Managing pandemic influenza in general practice

A guide for preparation, response and recovery
6.6 Clinical management and comorbidities
☰ Table of contents

6.6.1 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. GPs need to know how to investigate and what to do with a suspected 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 (eg. electronic communications).

Point-of-care testing may become more useful as current technology (eg. real-time polymerase chain reaction assays45) 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.

6.6.2 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 other medical attention during a pandemic for reasons of increased caseload, quarantine or travel restrictions.

Certain patient groups are at higher risk – those with underlying chronic disease (eg. type 2 diabetes, COPD, cardiovascular disease), Aboriginal and Torres Strait Islander patients, patients taking immunosuppressive medication, overweight and morbidly obese patients46,47, pregnant women and young children.48

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.

Consider that other healthcare providers (eg. antenatal and maternal health clinics, 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.

6.6.3 Preparing to manage patients at home

The practice also needs a policy for the management of home visits. This should cover:

  • 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 will the practice 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.

6.6.4 Antivirals

In any given pandemic, 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.

There are ongoing discussions regarding the efficacy of antivirals in treating pandemic influenza. During a pandemic, practices are advised to refer to the AHMPPI produced by the Department of Health for recommended treatment options.

Antiviral drugs given after patients show influenza symptoms may lessen symptoms and shorten the time of illness by 1–2 days. Antiviral drugs can have side effects and can become ineffective. Hence, the benefits and risks need to be carefully considered. There are also ethical considerations around the use of antivirals; for example, if antivirals are in limited supply, who should receive them.

If antivirals were given for pre-exposure prophylaxis, they would only be provided to healthcare workers who have continuous frontline exposure to infectious cases.

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 they 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), therefore transmission of infection
  • 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.

6.6.5 Pandemic influenza vaccination

Although pandemic influenza vaccination is unlikely to be available early in an outbreak, have a system of checking with the Department of Health and state and territory health departments about when a vaccine does become available for distribution, as well as immunisation strategies.12

Practices need to know where and how to order supplies and any security issues for storage. Practices should also consider their storage capacity for vaccines. If practices do not have capacity, it is suggested that they explore alternatives for safely storing vaccines and ensure that cold chain management principles are observed.

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 cross-protection (or ‘priming’ of the immune system) to, in some people, 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 and therefore the risk of diagnostic confusion and demands on the health system during a pandemic. 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-risks groups.

6.6.6 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 is also responsible for educating other clinicians and practice staff about the processes in place to collect this information. The data collected from the established symptoms will help provide an overall picture of affected areas (state and territory) and identify if there are any hot spots. This information may also help the government assess if current supplies are adequate and if additional supports are required.

The proposed system is that all year round, clinicians use the appropriate coding (as per 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 Commonwealth. 

  1. World Health Organization. Pandemic influenza risk management: WHO interim guidance. Geneva: WHO, 2013.
  2. Simonsen KA, Hunskaar S, Sandvik H, Rortveit G. Capacity and adaptations of general practice during an influenza pandemic. PLoS One 2013;8:e69408.
  3. Collins N, Litt J, Winzenberg T, Shaw K, Moore M. Plan your pandemic – guide for GPs. Aust Fam Physician 2008;37:794–99, 802–4.
  4. 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.
  5. 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.
  6. 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.
  7. 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.