Influenza A (H1N1)/swine flu

Frequently asked questions for general practices

UPDATED 19 June 2009 11:00am

What are the basic epidemiological facts about Influenza A (H1N1)?

  • Incubation period: most commonly around 3 days, but up to a maximum of 7 days
  • Period of communicability: from 24 hours prior to the onset of symptoms until either 7 days after onset of symptoms or until resolution of fever, whichever is longer
  • Means of virus transmission: most likely to be spread from person-to-person by inhalation of infectious droplets produced while talking, coughing and sneezing; transmission may also occur through direct and indirect (fomite) contact

What should the practice do if a suspected case presents?

If a suspected case presents to your practice, please do the following:

  • Try to keep the patient separate (at least 1 metre away) from other patients. Ask the patient to wear a mask
  • Australia ’s pandemic response phase stands at PROTECT nationally. All Australian jurisdictions will move to PROTECT activities by June 26. At present H1N1 Influenza 09 is best described as mild in most but severe in some. However, the disease will be watched closely for any changes that indicate it may be becoming more severe.
  • If nose and throat swabs are to be taken, or when coming within a metre of suspected cases, basic infection control precautions such as hand-washing and wearing appropriate personal protective equipment (gloves, surgical mask, eye protection ± gown) are sufficient
  • P2 masks are only required by health care workers performing aerosol-generating procedures, such as endotracheal intubation, use of nebulisers (if possible avoid nebulisers and use MDIs and spacers should be used instead), and ventilation with bag-valve-mask
  • All people who are symptomatic should isolate themselves and attempt to reduce spread of disease to others. Those people not requiring hospitalisation should be isolated at home until the diagnosis is excluded or the infectious period is over (currently defined as 7 days from onset of symptoms), provided fever has resolved.
  • Advice on symptomatic treatment should be provided in this instance (encourage appropriate hydration and analgesia)
  • Under the current PROTECT phase, contacts of cases should not receive prophylactic antiviral medication, and do not need to be placed under home quarantine
  • Patients at high risk of adverse outcomes should be encouraged to report febrile respiratory symptoms to their doctor

What do the World Health Organization (WHO) alert levels mean? Are they the same as the alert levels in Australia? Which levels should I follow?

Pandemic alert levels provide signals to governments to put their pandemic plans into action. The WHO levels describe the pattern on a global level and are different from the Australian alert levels because our necessary national response differs from the global response. Australian general practices and health organisations need to follow the Australian Government recommendations.

For Australian alert level information see: Health Emergency – Australian Government.

For more information on WHO levels see www.who.int/en and www.who.int/csr/disease/influenza/pandemic/en

What is the current pandemic level alert in Australia?

  • Australia ’s pandemic response phase stands at PROTECT nationally. All Australian jurisdictions will move to PROTECT activities by June 26. At present H1N1 Influenza 09 is best described as mild in most but severe in some. However, the disease will be watched closely for any changes that indicate it may be becoming more severe.
  • The focus of the PROTECT phase is:
    • identifying members of vulnerable groups in whom this disease may be severe;
    • early treatment of those identified as vulnerable who become ill
    • treating those with moderate or severe disease (especially respiratory difficulty)
    • voluntary home isolation of cases (especially school children), but not quarantining of contacts
    • not providing post exposure prophylaxis to any contacts, and not treating those with mild disease but who are not in a vulnerable group
    • re-focus of testing for H1N1 Influenza 09 to vulnerable groups, institutions, outbreaks and those with moderate or severe disease, as part of a surveillance framework

How can patients be triaged?

Patients are encouraged to contact practices by telephone and reception staff need to ask patients

  • Have they influenza-like illness symptoms consistent with the clinical case definition i.e.: An acute respiratory illness (ARI) characterised by fever (≥38°C or well documented history) with cough and/or sore throat. Other possible symptoms include fatigue, myalgia, arthralgia, rigors, chills, diarrhoea or vomiting.

Reception staff can ask questions in a manner that is reassuring, as well as providing reasons for the questioning and privacy assurance if required.

Practice information leaflets and notices in the waiting room can provide information that will further support the appropriateness of triage questions

Examples of questions to ask:

  • ‘Could you please give me an indication as to your health need so that I can ensure that I give you the most appropriate appointment?’
  • ‘So that our doctors can provide the best possible care, can you give me an indication of the nature of your visit?’
  • ‘You say that you are unwell, can you give me further information as to what you are experiencing? Do you have a fever, cough, diarrhoea or vomiting?’
  • ‘You probably know that there is an issue with flu at the moment. Could you tell me if you have a fever, muscle aches or cough?’
  • ‘Would you mind if I asked a couple more questions, as the information will help us care for you?’

