated person or surface. The virus can persist outside the body for 24-48 hours on hard surfaces, 8-12 hours on cloth/tissue and 5 minutes on hands. People are highly infectious for about four to five days from the onset of symptoms, and for longer in children and immuno-compromised people. The incubation period is one to three days; about 10% of people are infectious before they have symptoms. On average, one person will infect 1.4 others, but this may be a greater number in closed communities. Recovery usually occurs within seven days but complications such as bronchitis, pneumonia, pneumonitis, myocardidtis and pericarditis, myositis, encephalitis and Guillain-Barré Syndrome can cause serious illness or death. Bacterial pneumonia is the most common pulmonary complication; in 1918 many victims died rapidly of viral pneumonitis. Most complications usually occur in vulnerable groups such as the elderly or the chronically ill, but pandemic viruses can have serious complications in any age group. Illness is more severe than the usual seasonal influenza and may occur in all population groups. 14. COMMUNICATIONS AND MEDIA ENQUIRIES All communication from the media must be directed to Susan Bailey 29 15. QUESTIONS AND ANSWERS Is swine influenza contagious? It has been determined that this virus is contagious and is spreading form humanto-human. However, at this time it is not known how easily the virus spreads between people. What are the symptoms of swine influenza? The symptoms of seine influenza in people are similar to the symptoms of regular human seasonal influenza infection and include fever, fatigue, lack of appetite, coughing and sore throat. Some people with swine flu have also reported vomiting and diarrhoea. What measures can I take to prevent infection? General infection control practices and good respiratory hand hygiene can help to reduce transmission of all viruses, including the human swine influenza. This includes: Covering your nose and mouth when coughing or sneezing, using a tissue when possible. Disposing of dirty tissue promptly and carefully. Maintaining good basic hygiene, for example washing hands frequently with soap and water to reduce the spread of the virus from your hands to face or to other people. Cleaning hard surfaces (e.g. door handles) frequently using normal cleaning products. Making sure your children follow this advice. (Public information available from www.hpa.org.uk) 16. CONTACT DETAILS OF HEALTH PROTECTION TEAM Cardiff: 02920 402478 Gwent: 01495 332219 Carmarthen: 01267225042 Swansea: 01792 607358 North Wales: 01352 803255 17 References: 1. Simonsen L The global impact of influenza on morbidity and mortality. Vaccine 17 Suppl 1:S3-10.1999 2. Ryan-Poirier KA. Influenza virus infection in children. Adv Pediatr Infect Dis 1995 10:125-156 3. Giezen WP, Taber LH, Frank AL, Gruber WC, and Piedra PA. Influenza virus infection in the first year of life. Pediatr Infect Dis 1997; 11:1065 – 1068 4. Murphy BR and RG Webster. Orthomyxoviruses. , p 1397-1445. In: Fields Virology., 3rd edition, volume 1. 5. Giezen WP, Payne AA, Nelson Snyder D and Downs TD. Mortality and influenza. J Infect Dis 1982; 146:313-321 6. Paisley JW, Bruhn FW, Lauer BA and McIntosh K. Type 2 influenza in children Am J Dis Child 1978; 132:34-36 30 Appendix 1 31 Appendix 1 32 Appendix 2 Appendix 3 Summary of Influenza Stable Case: Patient with influenza like illness but without abnormalities meeting criteria for secondary assessment. Co-morbidity: >65 years pregnancy (second and third trimester) Chronic lung disease (asthma, bronchitis, bronchiectasis, emphysema, cystic fibrosis) Congestive cardiac failure Renal failure Immunosuppression (AIDs, transplant recipient) Haematological abnormalities (anaemia, haemoglobinopathies, oncological disorders) Diabetes Mellitus Hepatic disease, cirrhosis Patients on long-term acetylsalicylic acid therapy (for rheumatoid arthritis/ acute rheumatic fever/other) Criteria for secondary care assessment: Temp - < 35oC or > 39oC Pulse - new irregular beat or > 100/min BP - < 100 mmHg systolic. Dizziness on standing Respiratory Rate - > 24/minute (tachypnoea) Chest pain/symptoms – any abnormality on auscultation/chest pain Mental State – new confusion O2 saturation - < 90% room air Vomiting if very young or very old (> 3 episodes in 24 hours) Home Care: Paracetamol/Ibuprofen Fluids (hot fluids) Bed rest Decongestants Patients advised to seek help if: Increasing shortness of breath New pleuritic chest pain New purulent sputum Persistent vomiting 34 Complications of Influenza Respiratory: Lower respiratory tract complications are found in 10% of 5-50 year olds; 75% after 70 years of age Upper respiratory: Otitis Media, sinusitis, conjunctivitis Croup Bronchiolitis Bronchitis Pneumonia – 1° viral 2° bacterial Combined Complications of pre-existing disease Cardiovascular: Pericarditis Myocarditis Complication of pre-existing disease Muscular: Rhabdomyositis Rhabdomyolisis with myoglobinaemia and renal failure Neurologic: Encephalitis Reyes Syndrome Guillan Barre Syndrome Transverse Myelitis Systemic: Toxic shock Sudden death Droplet transmission Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (larger than 5 μm in size) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during the performance of certain procedures such as suctioning and bronchoscopy. Transmission via large-particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only short distances, usually 3 feet or less, through the air. Airborne or fine droplet transmission Airborne transmission occurs by dissemination of either airborne droplet nuclei (small particle residue [5 μm or smaller in size] of evaporated droplets that may remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and be inhaled and may become inhaled by or deposited on a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors. Direct contact transmission Direct contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patient-care activities that require physical contact. Direct-contact transmission also can occur between two patients (e.g., by hand contact), with one serving as the source of infectious microorganisms and the other as a susceptible host. Indirect contact transmission Indirect-contact transmission involves a susceptible host with a contaminated intermediate object, usually inanimate, in the patient’s environment. [Adapted from: Garner, J.S. and The Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. AmJ Infect Control 1996;24:24-52.] Available at www.cdc.gov/ncidod/hip/ISOLAT/ISOLAT.HTM 35 PATIENT CARE PATHWAY (Adult) Appendix 4 Telephone Triage Influenza Symptoms? Exhibits Flu Like Illness Influenza Symptoms? Primary Care No Refer to Primary Care No Yes Yes No Meets criteria For antiviral treatment Able to be Treated at home? Rapid Response Team No Treat as Appropriate in Non Flu Area If practicable Visit by GP Home Assessment Team Or Rapid Response Team As appropriate Yes Rapid Post-visit Deterioration? Yes Yes Does the patient need secondary care assessment? No No Treat at Home Patient representative to collect antiviral. Home delivery in exceptional circumstances Yes No Sub Acute Care Facility Sub Acute Placing available? Yes On clinical assessment Does patient satisfy Criteria for Secondary Care? No Yes Yes Yes Pneumonia with No co-morbidity? No Observation Results: Evaluation not definite Not able to cope Pneumonia & Co-morbidity Acute confusion Respiratory Failure Acute Cardiac deterioration Metabolic derangement No No Yes No Bed Available? Yes Admit To Hospital Terminology Definition Non Flu Area Telephone Triage Home Assessment Team An area set aside for the examination and treatment of patients without flu like symptoms Assessment of patient symptoms as given over the telephone to an experienced operator working from a pre-defined proforma A team of clinicians with the ability to undertake home assessment of patients who fall outside the patient group directive for the prescription of antiviral 36 Rapid Response Team Sub Acute Care Facility Secondary Care Assessment Patient Group Direction (PGD) medication. This team may be made up of either primary or secondary care clinicians according to circumstance. A team of clinicians or ambulance paramedics who would be able to undertake a more involved assessment of patients who deteriorate rapidly in the hours subsequent to telephone triage or home assessment. A care facility able to support those that cannot support themselves or rely upon the support of family in the home. The use of sub acute care facilities may also allow a more early hospital discharge to enable increased bed capacity for the acutely ill. Assessment in the hospital environment A PGD is a written instruction for the supply and / or administration of a named medicine in an identified clinical situation. 