National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 9: Respiratory health
Influenza prevention
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☰ Table of contents

Recommendations: Influenza prevention

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation

 Aboriginal and Torres Strait Islander people at high risk of influenza-related complications:
Children aged ≥6 months to <5 years
Youth and adults aged >15 years		 Offer vaccination to high-risk groups in the pre-influenza season months (March–April) Annual IIB 1,13, 32
All individuals aged ≥6 months with a chronic disease Prioritise provision of vaccination to high-risk groups in the pre-influenza season months (March–April) Annual IIC 1
Healthcare providers Offer influenza vaccine in the pre-influenza season months for the prevention of influenza (March–April) Annual GPP 1,45
Women who are pregnant or planning a pregnancy Offer immunisation at the first antenatal visit or with preconception counselling Part of routine antenatal care (refer to Chapter 2: Antenatal care) IIB 1, 35
All others aged ≥6 months for whom it is desired to reduce the likelihood of becoming ill with influenza Offer influenza vaccine in the pre-influenza season months Annual GPP 1
Children aged <6 months Influenza vaccination not recommended   GPP 1

Behavioural

 Those at higher risk of complications due to smoking and/ or obesity Encourage weight loss and/or smoking cessation   GPP

 
Household contacts of a person with influenza Recommend good hygiene practices, such as frequent handwashing and covering the mouth on coughing or sneezing, to decrease the spread of influenza, particularly from children to other household members Opportunistic IIIC 43
Healthcare workers Minimise exposure risk to patients by adhering to infection control guidelines

In addition to standard infection control procedures, personal protective equipment is recommended during influenza pandemics

 

 

 1, 45

Chemo-prophylaxis

 Healthy adults Neuraminidase inhibitors (NIs) are generally not indicated for the prevention of influenza

 

 IIB 48, 49
People at high risk of influenza complications where there are high levels of circulating virus Consider using NIs for highrisk individuals in close contact with someone with a proven case of influenza (ideally initiated within 48 hours) Opportunistic GPP 49, 51

Environmental

   Primary care, communitybased strategies to improve vaccination levels, particularly using reminder/recall systems, provider prompts, provider audit and feedback should be implemented   IB 40, 41, 42, 44
Communities Activities should also focus on increasing community awareness of benefits and timeliness of vaccines for vaccinations (media campaigns) and enhancing access to vaccination services (home visits, clinics in public settings, reduced costs)   GPP 40, 41, 42, 44, 52



Background

Influenza is a common respiratory disease caused mostly by influenza A and B viruses and transmitted person to person.1 These viruses cause minor or major epidemics of seasonal influenza in most years, usually during the winter months in temperate climates, but may occur throughout the year in more tropical regions. Overall, the disease burden from influenza is greater in Aboriginal and Torres Strait Islander peoples than in non-Indigenous Australians across all age groups.1,2 In healthy children and adults who are at low risk of complications, the health impact of influenza is generally mild and is related to absenteeism from school and work. However, severe disease and complications are more likely with advanced age, infancy, lack of previous exposure to antigenically related influenza virus, greater virulence of the viral strain, chronic conditions (heart disease, lung disease, renal failure, diabetes, chronic neurological conditions, conditions leading to immuno-compromise), obesity, pregnancy and smoking.1,3

In 2009, the world experienced its first pandemic influenza since 1968 after the emergence of the novel H1N1 influenza strain. Aboriginal and Torres Strait Islander peoples were disproportionately affected by the H1N1 influenza epidemic, being four times more likely to be admitted to hospital and accounting for 13% of the total deaths.4–6 Given the high rate of complications experienced by Aboriginal and Torres Strait Islander peoples, specialised planning should be considered in managing and preventing harm from future influenza outbreaks.7,8


Interventions

Administration of the latest influenza vaccine provides protection against the disease and its complications. Immunisation probably confers protection for about one year, therefore it is recommended that it be given annually, preferably in March or April, prior to the onset of the Australian winter when influenza rates are at their highest.1

Previously, only trivalent vaccines were available (containing two influenza A subtypes and one influenza B lineage). Since 2014, an inactivated, quadrivalent vaccine (QIV), which includes the same strains as the trivalent and an additional strain from the other B lineage, has been registered for use in Australia.1 The additional benefit gained from QIV administration depends on a number of factors. Modelling has suggested that the greatest benefit from QIV administration is in older people, where it is associated with significant reductions in infections and related complications.9 Some have argued, however, that prioritisation of immunisation to include those at high risk of transmission is more important than the vaccine type.10 The Australian Technical Advisory Group on Immunisation (ATAGI) recommends QIV; however, it advises that trivalent vaccine is an acceptable alternative, particularly if there is a risk of delayed vaccination due to supply barriers for QIV.1

The efficacy and effectiveness of both influenza vaccines also depends on the following: the age and immuno-competence of the recipient; the degree of similarity between the virus strains in the vaccine and those circulating in the community; and the endpoint measured (influenza-like illness, laboratory-confirmed influenza, general practice visits, hospitalisations, complications, mortality).1 Vaccine effectiveness (VE) estimates for laboratory confirmed influenza for Australia 2012–14 ranged from 38% to 60%, with better VE for A(H1N1) and B strains than A(H3N2) strains.11
Annual influenza vaccination is recommended for any person aged ≥6 months for whom it is desired to reduce the likelihood of becoming ill with influenza.1 However, in healthy adults, influenza vaccines have only a modest effect in reducing influenza symptoms and working days lost, and no effect on hospital admission or complication rates.12

