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Clinical guidelines

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

Influenza prevention

Author Dr Penny Abbott 
Expert reviewer Professor Anne Chang


Influenza is a common respiratory disease caused by influenza A and B viruses. These viruses cause minor or major epidemics of seasonal influenza in most years, usually during the winter months. 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 people 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.3,26,27 There are calls for Aboriginal and Torres Strait Islander people to be acknowledged as a high risk group requiring specialised planning to manage future influenza outbreaks.28 

The consequences of influenza in children and healthy adults at low risk are mainly absenteeism from school and work. However, severe disease is more likely with advanced age, lack of previous exposure to antigenically related influenza virus, chronic conditions such as heart or lung disease, renal failure and diabetes, chronic neurological conditions, pregnancy and smoking.2,29


Administration of the current influenza vaccine before winter, provides protection against the disease and its complications in up to 70% of those who are vaccinated.27 Immunisation should be given annually, preferably in March to April before the Australian flu season.2 

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.30 

Recommendations for vaccination of all individuals over 65 years of age and all individuals over the age of 6 months with chronic disease is made on the basis of the higher risk of hospitalisation and complications from influenza in these groups.2,31–33 As yet there is limited and conflicting evidence on the effectiveness of influenza vaccination for people aged 65 years and over and for many groups of people with chronic disease,30,34–36 though the evidence is clearer that influenza vaccination is effective in decreasing complications in COPD23,37 and diabetes.38,39

Influenza vaccination has been found to be effective in reducing infection in children.29,40–42 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 under the age of 5 years, however the Therapeutic Goods Administration and the Australian Technical Advisory Group on Immunisation continued to recommend other brands of seasonal influenza vaccine for children for whom it was indicated.31 There is as yet limited evidence that influenza immunisation for healthy children leads to a reduction in community transmission of influenza.29,43 Influenza vaccination during pregnancy is recommended based on the increased morbidity and mortality of pregnant women who contract influenza, coupled with no evidence of harm from immunisation in pregnancy.2,44

Australian guidelines recommend annual influenza vaccine should be given to all Aboriginal and Torres Strait Islander people aged 15 years and over in view of their substantially increased risk of hospitalisation and death from influenza and pneumonia.2 Effective strategies to promote influenza immunisation should be undertaken at a community level, particularly the use of recall and reminder systems,20,25,33,45 and should be tailored to the needs of the community concerned.

Infection control measures such as handwashing, particularly with young children, can be effective in preventing transmission of influenza.46 Healthcare providers can potentially transmit influenza to high risk patients and it has been shown that vaccinating the former protects those at high risk.2,47 Implementing barriers to transmission, such as isolation, and hygienic measures (wearing masks, gloves and gowns) can be effective in containing respiratory virus outbreaks or in hospital wards.46 The more expensive (but uncomfortable) N95 respirators might be superior to simple masks. It is unclear if adding virucidals or antiseptics to normal handwashing with soap is more effective.46 

Two classes of antiviral drugs are available for the treatment and prevention of influenza: the neuraminidase inhibitors, zanamivir and oseltamivir, which are active against both influenza A and B; and the adamantanes, amantadine and rimantadine, which are only active against influenza A.27 The neuraminidase inhibitors (NIs) oseltamivir (taken orally) and zanamivir (inhaled) are approved for use in Australia for the treatment and prevention of influenza A and B.48,49 Systematic reviews on the effectiveness of NIs for influenza prophylaxis in inter-pandemic years have come to conflicting conclusions. They generally show limited effectiveness in preventing influenza infection, its transmission and its complications in otherwise healthy adults.50,51 Consequently NIs are not recommended for the prevention of influenza in healthy adults.27,48,50,51 They may, however, have a role in the prophylaxis of at risk contacts of people with influenza, particularly during pandemics.27,50 Studies of post-exposure prophylaxis for 10 days have enrolled patients within 36–48 hours of exposure to a household contact, and have demonstrated a protective efficacy of 78–89% compared with expectant treatment at the onset of symptoms.48

The decision to use NIs for prevention of influenza in at risk individuals depends on the assessment of the likelihood of influenza, the likely benefits of treatment based on the presence of comorbidities and the risk of developing complications. Treatment must be initiated early in order to maximise efficacy.48,50 When initiated promptly, antiviral therapy can shorten the duration of influenza symptoms by 1–3 days; the benefit is greatest when given within the first 24–30 hours and in patients with fever at presentation. Little to no benefit has been demonstrated when treatment is initiated 2 days or more after the onset of uncomplicated influenza.

The availability of antiviral drugs, including public health policies regarding the distribution of the national stockpile, is also taken into consideration in a pandemic situation.48 Post-exposure prophylaxis with NIs continues to be recommended for vulnerable Aboriginal and Torres Strait Islander household contacts during influenza outbreaks within communities.52 

Recommendations: Influenza prevention
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation All people aged ≥15 years Offer influenza vaccine in the pre-flu season months for the prevention of influenza (March to April) Annually GPP2
Children with chronic illness aged 6 months to 14 years Annually IIC2,11,31
Women who are pregnant or planning a pregnancy Part of routine antenatal care (see Chapter 9: Antenatal care) IIB2,44
Healthcare providers Annually GPP2,47
Children under 6 months of age Influenza vaccination is not recommended N/A GPP2
Behavioural Household contacts of a person with influenza Good hygiene practice, such as frequent handwashing and covering the mouth on coughing or sneezing, is recommended to decrease the spread of influenza, particularly to reduce transmission from children to other household members Opportunistic IIIC46
Healthcare workers Minimise exposure risk to patients with influenza-like illness by adhering to current infection control guidelines
In addition to standard infection control procedures, personal protective equipment is recommended during influenza pandemics48,53
Chemoprophylaxis Healthy adults Neuraminidase inhibitors (NIs) are generally not indicated for the prevention of influenza N/A IIB50,51
People at high risk of influenza complications, where there are high levels of circulating virus Consider NIs for high risk individuals in close contact with someone with a proven case of influenza (ideally initiated within 48 hours), particularly in a pandemic situation or where there is high levels of circulating virus Opportunistic GPP27,50,52
Environmental N/A Primary care, community based strategies to improve vaccination levels, particularly using reminder/recall systems, should be implemented N/A IB20,25,33,45
Communities Activities should also focus on increasing community awareness of benefits and timeliness of vaccines for vaccinations and enhancing access to vaccination services


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