Managing pandemic influenza in general practice

Part C - Response

Infection prevention and control

Last revised: 16 Dec 2019

In the event of a pandemic, the priorities include staff staying well, prevention of cross-infection of patients and appropriate management of patients with pandemic influenza. To reduce risk:

  • do not allocate febrile patients to staff at increased risk
  • re-organise the clinic schedule to minimise cross-infection with minimal disruption of usual services45
  • consider delaying non-urgent and routine non-essential consultations during a pandemic (eg Pap smears).46

The importance of infection prevention and control procedures is critical during a pandemic. GPs and clinical staff should take a proactive approach and reinforce the importance of infection prevention and control measures during a pandemic.29

Review your current infection prevention and control plans in light of available pandemic information. Update or adapt protocols on:

  • hand hygiene (eg increase the number of alcohol-based hand sanitiser dispensers)
  • use of PPE for staff and patients
  • practice cleaning, removal of clutter and non-cleanable items such as waiting room toys and waste disposal (use no-touch waste dispensers)
  • the use of quarantine and social isolation (eg increasing home visits or practice modification to create separate waiting areas for influenza and non-influenza patients)
  • assigning personnel to different tasks and patients (eg one GP does not see any influenza patients, a practice nurse to see the ‘worried well’, one GP to do influenza home visits)
  • throat swabbing
  • vaccines (depending on availability, distribution and immunisation strategies).

Ensure that these protocols are clear, simple, easy to implement and are scaled appropriately to the level of risk. Display alert and education materials for staff and patients.

Febrile staff with respiratory symptoms should not come to work until considered non-infectious (based on current information about the influenza strain).

General practices may choose to encourage seasonal influenza vaccination of staff.29

Pneumococcal pneumonia is likely to be a significant complication of pandemic influenza. Practices should identify at-risk patients and offer pneumococcal vaccination.11

Check regularly with the relevant state or territory health department about pandemic vaccination availability and distribution and immunisation strategies.

Practices will need to check antiviral protocols with the state or territory health department.11 In some cases there may be targeted antiviral prophylaxis for contacts and frontline health workers.

During a pandemic, vigilance in detection and immediate reporting of suspected cases of pandemic influenza is critical. A person is classified a ‘contact’ if they have been in close proximity with a person who has been diagnosed with pandemic influenza and therefore has the potential of becoming infected. The exact definition of a contact depends on the nature of the illness and the phase of the pandemic.

It is important to be aware of the changes of ‘case definitions’ as a pandemic develops. The case definitions used by state and territory health departments will change at different phases of the pandemic, as knowledge about the disease increases.

Practice staff may be required to supply names and contact details of patients who have been in close contact with a patient with suspected pandemic influenza to health authorities. Patient confidentiality and privacy is a core element of the management of patient health information. However, during a pandemic, confidentiality and privacy may be overridden by public health concerns and mandatory reporting requirements.

Early recognition of patients with suspected influenza will allow for appropriate patient management and reduced risk of transmission. All staff need to be able to recognise the symptoms and signs of potentially infectious diseases. This should include matching patients who present to or call the practice to the current ‘case definition’ of the pandemic and responding appropriately.

Consider developing a checklist for patients and staff to identify potential cases of influenza.

This may include questions commonly asked at reception and examples of expected staff responses. All staff will need training in triage protocols. Ensure triage questions are easily accessible at the reception desk.

Leaflets and notices in the waiting room, posts on the practice website or messages while callers are on hold are additional strategies for providing patients with information to support the triage process.

During a pandemic, health authorities will provide a more specific case definition. Definitions used by health authorities to identify cases of pandemic influenza may change at different phases of a pandemic, as knowledge of the disease increases. General practices need to maintain good communication pathways with state and territory health authorities to ensure timely notification of any changes to case definition or clinical management.

Distance barriers are effective in preventing disease transmission.20 Exploring some patient flow options to reduce contact between patients with influenza-like symptoms and those without is useful. Examples include creating a mini-influenza clinic (eg a designated waiting area and GP), assigning a clinic nurse to those who are considered ‘worried well’36 and using areas such as the car park for patient triage. Practices may also have a dedicated consultation room to treat/manage patients with influenza-like symptoms. It is important to understand the differences between isolation and quarantine.