37 RC/DD/EIP/A&E- 2009-04 38 Emergency Department - Princess of Wales Draft guidance on patients with potential swine flu. 1. Sign on main entrance directing patient to ambulance entrance to ring bell. 2. If patient has already entered department, reception staff will give patient a surgical mask immediately to put on. Patient will be booked in reception staff to ask patient to remain were they are and inform nurse in charge. 3. Staff to put on protective face mask, apron and gloves. 4. Proceed to receive patient (at ambulance entrance or reception) – ask patient to put on surgical mask. 5. Proceed with patient to decontamination room. 6. Ask doctor to see patient in the decontamination room ( if unwell take patient to the secure room for barrier nursing ) 7. Complete initial assessment as per screening checklist. (See green folder ) 8. Manage patient as per screening algorithm. 9. Discuss with microbiology and CCDC and inform infection control. 10.If swabs indicated take 1 dry throat swab and 1 dry nose swab PLUS 1 throat swab and 1 nose swab put into a single container of virus transport medium.Culture medium available for swabs from microbiology lab. ( if taking swabs ensure goggles are worn) Swabs will be in packs form microbiology or contact on call microbiologist through switchboard. 11.Antiviral if indicated available from pharmacy ( out of hours from the on call pharmacist) 12.Patients should be managed in the community unless condition mandates admission to hospital. 13.Further information if required available from duty virologist at 02920 74 2178 during working hours or the On Call consultant Virologist via 02920 747 747 out of hours 14. Inform OONP who will inform necessary managers as per policy. 15. If patient has been nursed in the secure room ensure terminal cleaning has been performed. 16. Keep patient information in folder and those who have had contact with patient and give to Clinical nurse manager. Becky Gammon 1/5/09 RC/DD/EIP/A&E- 2009-04 39 LAC – Neath Port Talbot Guidance on patients with potential swine flu. 17.Sign on main entrance directing patient to ambulance entrance to ring bell. 18.If patient has already entered department, reception staff will give patient a surgical mask immediately to put on. Patient will be booked in reception staff to ask patient to remain were they are and inform nurse in charge. 19.Staff to put on protective face mask, apron and gloves. 20.Proceed to receive patient (at ambulance entrance or reception) – ask patient to put on surgical mask. 21.Proceed with patient to decontamination room. 22.Ask doctor/Nurse to see patient in the decontamination room ( if unwell take patient to a cubicle for barrier nursing) 23.Complete initial assessment as per screening checklist. (See folder) 24.Manage patient as per screening algorithm. 25.Discuss with microbiology and CCDC and inform infection control. 26.If swabs indicated take 1 dry throat swab and 1 dry nose swab PLUS 1 throat swab and 1 nose swab put into a single container of virus transport medium.Culture medium available for swabs from microbiology lab. ( if taking swabs ensure goggles are worn) - Swabs will be in packs form microbiology or contact on call microbiologist through switchboard. 27.Antiviral if indicated available from pharmacy ( out of hours from the on call pharmacist) 28.Patients should be managed in the community unless condition mandates admission to hospital. 29.Further information if required available from duty virologist at 02920 74 2178 during working hours or the On Call consultant Virologist via 02920 747 747 out of hours 30. Inform hospital manager who will inform necessary managers as per policy. 31. If patient has been nursed in cubicle ensure terminal cleaning has been performed. 32. Keep patient information in folder and those who have had contact with patient and give to Clinical nurse manager. R gammon 1/5/09 RC/DD/EIP/A&E- 2009-04 40 Accident & Emergency Unit, Morriston Hospital, Swansea, SA6 6NL. Minor Injuries Unit, Singleton Hospital, Swansea, SA2 8QA. West Division ACCIDENT & EMERGENCY SERVICE Clinical Governance Patient & Public Involvement Policy on the Management of Patients with Potential/Actual Swine Influenza [A/H1N1] Version 2 Date effective from Review date Expiry date Author Approved by April 2009 April 2010 September 2010 Rebecca Clarke – Senior Sister A&E Ann Paynter – Senior Sister A&E Delyth Davies – Lead Infection Control Nurse (Signature) Senior Nurse A&E & Emergency Planning Introduction This policy is to advise the Accident & Emergency Service staff in the management of patients who attend the A&E department potentially infected with swine influenza [A/H1N1]. In practical terms the key issue for the NHS in Wales is to ensure that returning travelers and visitors from countries affected by swine influenza presenting with febrile respiratory illness are managed appropriately. Action is required to ensure that possible cases that present to the A&E department are recognized and treated, appropriate infection control arrangements are in place and rapid laboratory tests are undertaken to confirm or exclude the diagnosis. If cases are confirmed it will be necessary to ensure RC/DD/EIP/A&E- 2009-04 41 that appropriate infection control measures are maintained and that antiviral chemoprophylaxis is provided for contacts of confirmed cases if indicated. Isolation Procedure During an outbreak of swine influenza, posters will be displayed at the main walking entrance to A&E instructing patients and visitors not to enter the A&E department via this way but instead to approach the ambulance entrance and press the ‘Isolated Patients Only’ call bell. This will alert the reception staff, who will then inform the nurse in charge. The nurse in charge should proceed to the decontamination room, and enter the patient via the external doors for triage to take place having first donned universal precautions. In instances where a patient/visitor has entered the department without ringing the bell, the receptionist should give the patient a face mask and ask them to remain where they are. The receptionist should then inform the nurse in charge who will proceed to the decontamination room and enter the patient via the walking side entrance of the decontamination room in order to minimize contact with other patients. Setting Up & Equipment The decontamination room should be in a state of readiness to accept and isolate patients at any time. All patients should enter the decontamination room via the external doors (keys are available from the controlled drug cupboard in decontamination room). A trolley is available specifically for isolated patients with the necessary equipment needed to maintain barrier nursing and infection control procedures. This trolley is kept in the decontamination room but should be removed and placed outside the ambulance entrance door prior to any potentially infected patients entering the room. Trolley Equipment: Green plastic aprons Blue ‘thumb loop’ plastic gowns Gloves (S,M,L) Surgical mask Goggles Surgical face masks FFP2 mask FFP3 mask (use only if fit testing completed) X-ray cassette covers Wound culture swabs RC/DD/EIP/A&E- 2009-04 42 Universal specimen containers Other equipment Viral transport media swabs (kept in major incident store cupboard fridge) Triage, Screening & Assessment In order for potentially contagious patients to remain isolated until proven otherwise the decontamination room should be utilized for triage and assessment purposes. A full history should be taken from the patient in order to decide if they fit the criteria for isolation or if they can be treated in the main areas of the department (see appendix 1). Once criteria are established you should inform the following and await further instruction: Lead Consultant/On-call A&E Consultant Senior Nurse Manager for A&E & Emergency Planning Infection Control Bed/site manager Pharmacy Consultant Microbiologist (in and out of hours) Treatment Where treatment is indicated, this should also take place in the decontamination room. Depending on clinical need, the patient should be nursed on a stretcher or treatment couch. Full oxygen and suction equipment is available in the room and any further equipment should be taken in as required (but then follow decontamination procedure advice given prior to removal from that room of equipment). One throat swab and one nose swab should be placed in viral transport media and one dry standard throat swab taken and sent to Cardiff National Public Health Service