Asking appropriate questions will help to detect suspect cases of influenza before the patient presents in the clinic. Patients can then have a phone consultation with the GP for further assessment of risk. If it is necessary for the patient to attend the clinic, practices should prepare an isolated space and have surgical masks, hand hygiene and disposable tissues at the ready.

Contact the RACGP to obtain copies of practice support posters: Patient Alert Poster and Bug Alert poster; putting on and taking off a surgical mask posters; and correct use of personal protective equipment poster. These posters can be downloaded from racgp.org.au/pandemicresources or email Nicole.bonne@racgp.org.au and request copies to be mailed

Download Patient Alert Poster

What are the current case definitions for influenza (clinical and confirmed)?

  • CLINICAL CASE DEFINITION: An acute respiratory illness (ARI) characterised by fever (≥38°C or well documented history) with cough and/or sore throat. Other possible symptoms include fatigue, myalgia, arthralgia, rigors, chills, diarrhoea or vomiting
  • If the medical practitioner has assessed that there is H1N1 Influenza 09 in the local community (community transmission) then anyone with ARI is considered to have H1N1 Influenza 09
  • In areas where there is no community transmission then the medical practitioner should refer the patient for pathology testing to confirm H1N1 Influenza 09 infection.
  • A confirmed case of H1N1 Influenza 09 infection is defined as a person with laboratory-confirmed H1N1 Influenza 09 virus infection by one or more of the following tests: viral sequencing, Influenzavirus A H1N1v 09 specific-PCR, or isolation of Influenzavirus A H1N1v 09 virus

What are the current recommendations for the use of antivirals?

People who should be given antiviral therapy are those who meet the case definition above and are:

  • Those with moderate or severe disease
  • Any person with confirmed H1N1 Influenza 09 infection who is deteriorating
  • Those identified as being in a vulnerable group (see above). A clinical assessment should be made of their risk of deterioration, and laboratory confirmation should be made if it is available in time, but early commencement of treatment is a priority
  • Residents living in high risk institutions such as aged care facilities or special schools in order to control outbreaks in these settings
  • Antiviral medication needs to be provided as soon as possible, preferably within 48 hours of onset of illness. Beyond 48 hours, antiviral medication may still be indicated on clinical grounds
  • All people who are symptomatic should isolate themselves and attempt to reduce spread of disease to others. Those people not requiring hospitalisation should be isolated at home until the diagnosis is excluded or the infectious period is over (currently defined as 7 days from onset of symptoms), provided fever has resolved. Advice on symptomatic treatment should be provided in this instance (encourage appropriate hydration and analgesia)
  • Under PROTECT, contacts of cases should not receive prophylactic antiviral medication, and do not need to be placed under home quarantine.

ALERT: Important antiviral note when administering oseltamivir (Tamiflu®) to children

The Tamiflu mixture (powder for reconstitution) packet comes with a measuring oral syringe (provided by the manufacturer). This syringe has markings that correspond to their recommended doses in mg (i.e. 30mg, 45mg, 60mg markings) – whereas all other syringes have markings in mL. Many would be used to measuring volumes with syringes, rather than ‘mg’ amounts. The dose instructions provided in the attachment are in both amounts and volumes.

PLEASE TAKE CARE WHEN DOSING CHILDREN

Can antivirals be given safely to a pregnant woman?

Always consult and work with the patient's obstetrician before giving antiviral medication to a pregnant woman in case new issues evolve during an epidemic — a telephone call will be sufficient. Pregnant women are known to be at higher risk for seasonal influenza complications and during prior pandemics. Pregnant women may be at higher risk for swine influenza complications. Oseltamivir (TamiFlu®) and zanamivir (Relenza®) are “Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. To date no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women. 

The drug of choice for prophylaxis is less clear.  Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications e.g. bronchospasm and medication delivery system challenges that may be associated with zanamivir, because of its inhaled route of administration, need to be considered, especially in women at risk for respiratory problems.

What are the recommendations on breastfeeding, human swine influenza and antivirals?

NB The following information is provided for guidance. These issues need to be discussed between each patient and their doctor.

General practitioners should become familiar with current expert recommendations on breastfeeding and human s wine flu to ensure that patients continue to receive the maximum health benefits from breastfeeding.

The general consensus is that women who are breastfeeding should continue to do so while receiving antiviral treatment or prophylaxis.

In addition, the US Academy of Breast feeding has released a statement saying “Breastfeeding can limit the severity of respiratory infections in infants and is particularly important for minimizing the risk and effects of infection during an influenza outbreak, such as the current H1N1 influenza virus.”

The UK National Health service is recommending that mothers should:

  • continue to feed on demand so that the infant receives as much of the maternal antibodies as possible
  • continue breastfeeding if she becomes ill but and increase feeding frequency.
  • express milk if she becomes too ill, if possible
  • The risk for swine influenza transmission through breast milk is unknown. However, reports of viraemia with seasonal influenza infection are rare

The US Center for Disease Control has published very similar recommendations, as does the US Academy of Breastfeeding.

