The guidance relating to vaccination in this document has been endorsed by the
Public Health Agency


Recent guidance issued by the Cabinet Office (22/10/09) suggests that although
the number of cases of swine flu continues to grow, the pandemic is evolving
steadily in the UK and the second peak may be lower than originally thought. The
worst-case planning assumptions can therefore be revised downwards.

The worst-case clinical attack rate across the population as a whole has now
been reduced from 30% to 12% between now and the end of the normal flu
season. This means that in the peak week of the pandemic up to 1.5 million
people may become ill and 5% of people could be absent from work, compared
to the 12% previously thought possible. It should be noted that this is in addition
to normal winter absence rates. There is no change to the advice about the
duration of illness: around 75% of people who become ill will recover within ten
days, and those with complications normally between ten and fourteen days.

While the previously feared disruption of services is unlikely to emerge the
pandemic still presents clinical staff with issues in relation to the information that
should be given to patients and how chemotherapy patients presenting with
swine-flue symptoms should be managed.

The purpose of this document is two-fold:
         1. To support staff in the provision of information to patients (see
            Appendix 1).
         2. To provide staff with guidance in relation to the management of
            chemotherapy patients who present with swine-flu symptoms and
            the need to exclude neutropenic sepsis (see Appendix 2).

This document is intended to be a “live” document and will reviewed and updated
in light of any new information for planners being issued by the Cabinet Office.

If you have queries in relation to this guidance, please contact NICaN office at or call 02890 565860.

<insert trust logo>

 Appendix 1: Swine Flu and Chemotherapy: Information for patients

 Swine Flu and Chemotherapy - Information for patients

 News about Swine Flu and its increase has led to some patients having concerns about
 their health. The following information may be helpful for you to read to address these

 Your immune system may be slightly weaker than normal which may make it harder for
 your body to fight off infections. This may be due to your condition (disease) or the
 treatment you are receiving (chemotherapy or steroids). This places you in a priority group
 to receive vaccinations against both seasonal and swine flu.

 It is advisable that you contact your GP and arrange to have these vaccinations. They
 cannot cause flu.

 Your vaccines should be given in the week before your next dose of chemotherapy. Both
 vaccines can be given on the same day.

 There are also some common steps that you can take to help protect yourself from flu.

        You will be more likely to get infection 7 to 14 days after your chemotherapy
         treatment. During this time you should avoid going out into crowds of people where
         you are in close contact with others. Also try to avoid places with groups of young or
         small children.
        Stay away from anyone who has a cold, or has diarrhoea, vomiting or flu like
         symptoms, until they are feeling better usually around a week later. If other family
         members or neighbours have flu, avoid visiting them.

       If someone in the same household as you develops any of these symptoms they
        should keep away from you. They should also cover their mouth and nose with a
        tissue when they cough or sneeze and put the used tissue in a waste bin right away.
        Regular cleaning of surfaces such as door handles, toilet handles and taps will help
        reduce the spread of viruses and germs.
       Keep your hands clean by washing them with warm water and soap after using the
        bathroom, blowing your nose, coughing or sneezing
       If you can’t wash your hands, use a sanitizing gel
       Avoid touching your eyes, nose, or mouth. Germs spread that way.

Symptoms of Swine Flu are similar to those of regular flu and include:-
Temperature                 Body aches
Cough                       Chills
Sore throat                 Fatigue
Headache                    Some people have also complained of vomiting and diarrhoea.

Some flu symptoms are similar to possible side effects of your treatment. You need
to contact your chemotherapy unit right away if you develop any of the symptoms
Monday to Friday, between 8:30am and 5:00pm: Telephone <insert number>
After 5:00pm or at the weekend: Telephone <insert number>

Appendix 2: Guidance for staff regarding chemotherapy patients

                              Guidance for Staff
         Chemotherapy Patients with Potential Swine Flu
          and the Need to Exclude Neutropenic Sepsis

a) Provision of information to patients

    All patients receiving chemotherapy (in patient or day case) should be given
     the NICaN leaflet entitled “Swine Flu and Chemotherapy”. This alerts patients
     to the fact that Swine Flu symptoms may be similar to those of Neutropenic
     Sepsis, and advises them to contact the unit helpline immediately