Laboratory for testing. A blue microbiology form indicating ‘influenza PCR testing’ should accompany them. If viral transport media is not available, a standard wound culture swab should be used with tips cut off and placed in universal containers (contact infection control team for more information. X-ray – if a portable x-ray is required, the AMX4 machine located outside Cyril Evans H.D.U should be utilized. Inform A&E radiographer as required. RC/DD/EIP/A&E- 2009-04 43 Pharmacy – A stock of anti-viral medication packs (Tamiflu) are available from the emergency cupboard in pharmacy. Contact pharmacy/on-call pharmacist when required. Further stock is available from Bridgend. Infection Control Team – Available via switchboard in and out of hours. Minor Injuries Unit Singleton Hospital At Singleton M.I.U a notice will be displayed at the entrance instructing patients to ring the bell, not to enter and wait for assistance. The nurse will don PPE and the patient will be taken into the relative’s room for triage. In instances where a patient/visitor has entered the department without ringing the bell, the receptionist should give the patient a surgical face mask and ask them to remain where they are. The receptionist should then inform the M.I.U nurse who will direct the patient to the relative’s room in order to minimize contact with other patients. The G.P, bed manager/NNP and infection control team should be informed as soon as possible. Other Information What is swine influenza? Swine Influenza is a respiratory disease of pigs caused by type A influenza viruses. Outbreaks of swine influenza happen regularly in pigs. People do not normally get swine influenza, but human infections can and do happen. Most commonly, human cases of swine influenza happen in people who are around pigs but it’s possible for swine influenza viruses to spread from person to person also. Recently, cases of human infection with swine influenza (A/H1N1) viruses have been reported in Southern California and near San Antonio, Texas. In addition, isolation of the same virus from cases in an outbreak in Mexico has indicated more widespread human-to-human transmission. Is swine influenza virus contagious? It has been determined that this virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people. What are the symptoms of swine influenza? The symptoms of swine influenza in people are similar to the symptoms of regular human seasonal influenza infection and include fever, fatigue, lack of appetite, coughing and sore throat. Some people with swine flu have also reported vomiting and diarrhoea. RC/DD/EIP/A&E- 2009-04 44 What measures can I take to prevent infection? General infection control practices and good respiratory hand hygiene can help to reduce transmission of all viruses, including the human swine influenza. This includes: - Covering your nose and mouth when coughing or sneezing, using a tissue when possible. - Disposing of dirty tissues promptly and carefully. - Maintaining good basic hygiene, for example washing hands frequently with soap and water to reduce the spread of the virus from your hands to face or to other people. - Cleaning hard surfaces (e.g. door handles) frequently using a normal cleaning product. - Making sure your children follow this advice. RC/DD/EIP/A&E- 2009-04 45 PANDEMIC FLU SCREENING CHECKLIST DATE: PATIENT DETAILS ASSESSOR: NAME: DoB: ADDRESS: PRINT __________________________________ SIGN __________________________________ HOME PHONE: MOBILE PHONE: OBSERVATIONS PULSE: SATS: BP: RR: TEMP: TRAVEL - WHERE COUNTRY / COUNTRIES AREA / RESORT POTENTIAL EXPOSURES: CROWDS (eg sports / tourists) PUBLIC TRANSPORT (bus / tube) SHOPPING (malls / markets) SPECIFIC INFECTIOUS CONTACTS TRAVEL – WHEN DATE LEFT UK: DATE AND TIME RETURNED TO UK: AIRPORT / FLIGHT NUMBER: METHOD OF AIRPORT TRANSFER: DURATION OF AIRPORT TRANSFER: METHOD OF TRANSPORT HOME: DURATION OF JOURNEY HOME: SYMPTOMS YES / NO DATE OF ONSET RAISED TEMP / FEVER COUGH HEADACHE RHINORRHEA VOMITING DIARRHOEA OTHER RC/DD/EIP/A&E- 2009-04 47 CONTACTS SINCE RETURN TO UK: PMH: (NB RENAL IMPAIRMENT) DH: IMMUNISATIONS UP TO DATE: YES / FLU VACCINE: YES / NO NO SOCIAL CIRCUMSTANCES: ADVICE GIVEN: YES NO ISOLATE MASKS GIVEN GP FOLLOW UP OTHER ANY ADDITIONAL INFORMATION: RC/DD/EIP/A&E- 2009-04 48 RC/DD/EIP/A&E- 2009-04 49 Section 4 On Call Cover LHB (Swansea, Bridgend & NPT) on call 25th May – 31st May Andrew Goodall 07971537039 Bridgend &NPTAcute on Call 2nd May 2009 – end August 2009 DATE TITLE NAME 2 May – 8 May 8 May – 15 May 15 May – 22 May 22 May – 29 may 29 May – 5 June 5 June – 12 June 12 June – 19 June 19 June – 26 June 26 June – 3rd July 3rd July – 10th July 10th July – 17th July 17th July – 24th July 24th July – 31st July 31st July – 7th August 7th August – 14th August 14th August – 21st August 21st August – 28th August Hof N Region M/S A.CC Med H of N WCH Med HR POWH POWH POWH HR NPTH Radiology HR HR Finance T Weston Steffan Gwynne Gill Skinner Dean Packman Veronique Hughes Bernie Steer Andrew Carruthers Donna Griffiths Gaenor Shaw Jo Williams Sian Franks Phil Spivey Karl Murray Ian McLelland Phil S to nominate Julia Dummer Angela Fisher Bridgend/NPT Executive on Call Rota 1st May to 21st December (On call period is 9am to 9am) NAME: Stephen Wade – until 5pm on 7th Huw Llewellyn – 5pm onward Geraint Evans Darren Griffiths Eiri Jones David Clementson Debbie Morgan Christine Lewis Ian Phillips Vicki Franklin FROM: 9am on… 1 May 2009 7 7th May 2009 8th May 2009 8th 15th 22nd 29th 5th 12th 19th 26th May May May May June June June June 2009 2009 2009 2009 2009 2009 2009 2009 15th 22nd 29th 5th 12th 19th 26th 3rd May May May June June June June July 2009 2009 2009 2009 2009 2009 2009 2009 st th TO: 9am on….. May 2009 RC/DD/EIP/A&E- 2009-04 50 Swansea First on Call – May 2009 4 – Midnight Cover Thursday 7th May Friday 8th May Saturday 9th May Sunday 10th May Monday 11th May Tuesday 12th May Wednesday 13th May Thursday 14th May Friday 15th May Saturday 16th May Sunday 17th May Monday 18th May Tuesday 19th May Wednesday 20th May Thursday 21st May Friday 22nd May Saturday 23rd May Sunday 24th May Monday 25th May Tuesday 26th May Wednesday 27th May Thursday 28th May Friday 29th May Saturday 30th May Sunday 31st May Tracy Jenkins Ceri Matthews Alison Kingdom Lee Davies Karen Jones Nell Brown Helen Griffiths Linda Bevan Sian Passey Emyr Phillips Heulwen Howells Nigel Weale Linda Howell Linda Reid Linda Davies Melanie Simmons Hazel Abbott Paul Davies Jenny Sanders Davina Lowndes Les Hammond Andrea John Tersa Humphreys Christine Griffiths Fiona Hughes SWANSEA - SECOND ON CALL TEAM Week Paul Baker Mike Bond Sally Buckland Jones John Calvert Calum Campbell Liz Rix Rob Royce Jan Thomas Malcolm Thomas Huw Williams Janet Williams √ 4.5.09 √ 11.5.09 √ 18.5.09 25.5.09 √ √ 1.6.09 8.6.09 15.6.09 22.6.09 √ √ √ √ 29.6.08 * Please note the second On Call Manager is also the designated officer for Civil Contingencies RC/DD/EIP/A&E- 2009-04 51 CONSULTANT MICROBIOLOGIST ON-CALL ROTA MICROBIOLOGY LABORATORY Any enquiries for clinical advice on microbiological matters and requests for antibiotic treatment advice should be referred to the consultant on-call. Please try home telephone number first. If there is no reply, please contact the consultant via the relevant mobile phone. For Dr. Keith Thomas and Dr. Louise Wooster, please contact via the Princess of Wales Hospital Switchboard Telephone No: 01656 752752 Saturday morning in Swansea laboratory Period beginning 5th May 2009 Dr. Nidhika Berry 11th May Dr. Khalid El-Bouri th 2009 9th May 2009 Dr. Nidhika Berry 16th May 2009 Dr. Khalid El-Bouri rd 18 May 2009 Dr. Ann Lewis 23 May 2009 Dr. Ann Lewis 26th May 2009 Dr. Nidhika Berry 30th May 2009 Dr. Nidhika Berry 1st June 2009 Dr. Keith Thomas 6th June 2009 8th June 2009 Dr. Khalid El-Bouri 13th June 2009 15th June 2009 Dr. Louise Wooster 20th June 2009 Dr. Khalid El-Bouri Dr. A. M. Lewis Dr. K. El-Bouri Dr. N. Berry Dr. A. Davies Dr. K. Thomas (01792) 203657 Mobile phone: 07974 672577 (01792) 414554 Mobile phone: 07773 768535 (01443) 230277 Mobile phone: 07812 637455 (01792) 456944 Mobile phone: 07961 364933 01656 646395 Mobile phone: 07969 918057 Contact via Princess of Wales Switchboard 01656 752752 Dr. L. Wooster Unavailable Mobile phone: 07974 666954 Contact via Princess of Wales Switchboard 01656 752752 NOTE: PLEASE REMIND STAFF NOT TO LEAVE MESSAGES ON HOME ANSWERPHONE Please notify consultant on-call about the following: All positive CSF specimens. All positive sterile fluids e.g. joint aspirates. On Sunday morning/Bank Holiday mornings, whether any blood cultures have become positive. More than expected numbers of microbiology specimens