General practitioners from the Rotterdam area gathered at the World Port Center this week for an exercise in how to deal with a flu pandemic. "Can you handle 90 extra patients a day? No, you can't."

By Antoinette Reerink for NRC International

On the 24th floor of the World Port Center in Rotterdam general practitioners from all over the Rijnmond region had gathered to prepare for the Mexican flu. The windows offered a grand view of the river Maas, but that didn't keep the doctors from hanging on the lips of lecturer Paul Mertens.

What to do when the flu pandemic disrupts the Netherlands? Who will be given medication and who won't? How do you make a fair selection when distraught citizens flood the general practitioners and demand to be given the scarce medication?

The 530 general practitioners in the Rijnmond region each have 2,500 patients on average. When the Mexican flu hits its peak they can each expect to have about 500 sick people on their hands.
 

As Paul Mertens told the general practitioners at the World Port Center, this is probably an exaggeration, adding that it is understandable for the government to make a high projection rather than risk being critised afterwards for underestimating the problem.

Lecturer Paul Mertens did the math. "If the Mexican flu hits hard you can expect about 90 patients per day depending on how large your practice is. Can you handle it? No, you can't. It is safe to assume that the Mexican flu at its peak is going to disrupt health care at the local level."

Worst-case scenario
Mertens is an expert in infectious diseases at the Erasmus hospital in Rotterdam and a consultant for the GHOR, the disaster and emergency service. The World Port Center is where the crisis centre would be located in case of a disaster, bringing everybody from pandemic experts to the mayor of Rotterdam together.

On this day the class focused on the blackest scenario, in which general practitioners are overwhelmed by large numbers of flu victims and can no longer cope. A situation like that could become a reality this autumn, when the Mexican flu is expected to peak in the Netherlands and Western Europe.

The general practitioners at the World Port Center were asked to participate in a role-playing game in which Mertens evoked what he called "a worst-case pandemic scenario": half the population is down with the Mexican flu, and there is only enough Tamiflu, the antiviral drug used to treat the flu, for 30 percent of the patients.

"Loud-mouthed people are going to demand that they are given priority, leaving the neediest patients wanting," Mertens warned. In order to avoid arbitrary distribution of medicines all general practitioners in the Rijnmond area were asked to work according to a triage system developed by Mertens.

But Mertens also offered some perspective. During a common winter flu, 0.2 percent of patients will die if they haven't been vaccinated. The casualty rate of the Mexican flu has so far not exceeded 0.5 percent of all reported infections. That's far less than the avian flu, for instance, which is now killing 65 percent of all reported patients, especially in Egypt, China and Vietnam. But the avian flu is spreading slower: worldwide only 433 people have been infected so far.

"I don't want to play this down," said Mertens. "We might be looking at 5,000 to 7,000 extra deaths this winter. But my advice this evening is: don't panic, eat well and sleep well."

Three weapons
The doctors and support staff in the room wanted to know what symptoms they have to look out for. Mertens: "Coughing, fever, fatigue, stomach and bowel problems." A patient is contagious from the day before these symptoms start to show.

Mertens stressed the point that Tamiflu must be administered within two days after the infection. The longer you wait, the less effective the drug is. Tamiflu shortens the disease by preventing new viral particles from being released by infected cells, and it reduces the risk of complications.

There are three weapons in the fight against the Mexican flu. A vaccine is being developed of which the Dutch government has ordered enough to inoculate everyone in the Netherlands, but the vaccine won't be available until October at the earliest. Tamiflu can help already infected patients. The Dutch government ordered large quantities of the drug during the avian flu scare. And patients who develop pneumonia on top of the Mexican flu, should be given antibiotics.

During the break the participants spoke nonchalantly of what is to come. Most were not worried about getting the Mexican flu themselves. "We are resistant to all kinds of these diseases," said one. "During common flu outbreaks we almost never get sick."

After the break the doctors are asked to diagnose four hypothetical cases. One is a nine-year-old boy who has diarrhoea but no fever. Several other kids in his class show the same symptoms. "Could it be the Mexican flu?" Mertens asked. Some of the participants hesitated, but in the end it was probably just a food infection.

Satisfied
A 24-year-old female nurse does not look sick, but she has a cold, coughs and feels sick. She has a fever of 39 degrees Celsius. Is she a candidate for Tamiflu? Most of the participants said yes. Mertens concurred: despite the fact that there is no risk of complications, her profession entitles her to Tamiflu.

The doctors were given forms with standard questions about each patient: profession, symptoms, breathing and heartbeat frequency. If there is a risk of complications, for instance because of a pre-existing chronic disease, extra points are added towards the patient being given treatment. Every answer leads to a new series of questions and ultimately to an answer: Tamiflu or no Tamiflu.

When all the case studies had been dealt with, a general practitioner from Rotterdam said he was satisfied with Mertens' triage system. He correctly diagnosed all patients.

Mertens was satisfied too. He said the general practitioners were going back to their practises with more confidence than before. "If we judge everyone by these criteria, there will be no room for disagreement."