    Near to the entrance of chemotherapy treating areas it may be helpful to have
     a poster alerting patients to report to reception immediately if they have flu-
     like symptoms (some units have alternate arrangements in place)

    Flu like symptoms:
    Fever, temperature over 38oC or a history of fever and two or more of the
    following symptoms:
    cough; sore throat; runny nose; limb or joint pain; headache; vomiting or

b) What staff should do if patients attend with above symptoms

        Act quickly as the patient may have neutropenic sepsis rather than flu

        Patients reporting these symptoms should be asked by staff to put on a

        Reception staff will immediately inform the nurse in charge

        The nurse in charge will immediately place the patient in an isolated room

        A trolley with PPE will be available for staff entering the room to assess
         the patient

        Assessment should exclude neutropenic sepsis (Temperature can be
         ↑38o or ↓36 o)

      Staff assessing the patient will alert Infection Control staff, and discuss the
       need for swabbing

c) Telephone Helpline Guidance

      Assess whether or not patients have the signs and symptoms listed in the
       box above

      Given that these signs and symptoms may be indicative of neutropenic
       sepsis, the nurse will follow the neutropenic sepsis protocol i.e. the patient
       will be asked to immediately attend the appropriate location for
       assessment, as per Figure 1

      Medical care for neutropenic sepsis may commence

      The nurse will immediately inform the reception, nursing, and medical staff
       of the patient's arrival, including details of their name, hospital number,
       signs and symptoms and estimated time of arrival.

      On arrival, the actions listed above (in section b) will be undertaken

      NB: On those fewer occasions when the patient’s symptoms urgently
       require the skills of A&E staff, (following discussion with medical staff) they
       should be advised to attend A&E. A&E staff must be informed that a
       patient with suspected swine flu (but who needs screened for potential
       neutropenic sepsis) is attending

d) Vaccination against Seasonal and Swine Flu

The Department of Health specifically identifies patients who are at risk of
immuno-suppression from treatment or disease as belonging to a high risk group
for complications of flu and they therefore have priority for vaccination against
BOTH seasonal and swine flu.

This clearly includes patients who are receiving or have recently received
chemotherapy (up to 12 months previously).

 Vaccines should be given in the week before the next dose of chemotherapy is
administered (both can be given on the same day). These vaccines are NOT live
vaccines and CANNOT cause flu.

Staff should now proactively advise patients receiving chemotherapy that
they should make arrangements to have the swine flu vaccination.

They should also advise patients that members of their household should
also avail of the vaccination to reduce the risk of exposure.

Doctors have no general discretion in this matter. The only acceptable approach
is to make it clear that Department of Health advice is that these patients are
priority patients for flu vaccination and advise that they should receive same.
Any different advice would have to identify a particular personal risk for a specific
patient such as previous allergy to vaccines or to eggs.

The DHSSPS have recently advised hospitals that they have a duty to
vaccinate any patient who is likely to be an inpatient for 7 days or more.

e) General Information about Chemotherapy and Swine Flu

   The consultant is responsible for minimising toxicity from chemotherapy and
   may consider G-CSF prophylactically. However it is not considered that G-
   CSF has a therapeutic role here unless the patient is demonstrated to be

   If a patient rings in with an elevated or low temperature or other symptoms,
   there is a need to undertake an urgent assessment of the patient (including
   blood test) to exclude neutropenic sepsis. Consideration needs to be given
   to allocating a side room or clinic room with masks etc so that patients can be
   assessed separately from those receiving chemotherapy.