Vaccination is strongly recommended, actively promoted and funded for Aboriginal and Torres Strait Islander people aged six months to <5 years and >15 years, and for all individuals aged >6 months with chronic disease.1,2,13 This is because of the higher risk of hospitalisation and complications from influenza in these groups compared to others not in these groups.1,13,14 The risk of influenza complications is not as high in healthy children aged 5–14 years. There remains some conflicting evidence on the benefits of influenza vaccination for all chronic disease groups;15–18 however, the strongest evidence of benefit is related to decreased complications in chronic obstructive pulmonary disease (COPD),19,20 diabetes21,22 and liver disease.23,24

Influenza vaccination has been found to be efficacious in preventing cases of influenza in children aged  >2 years,3,25–27 and two vaccine doses provide better protection than one dose if a child is being vaccinated against influenza for the first time.28,29 In Australian children, the burden of hospitalised influenza is highest in those aged 0–4 years.2 In this age group, rates of hospitalisation for Aboriginal and Torres Strait Islander children are higher than for other children: 2.5 times higher for those aged 0–5 months (but vaccination is not recommended for this age group) and for those aged six months to <2 years, and 1.4 times higher for those aged 2–4 years.2 There is also some evidence that vaccinating children at age 2–5 years may reduce the incidence of pneumonia and influenza in the elderly.30

During the 2010 influenza season, an excess number of cases of febrile reactions and febrile convulsions were observed in paediatric populations following immunisation with one of the registered seasonal trivalent influenza vaccines. This led to the suspension of the provision of this particular vaccine to children aged <5 years; however, the Therapeutic Goods Administration (TGA) and the ATAGI continued to recommend other brands of seasonal influenza vaccine for children for whom it was indicated.31,32 A national vaccine safety surveillance system (AusVaxSafety) has demonstrated low rates of fever and medical attendance after appropriate influenza vaccine in young children in the 2015 influenza season.33

Influenza vaccination during pregnancy is recommended based on the increased morbidity and mortality of pregnant women who contract influenza,3,14,34 and because the transplacental transfer of antibodies to fetus may protect infants for the first six months of life when the risk of hospitalisation for influenza is greatest.2,34 There is also no evidence of harm to the mother,35,36 the pregnancy37,38 or the newborn34,35,37 from immunisation in pregnancy. Recommendations from antenatal care providers may play a key role in increasing coverage in this group.39

Australian guidelines recommend annual influenza vaccine should be offered to all Aboriginal and Torres Strait Islander people aged >6 months. Effective strategies to promote influenza immunisation should be undertaken at a community level and tailored to the needs of the community concerned. Health services are encouraged to implement recall and reminder systems to support systematic vaccine coverage of the community.40–42

Infection control measures such as handwashing, particularly around young children, can be effective in preventing transmission of influenza.43 It is unclear if the addition of virucidals or antiseptic agents is more effective at preventing the transmission of respiratory viruses than routine handwashing with soap.43 Healthcare providers can potentially transmit influenza to patients, and it has been shown that vaccination of healthcare workers confers benefit to those at high risk of influenza complications.44,45 Implementing barriers to transmission, such as isolation and hygienic measures (wearing masks, gloves, gowns), can be effective in containing respiratory virus outbreaks or in hospital wards. However, there is only limited evidence that social distancing (restricting where people can gather in order to stop or slow the spread of infectious diseases – eg limiting large gatherings of people, closing buildings or cancelling events) is effective in reducing transmission.43

Two classes of antiviral drugs are available for the treatment and prevention of influenza – the neuraminidase inhibitors (NIs) zanamivir and oseltamivir, which are active against both influenza A and B; and the adamantanes amantadine and rimantidine, which are only active against influenza A.6 The NIs oseltamivir (taken orally) and zanamivir (inhaled) are approved for use in Australia for the treatment and prevention of influenza A and B.46,47 Systematic reviews on the effectiveness of NIs for influenza prophylaxis in interpandemic years have come to conflicting conclusions. They generally show only a very minor effect in preventing symptomatic influenza infection in individuals/households, and have been associated with adverse effects such as headache, nausea, psychiatric effects and renal events in adults and vomiting in children.48 Consequently, NIs are not routinely recommended for the prevention of influenza in healthy adults.49 They may, however, have a role in prophylaxis for people at high risk of complicated influenza who are close contacts of an infected individual and when therapy can be initiated within 48 hours of exposure.49 An alternative to routinely offering prophylaxis in such individuals is to start antiviral treatment promptly when symptoms of influenza start.49

Post-exposure prophylaxis with NIs continue to be recommended for vulnerable Aboriginal and Torres Strait Islander close household contacts during influenza outbreaks within communities as there are some studies showing prophylaxis can reduce household transmission of influenza,50 but there should be consultation with the local public health unit.
With respect to treatment of established influenza infection, NIs have been shown to slightly reduce the time to alleviation of initial symptoms in adults. However, there is limited evidence that NIs significantly alter complication rates. There is some evidence that oseltamivir reduces the risk of unverified (not radiologically confirmed) pneumonia and that zanamivir reduces the risk of bronchitis. Neither agent is effective in reducing otitis media, sinusitis, other serious complications or hospitalisations.48 Public Health England recommends that if treatment is started for those who are at risk of complications or who have moderate/severe disease, it should be done within 48 hours of onset of symptoms.49

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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