  • Isolation is used to physically separate symptomatic patients with an infectious disease from those who are healthy during the infectious period. In the practice, isolation includes distancing (eg seating patients with influenza at least one metre away from patients without influenza, ideally in another area or consultation room of the practice). Isolation could be extended to all patients with an influenza-like illness being seen at a separate facility, such as a flu clinic.
  • Quarantine is used to physically separate and restrict movement of asymptomatic persons who have potentially been exposed to an infectious disease to see if they become ill. People with influenza may be infectious before they become ill themselves. People in quarantine may be asked to monitor their temperature. They will need to know how to use a thermometer, how often to take their temperature and what to do if they develop a fever (ie temperature ≥ 38 °C). Quarantining of patients is not a mandatory requirement and therefore not enforceable. Practices should advise/recommend influenza patients to stay at home and limit contact with other people.

It may be particularly important to separate age groups. During the H1N1 pandemic, while adults were responsible for seeding the infection in communities, children frequently drove community outbreaks.47 General practices may need to liaise with local schools and childcare facilities.

  1. World Health Organization. Pandemic influenza risk management: WHO interim guidance. Geneva: WHO, 2013.
  2. Department of Health and Ageing. Review of Australia’s health sector response to pandemic (H1N1) 2009: Lessons identified. Canberra: Commonwealth of Australia, 2011.
  3. Jean-Gilles L, Hegermann-Lindencrone M, Brown C. Recommendations for good practice in pandemic preparedness: Identified through evaluation of the response to pandemic (H1N1) 2009. Copenhagen: WHO Regional Office for Europe, 2010.
  4. Moen A, Kennedy PJ, Cheng PY, MacDonald G. National inventory of core capabilities for pandemic influenza preparedness and response: Results from 36 countries with reviews in 2008 and 2010. Influenza Other Respir Viruses 2014;8:201–08.
  5. Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. Influenza pandemic 2009/A/H1N1 management policies in primary care: A comparative analysis of three countries. Aust Health Rev 2013;37:291–99.
  6. Simonsen KA, Hunskaar S, Sandvik H, Rortveit G. Capacity and adaptations of general practice during an influenza pandemic. PLoS One 2013;8:e69408.
  7. World Health Organization. Influenza (seasonal) fact sheet. Geneva: WHO Media Centre, 2016. mediacentre/factsheets/fs211/en [Accessed 21 March 2017].
  8. Simonsen L, Spreeuwenberg P, Lustig R, et al. Global mortality estimates for the 2009 influenza pandemic from the GLaMOR project: A modeling study. PLoS Med 2013;10:e1001558. [Accessed 21 March 2017].
  9. Muscatello DJ, Newall AT, Dwyer DE, Macintyre CR. Mortality attributable to seasonal and pandemic influenza, Australia, 2003 to 2009, using a novel time series smoothing approach. PLoS One 2013;8:e64734. [Accessed 21 March 2017].
  10. Quiñones-Parra S, Grant E, Loh L, et al. Pre-existing CD8+ T-cell immunity to the H7N9 influenza A virus varies across ethnicities. Proc Nat Acad Sci USA 2014;111:1049–54. [Accessed 21 March 2017].
  11. Collins N, Litt J, Winzenberg T, Shaw K, Moore M. Plan your pandemic – A guide for GPs. Aust Fam Physician 2008;37:794–99, 802–04. [Accessed 21 March 2017].
  12. Patel MS, Phillips CB, Pearce C, Kljakovic M, Dugdale P, Glasgow N. General practice and pandemic influenza: A framework for planning and comparison of plans in five countries. PLoS One 2008;3:e2269. [Accessed 21 March 2017].
  13. Larsen EL, Liverman CT (eds). Preventing transmission of pandemic influenza and other viral respiratory disease: Personal protective equipment for healthcare personnel. Update 2010. Washington: National Academies Press, 2011. [Accessed 21 March 2017].