from the same clinical area (this may suggest an outbreak of infection). * Please refer any requests for clinical advice or antibiotic treatment to the consultant on-call via the switchboard. RC/DD/EIP/A&E- 2009-04 52 RC/DD/EIP/A&E- 2009-04 53 Key Contact List Name Site Work No Mobile Calum Campbell THQ 01639 683326 07791592962 Acting Chief Executive Karl Murray NPTH 01639 Home : 01639 899376 Site Manager, NPTH & Executive Lead for Eergency Preparedness Vicki Franklin Mobile : 07968329572. THQ 01639 683308 07825429420 - personal Nurse Director Bruce Ferguson THQ 01639 683304 07771 644701 Medical Director Nicola Williams THQ 01639 683335 07966478099 THQ 01639 683330 07800 662215 THQ 01639 683332 07876707274 Morriston A&E 01792 703417 Bleep 3570 bleep 3770 01792 703422 ext 3422 01792703422/19 07785 541770 01792 703690 07794072420 POWH 01656 752652 or 752088 07974 312247 POWH 01656 752741 07590433142 Associate Nurse Director -Governance & Safeguarding Sue Bailey Associate Director of Corpriate Affairs Communciations Hazel Abbott Associate Director of Corpriate Affairs – Risk Management Emyr Phillips Senior Nurse Manager, A&E & Emergency Planning Delyth Davies Morriston A&E designated bleep holder Nurse in Charge Morriston Morriston Home – 01269 850166 Head of Incefction & Prevention Control Veronique Hughes Head of Nursing Medical Directorate Jayne Evans RC/DD/EIP/A&E- 2009-04 54 Fiona Reynolds Head of Nursing, Intermediate Care& Re-ablement Mike Tidley Consultant in Occupational Medicine Jeff O’Malley Occupational Health Janet Williams Site Manager, Morriston Hospital Linda Davies Lead Nurse, Morriston Hospital Malcolm Thomas Site Manager, Singleton Hospital Alison Kingdom Lead Nurse, Singelton Hospital Gaenor Shaw Site Manager, Princess of Wales Hsopital Sian Franks Deputy General Manager, POW Becky Gammon Block D NPTH 01639 683162 07974930748 Home 01792 850256 POWH 01656 752158 Morriston Hospital 01792 703610 Morriston Hospital 01792 703999 home number 01792 297439 mobile number 07968313186 Morriston Hospital Ext 7049 01554751045 Mobile 07855509222 Singleton Hospital 01792 285263 07967146596 Singleton Hospital 01792 285263 07773389695 Princess of Wales Hospital 01656 752445 07597565038 Princess of Wales Hospital 01656 752634 07779704997 Princess of Wales 01656 752397 07966597105 Lead Nurse, A&E, POW Assistant Co-ordinator South Wales Local Resilience Secretariat Rm 215, Merthyr Tydfil CBC, Civic Centre, Castle Street, Merthyr Tydfil CF47 8AN Tel: 01685 725149 [email protected] Fax: 01685 387740 <blocked::mailto:[email protected]> Mob: 07725 965053 [email protected] SECURE EMAIL [email protected] RC/DD/EIP/A&E- 2009-04 55 Advice regarding Staff Returning from Travel to Countries with Confirmed Cases of Swine Influenza A/H1N1 1. Staff symptomatic within 7 days of return from an affected area: Staff should contact their GP. The GP will undertake an assessment of risk in accordance with Health Protection Agency (HPA) guidelines. If considered necessary, the GP will prescribe anti-viral treatment and the member of staff should be excluded from work following advice from the Health Protection Team. If the GP assessment excludes Swine Influenza, the GP is likely to advise that the member of staff may return to work. 2. Staff who are asymptomatic following return from an affected area: Asymptomatic staff may continue working. 3. Staff who have returned from an affected country, but who have returned to work before developing symptoms: These symptomatic staff should refrain from work until they have sought advice from their GP and the local Health Protection Team. 4. Staff who are close contacts of a probable or confirmed case during the period when the latter was symptomatic AND last exposure occurred no more than 7 days ago: If symptomatic, contact GP and follow advice in section 1. If asymptomatic, the advice of the HPA is that exclusion from work is not required, even for healthcare workers. In all instances above, staff are responsible for notifying their Manager AND the Occupational Health Department of their symptoms and of any relevant advice received from their GP/Health Protection Team. Reference: HPA : P5 WHO PANDEMIC ALERT PHASE 5: Actions and post exposure prophylaxis for close contacts of probable or confirmed human case(s) of swine influenza A/H1N1 (updated 02.05.2009) RC/DD/EIP/A&E- 2009-04 56 RC/DD/EIP/A&E- 2009-04 57 FREQUENTLY ASKED QUESTIONS GENERAL What are we calling this infectious disease outbreak? We are referring to this outbreak as “Swine Flu.” What are the current WHO and UK Alert Levels? We are currently at WHO Alert Level 5 and the current UK Alert Level is 0. UK Alert Levels only come into action once we reach WHO Alert Level 6, eg. once a pandemic has been declared. A pandemic has NOT yet been declared. If WHO move to Alert Level 6, would the UK move to Alert Level 2 or 3 immediately? There are 4 UK alert levels (1= no cases in the UK, 2= virus isolated in the UK, 3= outbreaks in the UK, and 4 = widespread in the UK). Since there are confirmed cases in the UK, a UK alert level of at least 2 is expected if the WHO phase is raised to 6. Do we know when WHO may increase their Alert Level to Level 6? Scientists at WHO are currently reviewing the available evidence on the nature of the H1N1 influenza virus. We are in regular contact with the WHO and, as far as we are aware, the WHO has no plans at present to raise the pandemic alert level to Phase 6. HEALTH ISSUES PLANNING ASSUMPTIONS What are the planning assumptions we should use for this Swine Flu outbreak? We are collecting information at the present time and we will study the first 100 cases in detail so that we can provide an estimate of what we can expect from the current swine flu outbreak. Will all the interventions identified for WHO Phase 5 be implemented? The interventions outlined in the UK Government COBR response guide for Pandemic Influenza for WHO phases 4 to 6 are designed to assist decision making within COBR. These actions, priorities and decisions are not exhaustive or prescriptive. They are intended to provide an overview on how the Government will approach developing its response to a pandemic, which will depend on the nature of the virus. INFORMATION GATHERING AND DISSEMINATION Is the reporting of cases being limited to confirmed cases rather than including the number of probable cases? The HPA are releasing daily figures on their website (www.hpa.org.uk – announcement usually at 3pm) setting out the number of confirmed cases to date. The website also lists the number of cases currently under laboratory investigation. Cases currently under laboratory investigation change on a daily basis as some of those under assessment are discounted and new ones are introduced. SURVEILLANCE (INCLUDING PORT HEALTH AND TRAVEL ADVICE) What information and advice has been issued to the public at points of entry to the UK? Posters and leaflets are being made available at points of entry (airports) (text compiled by HPA, distribution via UK Border Agency). These include messages of what to do if you begin to show influenza like symptoms. Media messages are also seeking to ensure that any returning travellers who are symptomatic go home, stay home and contact their GP or NHS direct over the telephone. The RC/DD/EIP/A&E- 2009-04 58 posters and leaflets are www.ukba.homeoffice.gov.uk available online at the UK Borders Agency website at Has the above information (port health posters and leaflets) been sent to private airfields / charter aircraft? Posters and leaflets have been sent to all UKBA-staffed ports and airports. What arrangements are in place at airports to protect public health and maintain public confidence? The purpose of health activities at international terminals is to protect the UK population from the adverse impact of imported disease, and to comply with the International Health Regulations (IHRs). In public health terms, there are two issues; first, to ensure that cases are diagnosed rapidly and treated, and second, to trace close contacts and prescribe anti-virals. The existing arrangements for responding to Swine Flu at airports are based on a risk assessment aimed at protecting public health and should be maintained. Carriers for all direct flights from Mexico have been asked to keep the passenger manifest and seating plan for two weeks after landing. If this is not effective, and contact tracing is indicated, the HPA will consider publishing the flight number and asking passengers to contact the HPA. To maintain public confidence in the current situation: all direct flights from Mexico are met by an HPA employee all passengers are given the information leaflet HPA staff are