For more detailed information visit:

What are influenza-like symptoms and what is the difference between influenza and the common cold?

All practice staff need to be alerted to influenza-like symptoms (‘red flags’) to ask the question: could this be influenza?

Symptoms include:

  • Fever
  • Headache and generalised muscle and joint pains
  • Sore throat
  • Runny nose and cough
  • Diarrhoea and vomiting

Influenza versus the common cold

  • Influenza is more than a ‘bad cold’.
  • The flu causes a high fever; a cold sometimes causes a mild fever
  • Cold symptoms last 1–2 days; the flu can last up to a week
  • Muscular pains and shivering attacks occur with the flu, but not with a cold
  • Flu starts with a dry sensation in the nose and throat; colds cause a runny nose

Is there a need to vaccinate patients and staff with the annual flu immunisation?

The annual flu immunisation provides no protection against swine flu. Nevertheless, seasonal influenza vaccination is encouraged according to current immunisation guidelines. Pneumonia can be a severe illness and a complication of influenza infection. Pneumococcal vaccine is recommended to all at risk groups, according to recommendations in the National Health and Medical Research Council (NHMRC) Immunisation Handbook (9th edition).

 What travel advice should I give to patients?

People travelling to affected countries should reconsider their need to travel, and be advised to attend to cough etiquette and thorough hand hygiene, seek medical assistance if they become ill whilst travelling or within 7 days of return. For more information contact visit the Australian Government website Smarttraveller (visit: http://www.smartraveller.gov.au/ )

 When do I need to use a P2/N95 mask?

Patients who are suspected of having influenza should be encouraged to wear a surgical mask at all times. Practice staff and other patients in the clinic are required to wear a surgical mask if they are within a 1 metre distance from the patient. MASKS SHOULD ALWAYS BE APPLIED CORRECTLY ENSURING THAT CORRECT HYGEINE AND HANDWASHING PROCEDURES ARE FOLLOWED.

The current advice from the Chief Medical Officer is that:

  • If nose and throat swabs are to be taken, or when coming within a metre of suspected cases, basic infection control precautions such as hand-washing and wearing appropriate personal protective equipment (gloves, surgical mask, eye protection ± gown) are sufficient
  • P2 masks are only required by health care workers performing aerosol-generating procedures, such as endotracheal intubation, use of nebulizers (MDIs and spacers should be used instead), and ventilation with bag-valve-mask.
  • When using PPE, ensure that it is removed in the correct order:
    • Remove gloves
    • Wash hands
    • Take off your gown
    • Wash hands
    • Take off your goggles
    • Wash hands
    • Take off your mask
    • Wash your hands

Download and print the practice posters “Putting on a mask" and "Disposing of a mask” to help perform this procedure correctly.

 What should be done if there is no access to a P2/N95 masks?

When seeing patients, use a surgical mask (both staff and patient) and pay scrupulous attention to hand hygiene (especially hand washing), keep hands away from the face and mouth, and ensure that waiting room procedures such as social distancing and effective triage are in place.

If nose and throat swabs are to be taken, or when coming within a metre of suspected cases, basic infection control precautions such as hand-washing and wear appropriate personal protective equipment (gloves, surgical mask, eye protection ± gown) are sufficient.

P2 masks are only P2 masks are only required by health care workers performing aerosol-generating procedures, such as endotracheal intubation, use of nebulizers (MDIs and spacers should be used instead), and ventilation with bag-valve-mask.

What is the role of the public health unit?

Contact your local Public Health Unit for further advice (see below for contact details) if you see any of the following:

  • Suspected influenza outbreaks in high risk settings such as health care facilities, special schools, residential care facilities, etc.
  • All persons meeting the definition for a confirmed case must be notified to the local Public Health Unit

How do I contact my local public health unit?

Swine Influenza Outbreak – Contact Details - National

For doctors only:

State/Territory Contact Details
TAS 1800 358 362
WA (08) 9388 4830 or AH: (08) 9328 0553
S.A (08) 8226 7177
N.T (08) 8922 8044
QLD 13432584 or 13HEALTH
NSW Contact details for the 17 public health offices in NSW Area Health Service Areas can be found at: www.health.nsw.gov.au/publichealth/Infectious/phus.asp
ACT (02) 6205 2155
VIC 1300 651 160 or after hours through the paging service 1300 790 733

All Public Enquiries:

For all public enquiries (including patients), you can contact either:

  • Your local GP
  • Your local health services
  • National Commonwealth Health Hotline for Swine Influenza: 180 2007

Publication Date: 19 June 2009
Authorised By: Office of The CEO and President

Copyright | Terms of Use | Forums Terms of Use | Privacy Statement | Security Statement | Log out