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Interim National Pandemic Infl uenza
Management Plan for
ISBN: 0 642 82886 5 Online ISBN: 0 642 82887 3 Publications Approval Number: 3816 Commonwealth of Australia 2006 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney General's Department, Robert Garran Offices, National Circuit, Canberra ACT 2600 or posted at http://www.ag.gov.au/cca Commonwealth of Australia 2006 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney General's Department, Robert Garran Offices, National Circuit, Canberra ACT 2600 or posted at http://www.ag.gov.au/cca These guidelines will evolve over time, as new information becomes available on the epidemiological and clinical characteristics of the disease. Readers are advised to visit the Department of Health and Ageing website www.health.gov.au to ensure that they have access to the most current and up to date version. While this document includes guidance for those involved in providing patient care, readers should note that the information contained in the plan is not a substitute for, and is not intended to replace, independent professional advice. The Commonwealth of Australia does not accept any legal liability or responsibility for any injury, loss or damage incurred by the use of, or reliance on, or interpretation of the information contained in this plan.
INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES AUSTRALIAN GOVERNMENT DEPARTMENT OF HEALTH AND AGEING This document contains guidance primarily for health professionals regarding the assessment and management of avian and pandemic influenza patients, agreed by experts from a clinical working group of the National Influenza Pandemic Action Committee. It covers treatment in hospitals and the community, of both adults and children, but may need to be adapted for use in different settings. It is intended for use in Australia throughout the pandemic alert and pandemic periods (i.e., from phase Overseas 3 onwards).
Appendix A contains information to be used by the general public, to guide them in how to look after themselves in the event of a pandemic (phase Australia 6), including some preparative steps and information that will be useful during the pandemic alert period (i.e., from phase Overseas 3 onwards). This material may be given to patients by health care professionals or the general public may access it of their own accord.
REQUEST FOR FEEDBACK Pandemic planning is an ongoing activity. These clinical guidelines, including Appendix A, will need frequent revision to incorporate new information on the clinical and epidemiological features of the virus and local arrangements for access to medical care. Submissions and comment are invited and will contribute to future versions of the guidelines. These should be forwarded to: National Influenza Clinical Guidelines
Office of Health Protection Department of Health and Ageing Canberra ACT 2601 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) TABLE OF CONTENTS Authors and acknowledgements
Abbreviations and acronyms
I. Purpose and scope I . Varying approach through the phases IV. Ethical and staffing chal enges V. Psychosocial and mental health aspects Part One: General approach to assessment and management of patients
1.1 Epidemiology and clinical features
1.1.2 Epidemiology 1.1.3 Case definitions 1.1.4 Symptoms of influenza 1.1.5 Signs of influenza 1.1.6 Atypical presentations 1.1.7 Risk factors/exposures 1.1.8 Complications of influenza 1.1.9 The effect of co-morbidity 1.1.10 Severity of il ness/prognosis 1.1.11 Differential diagnosis 1.2 Investigations
1.3 Management
1.3.1 General principles 1.3.2 Antiviral medications Table 1: Antiviral medications Table 2: Side effects of antiviral medications Table 3: Antivirals during pregnancy Table 4: Antivirals during breastfeeding 1.3.3 Infection control 1.3.4 Vaccination 1.3.5 Psychosocial and mental health aspects 1.3.6 Public health aspects 1.3.7 Where to manage the patient 1.3.8 If discharged home Part Two: Assessment and management tools
2.1 Introduction
2.2 Screening in general practice
2.3 Screening in ambulance setting
2.3.1 Screening at point of call (i.e. cal s received at 000) 2.3.2 Screening when attending a patient 2.3.3 Communication. 2.4 Algorithms for use in assessment centres, general practice and emergency
departments
2.4.1 Notes on assessment algorithms Algorithm 1 Guidelines for primary/initial assessment of adult patients Algorithm 2 Guidelines for secondary/further assessment of adult patients Algorithm 3 Guidelines for assessing children in general practice or other primary/initial assessment centre Algorithm 4 Guidelines for secondary assessment of children in the emergency department or other secondary assessment centre 2.5 Draft forms for use in assessment centres
2.5.1 Primary/initial assessment centre 2.5.2 Secondary/further assessment centre Part Three: Resources for health professionals
3.1 Useful numbers for health professionals
3.2 Reading list
3.3 Useful websites
Appendix A: Information for the general public—looking after yourself in a pandemic
A.1 Staying well
A.1.1 Be informed about influenza A.1.2 Protect yourself against influenza A.1.3 Plan ahead A.2 When unwell
A.2.1 Is it the flu? A.2.2 What can you do for yourself? A.2.3 What to expect A.2.4 When to seek medical attention A.2.5 When a child is unwell A.3 Useful numbers for the general public
INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) AUTHORS AND ACKNOWLEDGEMENTS The Interim ‘National Pandemic Influenza Clinical Guidelines' have been developed by a working group of the National Influenza Pandemic Action Committee (NIPAC). NIPAC Core Group have endorsed this document. Members of the working group were: Dr Dominic Dwyer (Chair) NIPAC Core and Australasian Society for Infectious Diseases NIPAC Core and Faculty of Public Health Medicine Australia Dr Charlie Corke Joint Faculty of Intensive Care Medicine Royal Col ege of Nursing Australia Professor David Isaacs Australasian Col ege of Physicians Associate Professor Phil Jones Australasian Society of Infectious Diseases Associate Professor Tom Kotsimbos The Thoracic Society of Australian and New Zealand Convention of Ambulance Authorities Royal Australian Col ege of General Practitioners Dr Andrew Maclean Australasian Col ege for Emergency Medicine Ms Irene Wilkinson Australian Infection Control Association Department of Health and Ageing Department of Health and Ageing The working group would like to acknowledge the fol owing valuable sources of information on the clinical care of pandemic influenza, which were used as the basis for these guidelines:• Canadian Pandemic Influenza Plan, Clinical Care Guidelines and Tools• NSW draft pandemic influenza clinical guidelines.