available to deal with any queries that arise. Are we limiting travel control only to countries where there are swine flu mortalities and does this leave us at risk of visitors from countries where there are symptomatic people? FCO is currently only recommending against all but essential travel to Mexico because of the flu outbreak. This is being done in consultation with the HPA and is due mainly to the uncertainty over the spread of the disease (the epidemiology). To extend this advice to other countries at present would be contrary to WHO advice. PPE AND HYGIENE ADVICE Where can healthcare professionals find more information on Swine Flu? What advice (in the form of algorithms) have they received? The Health Protection Agency website contains a range of advice for healthcare professionals that may also be on interest to resilience practitioners. The Swine Flu page can be found at: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1240732817665?p=124073 2817665 Will guidance be available for the independent social care sector comparable to that given to other health care workers? General guidance is already available for health care workers and much of this is applicable to social care. In addition, in November 2007, the Department of Health published a strategic and operational framework called Responding to Pandemic Flu in Adult Social Care. This will be supported by a Social Care Tools and Implementation Pack which is designed to assist planning and response to a pandemic in the social care sector. Four modules of this pack are already available on the Department for Health website. A further five are being finalised and will be put on Department of Health website next week. We are aware that the door-drop leaflet advises people to maintain their personal hygiene. Please can you confirm what discussions have been held with the relevant retailers to ensure that hygiene products are kept well stocked within supermarkets and shops. BERR has been in touch with most of the leading national retailers of products mentioned in the doordrop leaflet as well as with the principal retailer trade bodies. In a further consultation by the BRC with RC/DD/EIP/A&E- 2009-04 59 major retailers on 5 May, retailers reported a significant increase in demand in hygiene products, particularly antibacterial wipes and gels. In some cases, this increase in demand was as high as 3000%. Nevertheless, retailers were confident that they could meet the demand for these products. It is possible there will be intermittent, very short-term, gaps on shelves from time to time, but retailers are closely monitoring this to ensure that shelves are swiftly replenished with supplies both from stock rooms and by new deliveries to stores. What information can you provide on national activity to obtain PPE for emergency responders? As detailed in previous guidance, the science does not support the use of facemasks by nonsymptomatic people outside of the health setting. The Dept of Health are purchasing facemasks for health and social care workers in line with agreed policy in this area. SHA report that DH have stated they will not have enough face masks for social care staff but for frontline NHS staff only. Can you confirm this? Arrangements are being made by the Department of Health to procure surgical facemasks for health and social care workers for use if required (based on a risk assessment if the situation escalates). One third of the stock of facemasks being procured will be provided for social care workers across both adult and children’s sectors. The remaining two thirds will be allocated to healthcare workers. Facemasks will be delivered to PCTs, and Local Authorities will need to arrange collection and distribution from there on. Facemasks should only be used by social care workers who have close (within 1 metre) contact with a symptomatic individual. There is no benefit in staff who are not in this situation wearing a mask. Local authorities will need to identify staff who may have close contact with symptomatic individuals and prioritise their supplies of facemasks. Guidance for Local Authorities on Facemasks for Social Care Workers has been issued by DH on 5 May (sent via RRTs to LAs). DH have confirmed that the facemasks should start to be delivered to the PCTs from 11 May. Until then, the only stocks available will be those PCTs are currently holding or those LAs have decided to purchase. What advice can you provide for employers on the use of PPE by their staff? DH/HPA/CCS recently published a risk assessment document for employers (see below) which can be used to assess the potential risk that individuals will face in the event of a pandemic and provides information on appropriate infection control mechanisms, including facemasks. Only on very rare occasions would a facemask be deemed an appropriate precaution. No further advice will be issued by Government on PPE. http://www.cabinetoffice.gov.uk/media/187638/flu_businesses_risk_guidance.pdf Useful information on facemasks can also be found on the HPA website at http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733839643?p=1191942170 467 and on the HSE website at http://www.hse.gov.uk/news/2009/swineflu.htm What action should the Police take if they suspect that someone in custody may have Swine Flu? If the police suspect that someone in custody may have swine influenza, then they should ensure that the person is assessed by a medical practitioner as soon as possible. However, they need to bear in mind that unless the suspect was in Mexico or the US in the seven days before they became unwell, or is a contact of a probable or confirmed case, then the likelihood of this being swine influenza is still very low. The immediate steps would be to isolate the suspect and ask the suspect to wear a mask if they are likely to be in close contact with anyone. If close contact with the prisoner is necessary, then RC/DD/EIP/A&E- 2009-04 60 the police officers should wear a facemask, disposable plastic apron and gloves while with the suspect and wash their hands afterwards. The suspect should be encouraged to adopt good respiratory hygiene. Do we have advice for people working in polling stations for the forthcoming local and European elections re. arrangements for general hygiene? There are currently no restrictions in place regarding mass gatherings, however basic hygiene and cleanliness of designated polling stations should be maintained. Information can be found on the Business Link website (www.businesslink.gov.uk/swineflu) which offers advice to businesses specifically relating to the outbreak of Swine Flu. This includes a risk assessment in the occupational setting. The Health Protection Agency and the Department of Health have worked closely with the healthcare sector and certain non-healthcare services, such as the police and fire and rescue services, to develop pandemic influenza infection control guidance for specific occupational settings (available at http://www.cabinetoffice.gov.uk/ukresilience/pandemicflu/guidance/sector_specific.aspx). However, it is not possible to outline detailed pandemic influenza infection control guidance for every occupation or to cover every conceivable scenario where a person might be exposed to the risk of infection from flu. With this in mind, this simple and generic guidance has been developed to raise awareness of the measures that may be employed to reduce the spread of the flu virus at work. It aims to: allow businesses to evaluate potential situations where there may be possible exposure to the flu virus describe the steps that can be taken to moderate any potential exposure to the flu virus in the workplace set out the measures that might be used to reduce the spread of the flu virus in the workplace provide a matrix that can be used to consider the best ways of reducing the spread of flu in a work environment put into context the relative value of personal protective equipment, including the wearing of face masks, when compared with other environmental and organisational approaches. http://www.cabinetoffice.gov.uk/media/187638/flu_businesses_risk_guidance.pdf The Department of Health website also contains a range of materials (primarily aimed at health and social care professionals) to help communicate the public health information contained in the national media campaign. In particular, the Catch It, Bin It, Kill It posters may be useful for display in public buildings. http://www.dh.gov.uk/en/Publichealth/Flu/Swineflu/DH_098802 MEDICAL COUNTERMEASURES How will antivirals be distributed? The Department of Health are currently reviewing this issue as a matter of urgency. They are engaged