Preparing to manage cases of pandemic influenza
GPs play a major role in influenza epidemics and pandemics. Most people with an influenza-like illness are treated in general practice or by primary care doctors on duty in out-of-hours services.6
All staff need to be able to identify patients with possible influenza and institute the necessary alerts and patient management protocols. General practices may be the first to see a suspected pandemic influenza case.
Laboratory diagnosis is important in the early phase of a pandemic to determine the strain of influenza. Clinical staff need to know the processes of confirming cases of pandemic influenza, such as swab collection protocol. Discuss with the local pathology laboratory what processes the clinic staff need to know. This will include a review of collection and referral processes.
Point-of-care testing may become more useful as current technology (eg real-time polymerase chain reaction assays40) become more widely available and cost effective. If point-of-care testing is to be used, staff will need training in collecting samples and running the test.
Clinical staff should demonstrate an understanding of the roles of seasonal, candidate and customised pandemic vaccines during a pandemic, as well as the role of antiviral medication.
During a pandemic, clinical staff may be required to deliver vaccinations from a multidose vial. The pandemic coordinator needs to ensure that the pandemic plan includes policies around safe delivery of vaccines from a multidose vial. Guidelines for the use of multidose vials will be released by the Department of Health and the RACGP during the pandemic. The policies should consider principles of infection control, cold chain, anaphylaxis and cross-contamination.
Preparing to manage vulnerable groups and patients with comorbidities
General practices will need to manage much more than influenza during a pandemic. Patients who might otherwise be managed in hospital or at other specialist facilities may not be able to access medical care as usual during a pandemic for reasons of increased caseload, quarantine or travel restrictions.
Certain patient groups are at higher risk. This might include people with chronic disease, Aboriginal and Torres Strait Islander peoples, people who take immunosuppressive medication, overweight and morbidly obese patients,41,42 pregnant women and young children.43
Practices will need to identify at-risk patients and develop strategies to prevent infection and manage concurrent illnesses and conditions, should infection occur.
It will be important to ensure patients taking medications for chronic conditions have adequate supplies. This may mean providing prescriptions for more medication or organising alternative methods for repeat prescriptions.
Other healthcare providers such as antenatal and maternal health clinics and Aboriginal Health Services may not be able to provide patient care during a pandemic.
Practices could consider using telehealth services or phone consultations with other providers (eg other specialists and allied healthcare providers such as psychologists) to ensure continuity of care.
Preparing to manage patients at home
All practices should have a policy for the management of home visits. This should include:
- how the practice identifies its ability and willingness to provide patients with home visits during a pandemic
- under what circumstances and in what geographical area the practice will perform home visits
- which practice staff will attend to home visits (eg doctor or practice nurse)
- what equipment and PPE supplies will be required for a home visit bag
- how to manage disposal of clinical waste
- who will be responsible for checking and restocking the home visit bag
- how details will be recorded in the patient file.
The role of antivirals (if any) will be established once a pandemic has emerged and more knowledge is gained as to the particular virus strain.
The benefits and risks of antivirals in treating pandemic influenza should be carefully considered. Antiviral drugs given after patients show influenza symptoms may lessen symptoms and shorten the time of illness by one to two days. Antiviral drugs can have side effects and can become ineffective. There are also ethical considerations around the use of antivirals; for example, if antivirals are in limited supply, who should receive them?
During a pandemic, practices are advised to refer to the AHMPPI produced by the Department of Health for recommended treatment options.
The Australian Government has developed a stockpile of antivirals to be used in the event of a pandemic. The WHO and Australian Government will provide advice regarding recommended treatment options.
Generally, whether or not antivirals are used depends on:
- the likelihood that an individual with pandemic influenza disease will experience a medical benefit if provided antiviral medication1
- the effectiveness of antivirals in preventing infection (including any evidence of antiviral resistance)
- the effectiveness of candidate and customised pandemic vaccine
- the protection offered by natural infection
- the availability of resources
- the anticipated length of time until the customised pandemic vaccine will become available.
During a pandemic, practices can obtain up-to-date information regarding new antiviral medications from state and territory health departments, the Department of Health and the RACGP.
Pandemic influenza vaccination
Pandemic influenza vaccination is unlikely to be available early in an outbreak. It is recommended that practices implement a system for checking with the Department of Health and state and territory health departments when a vaccine becomes available for distribution, as well as immunisation strategies.11
It is important to know where and how to order supplies and any security issues for storage. Practices should consider their storage capacity for vaccines. If practices do not have capacity, it is suggested that they explore alternatives for safely storing and transporting vaccines within the safe temperature range of +2 °C to +8 °C (ensuring cold chain management).