  14. Dominguez A, Castilla J, Godoy P, et al. Effectiveness of pandemic and seasonal influenza vaccines in preventing pandemic influenza-associated hospitalization. Vaccine 2012;30:5644–50. [Accessed 21 March 2017].
  15. Valenciano M, Ciancio B, I-MOVE study team. I-MOVE: A European network to measure the effectiveness of influenza vaccines. Euro Surveill 2012;17(39). pii:20281. [Accessed 21 March 2017].
  16. Kissling E, Valenciano M, I-MOVE Case-Control Studies Team. Early estimates of seasonal influenza vaccine effectiveness in Europe among target groups for vaccination: Results from the I-MOVE multicentre case-control study, 2011/12. Euro Surveill 2012;17(15). pii: 20146. [Accessed 21 March 2017].
  17. Barberis I, Martini M, Iavarone F, Orsi A. Available influenza vaccines: Immunization strategies, history and new tools for fighting the disease. J Prev Med Hyg 2016 57(1): E41-E46. [Accessed 21 March 2017].
  18. Garten RJ, Davis CT, Russell CA, et al. Antigenic and genetic characteristics of swine-origin 2009 A(H1N1) influenza viruses circulating in humans. Science 2009;325:197–201. [Accessed 21 March 2017].
  19. York I, Donis RO. The 2009 pandemic influenza virus: Where did it come from, where is it now, and where is it going? Curr Top Microbiol Immunol 2013;370:241–57. [Accessed 21 March 2017].
  20. Milne GJ, Halder N, Kelso JK. The cost effectiveness of pandemic influenza interventions: A pandemic severity based analysis. PLoS One 2013;8:e61504. [Accessed 21 March 2017].
  21. Nelson C, Lurie N, Wasserman J, Zakowski S. Conceptualizing and defining public health emergency preparedness. Am J Public Health 2007;97(1):S9–11. [Accessed 21 March 2017].
  22. Nori A, Williams MA. Pandemic preparedness – Risk management and infection control for all respiratory infection outbreaks. Aust Fam Physician 2009;38:891–95. [Accessed 21 March 2017].
  23. La Torre G, Semyonov L, Mannocci A, Boccia A. Knowledge, attitude, and behaviour of public health doctors towards pandemic influenza compared to the general population in Italy. Scand J Public Health 2012;40:69–75. [Accessed 21 March 2017].
  24. Godoy P, Castilla J, Delgado-Rodríguez M, et al. Effectiveness of hand hygiene and provision of information in preventing influenza cases requiring hospitalization. Prev Med 2012;54:434–39. [Accessed 21 March 2017].
  25. World Health Organization. Vaccines against influenza. WHO position paper. Geneva: WHO, 2012. [Accessed 21 March 2017].
  26. Department of Health. The Australian immunisation handbook. 10th edn. Canberra: NHMRC, Commonwealth of Australia, 2015. [Accessed 21 March 2017].
  27. Blank PR, Bonnelye G, Ducastel A, Szucs TD. Attitudes of the general public and general practitioners in five countries towards pandemic and seasonal influenza vaccines during season 2009/2010. PLoS One 2012;7:e45450. [Accessed 21 March 2017].
  28. Aguilar-Diaz Fdel C, Jimenez-Corona ME, Ponce-de-Leon-Rosales S. Influenza vaccine and healthcare workers. Arch Med Res 2011;42:652–57. [Accessed 21 March 2017].
  29. Carlson AL, Budd AP, Perl TM. Control of influenza in healthcare settings: Early lessons from the 2009 pandemic. Curr Opin Infect Dis 2010;23:293–99. [Accessed 21 March 2017].
  30. Bellia C, Setbon M, Zylberman P, Flahault A. Healthcare worker compliance with seasonal and pandemic influenza vaccination. Influenza Other Respir Viruses 2013;7 Suppl 2:97–104. [Accessed 21 March 2017].
  31. van der Sande MA, Jacobi A, Meijer A, Wallinga J, van der Hoek W, van der Lubben M. The 2009 influenza A (H1N1) pandemic. Management and vaccination strategies in The Netherlands. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013;56:67–75. [Accessed 21 March 2017].
  32. Devnani M. Factors associated with the willingness of health care personnel to work during an influenza public health emergency: An integrative review. Prehosp Disaster Med 2012;27:551–66. [Accessed 21 March 2017].
  33. Seale H, Ward KF, Zwar N, Van D, Leask J, Macintyre CR. Examining the knowledge of and attitudes to pandemic influenza among general practice staff. Med J Aust 2010;192:378–80. [Accessed 21 March 2017].
