Viewpoint - The impact of swine flu on a large school

Dr Jonathan Holliday describes how his school coped with an outbreak.

Eton College is a school of 1,300 boys, all of whom are boarders. The boys live in 25 houses of roughly 50 each. All houses have boys from all ages, which is important in understanding why we are so efficient at transmission.

During the day there is horizontal mixing with boys of the same year group but from different houses. During the evening there is vertical mixing within houses across the different year groups.

That boarding houses should be such good breeding grounds for influenza has long been recognised by the Health Protection Agency (HPA) Centre for Infections in Colindale, north-west London. It has collected data on a weekly basis from boarding schools across the country for over 25 years for the express purpose of getting some sort of early warning system for incoming, low-flying epidemics.

So it proved this time, with our school being one of the early clusters in the development of this pandemic.

You might not think it, but we were pretty well prepared. A couple of years ago the school doctors did a piece of work with the school authorities in preparation for avian flu. We had agreed what we would do should pandemic flu reach the UK. We had agreed at what point on the WHO scale we would activate each part of our plan.

We knew, for example, when to bring in extra freezers for the catering department, when we would clear a house to act as a secondary sanatorium and when to activate the back-up nursing team. So when swine flu came along all we had to do was consult the avian flu plan.

But even though we were aware and looking for swine flu we still somehow did not see it when it arrived. We were looking for a devastating illness rather than a short-lasting viral infection that laid boys low for a couple of days.

In mid-May we started having one or two boys with temperatures, by the week of 18 May both school doctors were seeing one or two a day, and over the weekend of 23/24 May there were 12.

Most had temperatures under 38 degsC and, quite specifically, none met the requirements of the swine flu algorithm. None of our boys with febrile illness had either had contact with someone with swine flu or had travelled to an area of the world where there was person-to-person transmission.

But with 12 affected over the weekend I thought that it was time that we knew what was going on. And to be fair, so did our very experienced sanatorium sister.

Viral swabs
As I said, none of our febrile boys met the requirements of the swine flu algorithm, and at that time the HPA had to authorise each swab taken. But our link with the Centre for Infections meant that we were able to get viral swabs cultured there, and it was to them I sent swabs on Monday 25 May.

Fortunately, all boys at Eton have their own bedrooms and there are no communal dormitories. So it is quite possible to send boys back to their house with instructions that they are not to mix with others, and so a degree of isolation is maintained.

King George III was a generous friend to Eton throughout his long reign. In recognition of this the school, to this day, remembers him with a special holiday on a Wednesday close to his birthday, which is 4 June. The day is the school's summer parents' day but siblings and girlfriends also come from other schools. At the end of the afternoon all the boys go off for half term. By 4.30 on the afternoon of Wednesday 27 May all the boys had gone. At 6pm we received the call from the Centre for Infections telling us that we had swine flu in the school.

The up side of this was that we had four days before they were due back. The down side was, of course, that we had it at all.

I knew that we had significant numbers in the school who had it, and that we had just been visited by pupils from schools all over the country who had therefore been exposed to it.

We got to work straight away to try to assess how much of a problem we had. We ran searches through that evening to find out the names and houses of all the boys seen at the sanatorium in the preceding two weeks with febrile illness.

It looked like we had 50 boys in that category spread throughout the school site, but interestingly there seemed to be a sparing effect for the top year. About half of those affected had spent one or two nights in the sanatorium. But we also knew that many more had experienced more minor symptoms, cared for in the houses.

Respiratory failure, overwhelming gastroenteritis, shock, heart failure and encephalitis are the most likely modes of critical illness in children suffering from swine flu.

Complications such as sepsis and meningitis may co-exist.
Criteria labelRefer children to the nearest general hospital emergency department if they present with any of the following:
ASevere respiratory distress. Lower chest wall indrawing, sternal recession, grunting, or noisy breathing when calm.
BIncreased respiratory rate measured over at least 30 seconds.
≥50 breaths per minute if under 1 year, or ≥40
breaths per minute if ≥1 year.
COxygen saturation [s39]92% on pulse oximetry, breathing air or on oxygen. Absence of cyanosis is a poor discriminator for severe illness.
DRespiratory exhaustion or apnoeic episode. Apnoea defined as a
≥20 second pause in breathing.
EEvidence of severe clinical dehydration or clinical shock. Sternal capillary refill time >2 seconds, reduced skin turgor, sunken eyes or fontanelle.
FAltered conscious level. Strikingly agitated or irritable, seizures, or floppy infant.

Causing other clinical concern to their own GP or clinical team e.g. a rapidly progressive or an unusually prolonged illness.

Source: DoH

HPA involvement
The local HPA became involved at this point and recommended prophylaxis be offered to all staff and families, in keeping with the plan of containment that was then in place.

The PCT, using our local out-of-hours providers and the school doctors, handed out 2,000 courses of Tamiflu on 31 May/1 June, in wonderful chaos.

The week following half-term was the start of GCSE exams, with AS and A2 exams following close behind. Our aim was to try to get as many pupils as possible sitting their papers. The aim of the HPA was to contain spread.

It was agreed that the bottom two years did not need to return on 31 May as they had no external exams. They would continue to be 'taught', with work set, submitted and marked via the internet. The others would be allowed back as and when their exams demanded.

We set up strict criteria for return and informed parents of this by email. The boys had to be well with no symptoms of flu. They had their temperature taken on their return and if it was raised they were sent home.

All boys returning to school were offered Tamiflu prophylaxis 75mg daily for 10 days. Most of them took it, and some were a bit queasy on it.

As a result, well over 90 per cent of papers were sat and no student missed enough of any subject as to make it not possible to award a grade.

In total there were 70 positive swabs taken either at home or at school. During the first 10 days or so we were having frequent meetings with the HPA and it was fascinating to see the algorithms changing in front of our eyes.

It seemed that as we learnt more about the presentation of the illness, and the algorithm did not fit with the actuality, so the algorithm changed.

  • Dr Holliday is a GP in Eton, Berkshire


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