with local health providers who have been asked to develop their own plans in this area. We would encourage LRFs to engage with PCTs and the NHS in their area on this issue. How does the current distribution of antivirals fit into the overall policy framework? As detailed in the National Framework for responding to an influenza pandemic the UK may use AVs for post-exposure prophylaxis in the early stages in order to contain spread, allow planners more time to prepare and also enable clinical analysis of the first few hundred cases to inform planning assumptions. Post-exposure prophylaxis to immediate contacts at the same time as treating a symptomatic patient is given on the grounds that some of the contacts may already be incubating the infection. The response we are currently seeing is in line with this. Pre-exposure prophylaxis is not being implemented. RC/DD/EIP/A&E- 2009-04 61 Apart from attempts to contain initial spread, general prophylaxis (pre-exposure) is not currently regarded as an effective or practical response strategy. If antivirals are prescription only, how is it legal for organisations to distribute stocks to staff? What statutory instruments have been tabled by the Department of Health in relation to prescriptions and anti-virals, and what will they achieve? Policy and legal officials are looking at this issue and will provide guidance in due course. What messages are being given to the public regarding what anti-virals do? The DH leaflet that will be going to all UK households, and is currently available online at http://www.direct.gov.uk/en/Swineflu/DG_177831?CID=SFlu&TYPE=sponsoredsearch&CRE=2, details how taking antivirals can help symptomatic people: Antiviral drugs are not a cure, but they help you to recover if taken within 48 hours of symptoms developing, by: Relieving some of the symptoms. Reducing the length of time you are ill by around one day and reducing the potential for serious complications, such as pneumonia. What information has been provided about the risks of purchasing tamiflu online (worries about counterfeit drugs)? A statement has been released by the Royal Pharmaceutical Society of Great Britain. This can be found at http://www.rpsgb.org.uk/pdfs/pr090429.pdf What extra antibiotics have been purchased? Antibiotics will play an important part in our response to a pandemic. DH have worked with clinicians to develop clinical management guidelines which identify the types of antibiotics needed to treat the complications arising for pandemic influenza. The clinical management guidelines have been published on the DH website and in a number of academic journals. Further purchases of antibiotics are currently being accelerated. Why do you need antibiotics in a pandemic? While antivirals may reduce the number of complications, there are still likely to be significant numbers of complications occurring in a pandemic. Some of the most common include bacterial infections in the respiratory tract and lungs. Antibiotics are needed to treat such complications. Antibiotics will be used to treat people in the community, if they develop complications. In secondary care, antibiotics will be used to treat the sickest patients and may reduce the length of hospitalisation. Is there consideration being given to extending sickness self-certification arrangements during the outbreak? Yes. If the circumstances warrant it, ministers can extend the current 7 day period to reduce the burden on GPs. EXCESS DEATHS When will national guidance on excess deaths be issued? The Home Office and Ministry of Justice have been tasked with taking this forward as a matter of urgency. A working group has been established to take this forward. We hope to be in a position to provide regional and local partners with the outstanding guidance documents and further clarification as soon as possible. When will the final version of the national guidance document Pandemic influenza - draft guidance on the operation of the coroner system in England and Wales be published? Pandemic Influenza - Guidance on the Operation of the Coroner System in England and Wales for Coroners is available to coroners on the Coroners’ Society’s members only website (5 May). RC/DD/EIP/A&E- 2009-04 62 This document is not being made available on public websites nor is it available to the media at present to prevent misunderstandings with regard to the current swine flu situation. CCS circulating this document to Regional Resilience Teams (for onwards transmission to Local Authorities and other relevant partners) on 6 May. Where can I find the most up to date guidance on Death Certification? I remember being consulted on a draft guidance document Pandemic influenza - Guidance on the management of death certification and cremation certification by the Dept of Health in May 2008 – is this the latest document? Will there be specific guidance for doctors and police officials? The most up to date guidance on Death Certification can be found at the address below. This replaces the document which was issued for comment on the 19 May 2008. There are no plans to issue specific death certification guidance for doctors and police officials as the main guidance covers these issues. If, however, there are any specific concerns in relation to this, please raise these concerns via your RRT / through the CCSControl mailbox. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086 832 Can you provide clarity on the length of time a body can be stored under chilled conditions (not embalmed)? As lead department for mass fatalities, the HO have set up a working group to consider all issues relating to this subject, including body storage. CCS are keen that the issue of storage is fully considered and that lines/guidance are not provided until they have been fully considered by all of the key players. NON-HEALTH ISSUES SCHOOLS What guidance has been issued to schools? DCSF have issued specific guidance and a series of Q&As for schools on Teachernet. This can be accessed via the following links: Main emergency planning page: http://www.teachernet.gov.uk/emergencies/planning/flupandemic/ Updates page: http://www.teachernet.gov.uk/educationoverview/flupandemic/ Q and A page: http://www.teachernet.gov.uk/educationoverview/flupandemic/flupandemicqanda/ What guidance is going to schools regarding closure if cases are identified among students or staff? It is too early to consider whether school closures will be appropriate measure as we move forward. As the situation develops, a risk assessment will be carried out by HPA/DH/DSCF who will then advise (through CCS and the RRTs cc DAs) local responders of the decision. The processes are outlined in guidance previously issued. How will advice on closure of independent residential schools be communicated? In the event of a decision being made to advise schools to close (as described above), the communications mechanisms are for DCSF (via CCS) to let RRTs know, and then for RRTs to ensure messages are passed to LAs and then onwards to all schools (including private / independent schools, etc) in their area. DCSF would follow up the cascaded message with a direct message to schools. For residential schools, slightly different measures may be required, for instance moving some children to guardians, or accommodating those who have nowhere to go while reducing social mixing. DCSF RC/DD/EIP/A&E- 2009-04 63 guidance to schools (issued by then DfES in 2006) provides more information - schools should consider paragraphs 2.31 - 2.36 of that guidance. What plans are being put in place in case school examinations are affected by the Swine Flu outbreak? Ofqual has worked with awarding bodies, regulators in Wales and Northern Ireland, UCAS, higher education institutions and government to ensure that contingency plans are in place in the event of disruption to the test and examination system. Schools will be made aware of the appropriate contingency plans if they need to take any action with regard to examinations. DCSF have published specific guidance on examinations in a series of Q&As on Teachernet. The link is as follows: http://www.teachernet.gov.uk/educationoverview/flupandemic/flupandemicqanda/ What action should schools take when a pupil is known to be (by the school and parents) a contact of a probable or possible infected person (ie. one of flu symptoms under investigation)? Issues of containment of infection are not sectoral. HPA will decide appropriate containment / voluntary quarantine measures for each case. HPA are currently carrying out contact tracing of possible and probable cases and contacts (such as the pupil above) would be directly contacted by HPA and provided with