  34. Martin SD, Brown LM, Reid WM. Predictors of nurses’ intentions to work during the 2009 influenza A (H1N1) pandemic. Am J Nurs 2013;113:24–31. [Accessed 21 March 2017].
  35. Council of Australian Governments. National action plan for human influenza pandemic. Canberra: Department of the Prime Minister and Cabinet, 2009. [Accessed 19 April 2017].
  36. Bocquet J, Winzenberg T, Shaw KA. Epicentre of influenza – The primary care experience in Melbourne, Victoria. Aust Fam Physician 2010;39:313–16. [Accessed 19 April 2017].
  37. Fleming DM, Durnall H. Ten lessons for the next influenza pandemic – An English perspective: A personal reflection based on community surveillance data. Hum Vaccin Immunother 2012;8:138–45. [Accessed 19 April 2017].
  38. Sherlaw W, Raude J. Why the French did not choose to panic: A dynamic analysis of the public response to the influenza pandemic. Sociol Health Illn 2013;35:332–44. [Accessed 19 April 2017].
  39. State Emergency Management Committee Western Australia. Emergency preparedness report 2012. Government of Western Australia. West Leederville: SEMC, 2012. [Accessed 19 April 2017].
  40. Angione SL, Inde Z, Beck CM, Artenstein AW, Opal SM, Tripathi A. Microdroplet sandwich real-time rt-PCR for detection of pandemic and seasonal influenza subtypes. PLoS One 2013;8:e73497. [Accessed 19 April 2017].
  41. Jimenez-Garcia R, Hernández-Barrera V, Rodríguez-Rieiro C, et al. Hospitalizations from pandemic influenza [A(H1N1) pdm09] infections among type 1 and 2 diabetes patients in Spain. Influenza Other Respir Viruses 2013;7:439–47. [Accessed 19 April 2017].
  42. Paich HA, Sheridan PA, Handy J, et al. Overweight and obese adult humans have a defective cellular immune response to pandemic H1N1 Influenza A virus. Obesity (Silver Spring) 2013;21:2377–86. [Accessed 19 April 2017].
  43. Weeramanthri TS, Robertson AG, Dowse GK, et al. Response to pandemic (H1N1) 2009 influenza in Australia – Lessons from a state health department perspective. Aust Health Rev 2010;34:477–86. [Accessed 19 April 2017].
  44. World Health Organization. Avian influenza, including influenza A (H5N1), in humans: WHO interim infection control guideline for health care facilities. Geneva: WHO, 2006. [Accessed 19 April 2017].
  45. Lee A, Chuh AA. Facing the threat of influenza pandemic – Roles of and implications to general practitioners. BMC Public Health 2010;10:661. [Accessed 19 April 2017].
  46. Anikeeva O, Braunack-Mayer AJ, Street JM. How will Australian general practitioners respond to an influenza pandemic? A qualitative study of ethical values. Med J Aust 2008;189:148–50. [Accessed 19 April 2017].
  47. Apolloni A, Poletto C, Colizza V. Age-specific contacts and travel patterns in the spatial spread of 2009 H1N1 influenza pandemic. BMC Infect Dis 2013;13:176. [Accessed 19 April 2017].
  48. National Health and Medical Research Council. Australian guidelines for the prevention and control of infection in healthcare. Canberra: NHMRC, 2010. healthcare_140616.pdf [Accessed 1 May 2017].
  49. Hall GG, Perry AG, vanDijk A, Moore KM. Influenza assessment centres: A case study of pandemic preparedness to alleviate excess emergency department volume. CJEM 2013;15:1–8. [Accessed 1 May 2017].
  50. Pearce C, Shearer M, Phillips C, et al. Views of GPs and practice nurses on support needed to respond to pandemic influenza: A qualitative study. Aust Health Rev 2011;35:111–15. [Accessed 1 May 2017].
  51. Etingen B, LaVela SL, Miskevics S, Goldstein B. Health information during the H1N1 influenza pandemic: Did the amount received influence infection prevention behaviors? J Community Health 2013;38:443–50. [Accessed 1 May 2017].
  52. Tooher R, Collins JE, Street JM, Braunack-Mayer A, Marshall H. Community knowledge, behaviours and attitudes about the 2009 H1N1 Influenza pandemic: A systematic review. Influenza Other Respir Viruses 2013;7:1316–27. [Accessed 1 May 2017].
  53. Earnshaw VA, Quinn DM. Influenza stigma during the 2009 H1N1 pandemic. J Appl Soc Psychol 2013;43:e109–14. [Accessed 1 May 2017].
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log