   Decisions on whether to continue with treatments or on the priorities of
   treatments will occur at a later stage

Figure 1: Current system for assessment of chemotherapy complications when neutropenic sepsis is suspected

Treating                      Contact During Hours                                                Out of Hours
Hospital                           9am - 5 pm                                                      After 5pm

Belfast City   Bridgewater oncology patients                           Oncology patients:                   Belfast City Hospital AE
Hospital       028 9026 3805                                           028 9026 3805                        (A&E Numbers not given to
               Bridgewater haematology patients                        Haematology patients                 Direct Dial
               028 9026 3984                                           028 9026 3984                        028 9026 3877

               During hours                                            Out of hours
                Day hospital patients advised to contact BW            Day hospital patients advised to contact helpline number
                  directly for assessment                               If bed available in Cancer Centre, Helpline Nurse advises
                Discharged in-patients advised to contact BW             patient to come to ward for assessment by SHO
                  directly for assessment                               If no bed available in Cancer Centre, patient advised to
                                                                          attend BCH A/E
                                                                        Helpline Nurse informs BCH AE and Oncology/Haematology
                                                                        Oncology/Haematology SHO assesses patient in AE

               Patients who are treated at the Cancer Centre but who live in another HSC Trust’s catchment area:
                Oncology patients treated in BCH, but who live in another Trust’s catchment area, are advised to travel to BCH for
                  assessment, if travelling distance and apparent clinical condition permits
                If patient’s clinical condition requires more urgent assessment they are signposted to the relevant cancer unit at the
                  location outlined below
                Helpline nurse rings and notifies the cancer unit’s contact location (i.e.: Appropriate ward & local AE)

Treating                   Contact During Hours                                      Out of Hours
Hospital                        9am - 5 pm                                            After 5pm

Ulster     MacDermott Unit                                 Ward 25                               Ulster Hospital A&E
Hospital   028 9056 1437                                   028 9055 0448                         Via Switchboard
                                                                                                 028 9048 4511

           During hours                                    Out of hours
            Patient advised to contact unit direct         Patient advised to phone ward 25 direct
            Attends unit for assessment                    If a neutropenic bed is available in ward 25, the patient is
                                                              advised by the ward nurse to come directly to the ward for
                                                            If no bed available patient advised to attend AE.
                                                            Ward lets AE know

Antrim     Laurel House                                    Ward B1                               Antrim Hospital A&E
Hospital   028 9442 4240                                   028 9442 4505                         Direct Dial
           028 9442 4201                                                                         028 9442 4548 / 4877

           During Hours                                    Out of Hours
            Patients advised to contact unit direct        Patients advised to contact their GP first
            Attends unit for assessment                    GP then phones ward B1 (all calls taken by SHO) will be
                                                              advised to attend ward direct
                                                            Patients living in Northern Trust catchment area, but who are
                                                              treated in BCH, turn up at (or are sent by their GP to) Antrim
                                                              AE, they will be directed for assessment to ward B1

Treating                      Contact During Hours                                             Out of Hours
Hospital                           9am - 5 pm                                                   After 5pm

Craigavon     Mandeville Unit                                         Ward 2 North                         Craigavon Hospital A&E
Hospital      028 3861 2821                                           028 3861 2509                        Direct Dial
              028 3861 2823                                           028 3861 2536                        028 3861 2014

              During Hours                                            Out of Hours
               Patients contact unit direct                           Patients advised to phone ward 2 North direct
               Patients advised to attend AE for assessment           Ward nurse triages patients condition and if required advises
               Unit lets AE know                                        patient to come to Craigavon AE for assessment
                                                                       Ward lets AE know

Altnagelvin   Sperrin Room                                            Ward 43                                      Altnagelvin
Hospital      028 7161 1289                                           028 7129 6151                                Hospital A&E
                                                                                                                   Direct Dial
                                                                                                                   028 7161 1379

              During Hours                                            Out of Hours
               Patients contact unit directly                         Patient advised to contact ward 43 directly
               Patient advised to attend unit for assessment          Ward nurse triages patients condition via phone takes
               Acutely ill patient requiring urgent medical care        appropriate action
                 advised to attend A/E                                 Ward nurse advises patient to come to ward for assessment if
               Sperrin unit staff advise A/E on patient and follow      required
                 up on A/E action                                      Patient will be assessed by SHO on ward
               Also alert ward 43 of potential admission              Acutely ill patients requiring urgent medical care advised to
                                                                         attend A/E
                                                                       Ward staff advise A/E and follow up on A/E actions


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