advice if there was any action required. What advice/guidance is available for schools on what to do with pupils returning from Mexico although showing no flu symptoms? HPA advise that children in this situation should go to school. The same applies to staff members who have been to Mexico. What advice/guidance is available for schools on what to do with pupils arriving at school showing flu-like symptoms? Children with any flu-like symptoms should not be taken to their school or childcare setting, and their parents should be told to take them home if they arrive with symptoms. If a child is taken ill in the day, their parents should be called immediately, and asked to collect the child, and the child should be kept separate from other children - to reduce the risk of infection - until they are collected. In a boarding school, we would expect the child to be in a sick room or similar - arrangements will depend on local circumstances. PRISONS AND THE CRIMINAL JUSTICE SYSTEM What guidance will be issued to prisons? Will it cover restrictions on visitors and include the securing of young people? The Ministry of Justice are finalising guidance for the criminal justice system. This will be issued as soon as it is signed off by Ministers. The guidance includes advice on prisons and the Youth Justice Service. Prison Service have reiterated to Managers the need to ensure contingency plans are in place in line with existing guidance on pandemic influenza. Decisions on regime levels and activities, including the running of visits, will be taken in the light of local circumstances and existing policy. Can you provide advice on when guidance for the judicial system will be made available? The Ministry of Justice (MoJ) are currently finalising this guidance and it will be published in the near future (see above). FAITH GROUPS Advice sought from Faith Groups on the subject of Passing of Chalice at Communion Faith Community guidance is available at RC/DD/EIP/A&E- 2009-04 64 http://www.communities.gov.uk/documents/communities/pdf/1219379 Page 20 provides specific advice on the subject of Passing of Chalice at Communion. “In a pandemic, sharing of common vessels for food and drink should cease. For example, the sharing of cups for Christian Communion or Eucharist, and the tradition of Langar in the Sikh religion for the free vegetarian-only food served in a Gudwara.” What information has been produced by Faith Groups for their members? The Hindu Forum of Britain has prepared guidance which was sent out to all its member organisations on 5 May. The guidelines are aimed at those practicing or gathering for Hindu rituals and services in temples and community centres and offers simple advice on reducing the levels of infection. http://www.hfb.org.uk/Default.aspx?sID=45&cID=358&ctID=43&lID=0 INFRASTRUCTURE What national engagement is taking place with Critical National Infrastructure owners/operators? Many operators of Critical National Infrastructure are members of the wider resilience community as Category 2 responders under the Civil Contingencies Act 2004, and are therefore engaged at various levels of response within the UK. Those organisations with links with Local and Regional Resilience Forums will be working in partnership with other organisations in response to the outbreak of Swine Flu. In addition, Government Departments are keeping contacts in the Critical National infrastructure community apprised of the situation with bespoke briefings and the Top Lines Brief prepared by the National News Coordination Centre. MASS GATHERINGS How will any decisions be taken on mass gatherings, and how will these decisions be communicated and to whom? The Government are not recommending the cancellation of mass gatherings at this stage. To reach a decision on specific emergency measures that might be required if a pandemic were declared, in the absence of more information on the nature of the virus and an evidence-based assessment of the likely consequences for the UK, would be premature at this stage. The Government stands ready to take whatever measures are necessary to respond to the virus. As part of the detailed planning that has been undertaken during the past five years, Government departments have identified potential changes to existing legislative provisions that might be necessary during a pandemic, including measures relating to mass gatherings and other social-distancing aspects. Some of these may be addressed through existing secondary legislation, others might require new primary legislation, or use of Part 2 of the Civil Contingencies Act. Any decisions will be cascaded though the RRTs (cc DAs). What definition is being used for “mass gatherings”? Mass gatherings are defined as events attracting significant numbers of people to an event. They can take place nationally, regionally or locally and may involve use of public transport. They include sporting events, concerts, church services, etc. but do not cover school attendance or public transport. We are not currently advising against mass gatherings. This is being kept under review and will update RRTs if our position changes. ANIMAL HEALTH RC/DD/EIP/A&E- 2009-04 65 Have Defra issued (or do they intend to issue) guidance to farmers and the public to respond to issues around public perception of eating pork or pork products? This is a public health matter and the Department of Health and HPA are in the lead. Defra is providing them with support. Advice to the public re. eating pork / pork products has been included in the Top Lines Brief. The following lines have been sent to key pig and avian stakeholders given their mutual interest in A type flu viruses which can infect animals and humans. Please feel free to draw on this in communications to your stakeholders. The CVO has stated: There is continual surveillance of pigs in this country and there is currently no evidence of this variant of the disease. Swine Influenza cannot be transmitted by eating pork products. Eating properly handled and cooked pork and pork products is perfectly safe. Existing EU rules which prevent imports of all live pigs and pigmeat from Mexico into the EU will continue to be upheld. Defra have also prepared some Q&A material which you may want to draw upon - see below – plus you can find information about swine influenza on the animal disease pages of Defra’s website. Q&A material Why is this called swine influenza? The virus associated with the human cases in Mexico and USA have characteristics from a number of influenza viruses found in pigs, birds and humans. There are no reports of the virus which is currently causing disease in humans being found in pigs (although the situation in Mexico is uncertain). There are no reports of an increase in influenza in pigs occurring in the US/Mexico or elsewhere in the world. Therefore, although parts of this virus may have originated in pigs, it now appears to be transmitting from human to human direct. There is no evidence that pigs are currently involved in this human disease although further work is needed. What are the rules about imports of pigs and pigment into the EU? EU rules do not permit the importation of live pigs from either the US or Mexico. EU rules do not permit the import of pig meat from Mexico, but pigmeat products can be imported from the US. However, even if pigs are involved with this virus, the risk to humans from pigmeat is considered by the US CDC to be negligible. EU rules do not allow the personal import of meat or meat products from either the US or Mexico. Can people catch swine flu from eating pork? No. Swine influenza viruses are not transmitted by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork and pork products is safe. Cooking pork to an internal temperature of 160°F kills the swine flu virus as it does other bacteria and viruses. We have heard reports of the H1N1 virus being transferred from human to pigs in Canada and wonder whether there is the potential for the disease to mutate? Also, will the UK consider culling pigs as a means of controlling the H1N1 virus as in Egypt? This strain of swine flu has not been found in pigs in the UK and DEFRA will maintain their surveillance procedures. However the transmission from humans to pigs is not unexpected and DEFRA guidance to pig keepers reflects this. Swine Flu does not pose a food safety risk to consumers and has not been shown to be transmissible to people through eating pork and pork products. RC/DD/EIP/A&E- 2009-04 66 EU rules currently allow the import of live pigs from Canada to the EU. Trade in live pigs to the UK from Canada is limited and only one consignment has been sent this year (in February). DEFRA will