A vaccine that gives good protection against a pandemic influenza virus can only be developed after the new strain of virus appears. It may take several months to produce a specific vaccination (called a customised pandemic vaccine) and initially it will be in short supply.
Early in a pandemic, a candidate pandemic vaccine may be used. Candidate vaccines are based on a viral strain thought to have ‘pandemic potential’. The virus strain from which these types of vaccines are made is unlikely to be an exact match to the strain that eventually causes the pandemic. However, they may provide enough crossprotection (or ‘priming’ of the immune system) to prevent infection, decrease the severity of illness or reduce the number of doses of customised vaccine required.
The use of seasonal influenza vaccine can reduce the incidence of circulating seasonal influenza virus. This means that the risk of diagnostic confusion and demands on the health system during a pandemic may be reduced. When a pandemic arrives in Australia, the availability of seasonal influenza vaccine may be limited. At this stage it will be necessary to prioritise the remaining stocks of seasonal influenza vaccine to high-risk groups.
Systems for data collection
During the planning stage, the pandemic leader should be responsible for establishing and maintaining systems to collect influenza data within the practice. The pandemic leader should also ensure other clinicians and practice staff are educated about the process for collection of this data. Data collected will help provide an overall picture of affected areas and identify high-risk areas. This information may also help to assess if current supplies are adequate and if additional supports are required.
The RACGP and the Australian Government would like to see a system where adequately resourced general practices use the appropriate coding in their practice software to flag patients with influenza-like symptoms. During the standby stage, it is suggested that practices use this data to create weekly reports which are de-identified (only numbers are required) and report to their RACGP state/territory faculty office on a weekly basis. The faculty can then collate this information and report to the relevant state or territory health department, who would report to the Federal Government.
Infection prevention and control outside the practice
Practices need to ensure that provisions for these precautions are made for patients seen offsite (ie in home visits or visits to residential aged care facilities). Home visit kits must be appropriately stocked to manage patient needs and staff protection (eg with clinical waste disposal equipment).
Personal protective equipment
PPE is a first line of defence against the spread of viral infection, and an integral component of quality healthcare.13,44
What PPE is required?
PPE is not a substitute for hand hygiene and cough etiquette and should be used in conjunction with individual, organisational and environmental measures.
The SARS outbreak demonstrated the importance of basic infection control precautions in healthcare facilities. Failing to take standard precautions can lead to transmission of disease.44
Communicating with staff about PPE
All members of the practice team should be informed that PPE is available and where it is stored, as availability of PPE may influence the likelihood of work attendance during a pandemic.32
Staff should know how to order more supplies and should establish contingency plans where primary sources become limited.
These communications might include:
- ensuring staff and patients understand how to put on, take off and dispose of PPE
- scheduling a team meeting and getting staff to fit and check P2/N95 masks
- consulting with local state or territory health departments about access to potential stockpiles, or communicating with alternative sources of PPE (eg veterinary hospitals).
The PPE appropriate for a pandemic includes:
- disposable plastic aprons
- surgical masks
- P2/N95 masks (respirators)
- face shields
Disposable PPE should be used because the influenza virus can remain infectious on surfaces for long periods of time.
General principles for PPE selection and use are that PPE should be:13
- appropriate to the occupational risk
- acceptable and usable by healthcare personnel in their daily tasks
- practical regarding issues of cost, time and training to use.
From a patient perspective, approaching someone wearing PPE can be very confronting. The use of PPE should aim to minimise negative interaction with or effects on patients and their families.13
Past events indicate that during a pandemic there is an increased demand for PPE, often resulting in a shortage of essential equipment. Where possible, practices should have appropriate stocks of clinical and non-clinical supplies to ensure continued provision of essential patient services and staff safety in the event of a pandemic.
How much PPE should a general practice have in stock?
Practices are responsible for sourcing and providing PPE for staff and patients within the practice. While there is a medical stockpile of PPE held by the national, state and territory governments, supplies are limited and access to the stockpiles should not be assumed.
Practices might consider maintaining a supply of hand-hygiene products, tissues and PPE for staff for the duration of a pandemic wave (approximately four weeks). This may be costly, so practices should factor this in during their preparations.
Practices need to consider if they have sufficient storage space to house the PPE. If necessary, they may consider relying on existing networks (eg a local pharmacy) to store supplies until required.
Stocks need scheduled checks, as some items are perishable. For example, P2/N95 masks have perishable elastic and an expiry period of five to seven years.