review the current rules at EU level. Given the high health status of the consignments likely to come from Canada, their infrequency, and the fact that disease has been found in only one herd to date (which had an epidemiological link to Mexico), the risk from live pig imports from there is very low. DEFRA advice to pig keepers is that they should stay out of contact with pigs if they have influenza signs. This is consistent with the Health Protection Agency advice to returning travellers, which asks people to stay out of contact with other people if they have influenza signs. CONSTITUTIONAL ISSUES Can you provide advice on the implications of Flu Pandemic for constitutional matters, including local and European Elections? Preparations for holding the elections on 4 June should proceed as planned, however, the position is, of course, being kept under review. When will we know whether the elections will be held or delayed? The Ministry of Justice, working with other Departments, is reviewing how Swine Flu may impact on the elections. They are also in touch with the Electoral Commission, Regional Returning Officers, and the AEA. For the present, they are not advising that any specific steps be taken. However, they are monitoring the situation carefully and will issue further updates through the Regional Returning Officers network for distribution to electoral administrators. Local authorities should be considering contingencies within their area, and Regional Returning Officers should be discussing plans with Local Returning Officers in their region. It may be useful to share this planning for the benefit of others and the Regional Returning Officers co-ordination group circulation list may prove to be a suitable tool for that. The European Parliamentary election is set for 4-7 June in European Union Member States. Any decisions on the timing of those elections need to be taken in consultation with other Member States. At present, there are no plans to change the timing of the elections. If people have specific queries in relation to the elections and planning for them, please send those through to MoJ at the elections mailbox at [email protected] (given that many of the queries may be similar, or the answers of interest to others, MoJ will seek to respond to those all together). Do we have advice for people working in polling stations for the forthcoming local and European elections re. arrangements for general hygiene? (For answer, see the PPE AND HYGIENE ADVICE section above) PUBLIC COMMUNICATIONS How will national web communications for the public be co-ordinated? A protocol has been agreed that makes: Directgov (www.direct.gov.uk/swineflu) the primary government website for essential cross-government swine flu messages; NHS Choices (www.nhs.uk) the primary public-facing health information and advice service; the Department of Health website (www.dh.gov.uk) the home of content relating to health and care professionals; and Business Link (www.businesslink.gov.uk/swineflu) the home of business-related information Directgov are leading the coordination of Swine Flu cross-government messages and information (including video and online updates (RSS feeds)) from all relevant Departments. The Department of Health is the policy lead for all health-related information and will clear all health-related information placed on websites. RC/DD/EIP/A&E- 2009-04 67 What public communications activity will we see in the next few days? The Department of Health's flu TV ad aired from 30 April. The leaflet (to be door-dropped from Tuesday 5 May) was available online from 10pm on 29 April on the Directgov, NHS Choices, and Department of Health websites. What is the Swine Flu Information line? The Swine Flu Information line has been set up to provide information on the swine flu virus. This is a recorded service and the telephone number is 0800 1 513 513. The information provided on the Line is the same as that contained in the door-drop leaflet and on the websites listed above. What information is contained in the door-drop leaflet? The leaflet includes information about what swine flu is and how it could spread, what UK governments have done to prepare for a wider outbreak of flu, how you can protect yourself against flu, and what to do if you have flu symptoms. Will the door-drop leaflet be made available in other languages / accessible for people with disabilities? The alternate formats (16 languages in simple PDF version, large print, and audio) were posted on the Directgov website on Tuesday 5 May (http://www.direct.gov.uk/en/Swineflu/News/DG_177995). Hard copy audio CDs, Braille sheet, and large print formats will be available to order from Thursday 7 May and will take up to a week to deliver depending on demand. Hard copies of ten translations will be available to order from Friday 8th May (including Welsh/English bilingual, Polish, Bengali, Chinese, Urdu, Arabic, Punjabi, Gujarati, Somali, French) and will take up to a week to deliver, depending on demand. The leaflet has been translated into Welsh and can be found at http://wales.gov.uk/topics/health/protection/communicabledisease/swine/?skip=1&lang=cy. The Stakeholder team at DH have spoken to RNIB and Help the Aged about this campaign and are talking to more groups as the accessible and translated information comes on stream. The Swine Flu Information Line is a recorded service using the information in the leaflet. Therefore, its use should not be an issue for people with speech impairments. What work is taking place nationally to brief the media? As part of the Government strategy to ensure that media at all levels are as informed as possible about the ongoing Swine Flu situation, the National Media Emergency Forum met on May 7. This meeting included a briefing from the Chief Medical Officer, informing the group about the current Swine Flu situation and associated medical advice. Ministers (including Devolved Administration Ministers) and the Chief Medical Officer, as well as the HPA, are doing a wide range of interviews, plus DH and HPA as well as the DAs are issuing regular updates on line. What communication is being undertaken nationally with the Trade Unions? Although there are no formal communications aimed specifically at Trade Unions, DWP has a close working relationship with them and are keeping them up to date with the key issues through the HR representatives on the Business Disruption Forum. This forum was set up to support the business continuity management process in relation to the Departmental response to Swine Flu. What advice is available for employers? Annex A contains details of current guidance that is available for employers. This information is included on the Business Link website at: RC/DD/EIP/A&E- 2009-04 68 http://www.businesslink.gov.uk/bdotg/action/detail?type=ONEOFFPAGE&itemId=1082470688&r.li=108 2470975&atom_id=0.PR270942&r.lc=en&r.pp=11&r.pt=global&furlname=swineflu&furlparam=swineflu& ref=&domain=www.businesslink.gov.uk Request for the Health and Safety Executive Website to be updated to refer to Swine Flu rather than Bird Flu. The Health and Safety Executive website was updated on 30 April. The bird flu advice remains, but specific swine flu advice has been added. The relevant page can be found at: http://www.hse.gov.uk/news/2009/swineflu.htm What advice is available for elected members? A toolkit for MPs and other elected representatives has been created. We are currently awaiting confirmation that this can be published on UK Parliament intranet, by DAs on their parliamentary sites, and on Info4Local. OTHER ISSUES LRF / GO WORKLOADS What relaxation of deadlines have been given for LRF work (eg. flood planning) to ensure LRF capacity and capability can be diverted to dealing with the Swine Flu outbreak? RRTs have provided CCS with details of the regional and local work which they would like to see put on hold / delayed. CCS is in discussions with the relevant Government departments on this. Initial feedback has been provided to RRTs (1 May) and a further update will be issued on Tuesday 5 May. FOI REQUESTS Could we have some advice from the Legal Cell on dealing with FOI questions? Most organisations would like to give out as much information as they can if asked, but also want to keep in step with the rest of the country. Organisations are responsible for seeking their own advice on FOI requests as each case needs to be taken on its own merits. We acknowledge that it is important to maintain a degree of consistency with regards how FOI requests are treated. The Legal Cell is looking at options for how best to deliver this and will produce guidance in due course. RC/DD/EIP/A&E- 2009-04 69