Thanks also to Professor Beverley Raphael, Professor Ian Spence, Professor Ian Gust, Dr Paul Armstrong, Dr Ann Koehler, Dr Graham Tal is and others who have contributed. Additional reference materials are found in the Reading List.
ABBREVIATIONS AND ACRONYMS arterial blood gas acquired immuno-deficiency syndrome adult respiratory distress syndrome Aboriginal and Torres Strait Islander creatinine kinase-MB central nervous system electrolytes, urea, creatinine General Practitioner healthcare workers human immunodeficiency virus intensive care unit liver function tests National Medicines Stockpile polymerase chain reaction Public Health Unit personal protective equipment respiratory syncytial virus World Health Organization INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) PURPOSE AND SCOPE These guidelines are written from the national perspective, and are intended to be adapted for use in varying health care settings across Australia. They are intended to be used throughout the pandemic alert and pandemic phases. The different phases leading up to and including the pandemic are listed in the Australian Health Management Plan for Pandemic Influenza 2006.
Logistic and operational issues, such as the use of influenza-specific hospitals, fever clinics or other facilities, are being further considered at the jurisdictional and local level. The principle of keeping influenza patients separated from non-influenza patients in the interests of reducing spread of the virus is supported.
The management of patients with pandemic influenza is complicated by the uncertainty that may exist about the clinical and epidemiological features of a newly emergent influenza virus, the wide spectrum of clinical presentations in different age groups, the largely non-specific nature of the initial signs and symptoms of influenza, and the need for different approaches to management during the different phases of a pandemic.
As new information becomes available on the clinical and epidemiological characteristics of the disease these guidelines will be updated.
II. VARYING APPROACH THROUGH THE PHASES It is impossible to predict which strain of influenza A will cause the next pandemic. It is not certain that the H5N1 avian influenza virus that re-emerged in Asia in December 2003 and has since spread widely will be responsible.
Although there are many crucial differences between a pandemic influenza virus and the H5N1 avian influenza virus that is currently causing sporadic human infections (the most important being that the current H5N1 virus does not transmit effectively between humans whereas a pandemic influenza virus does), the mainstays of management of individual patients are expected to be similar. Therefore, these guidelines have been developed for the care of patients infected with an avian influenza or pandemic influenza virus. Where there are differences (e.g., case definitions, use of antivirals and laboratory testing), they are outlined.
The aim of the Australian response to pandemic influenza in the early phases is to contain the spread of the virus. Along with the judicious use of antiviral medications, crucial strategies for containing the spread of the virus are detection and isolation of cases, identification and monitoring of contacts, strict adherence to infection control precautions, and in some instances, measures such as quarantine to restrict the movement of potential y infected persons. If transmission can be slowed, the impact on health services may be reduced and more time made available for the production of a pandemic vaccine.
Once a pandemic is established, because containment may not be as effective a strategy and may not be feasible due to the large numbers of cases, the strategy may change to maintenance of social function.
Different approaches to the assessment and management of cases may be needed depending upon the phase of the pandemic because of the need to try to contain the spread of the virus in the early phases, the varying case and exposure definitions during the different phases, the differential approach to the use of antiviral medications and diagnostic testing according to the phase of the pandemic. For example, before the pandemic strain enters Australia (or when the first few cases occur), very sensitive and specific diagnostic testing of all suspected and confirmed cases will be important. In contrast, in an area of high known pandemic activity, clinical diagnosis alone may suffice for most cases. In the early phases of a pandemic that originates overseas, a travel history would be required to raise the suspicion of the diagnosis, whereas later, symptoms and signs would be sufficient. In all phases, known contact with proven or suspect cases will be an important clinical feature.
More importantly, when the number of cases in Australia increases, measures such as the use of negative pressure isolation rooms and contact tracing may not be achievable. In these later phases, healthcare workers (HCWs) will need to do the best that is possible given the available resources. An influenza pandemic will not be ‘business as usual' for health services in Australia. Staff will be required to work flexibly to meet increased demands and usual clinical and infection control practices may need to be altered to accommodate the exceptional circumstances.
Parts one to three of these guidelines are intended to be used by health professionals, or others that may be required to assess and triage patients in the event of a pandemic. Appendix A is intended to be used by the general public and could be the basis of general educational materials.
Part one is a general approach to the assessment and management of suspected and confirmed pandemic influenza patients for use throughout the various phases of the pandemic.
Part two consists of some assessment and management tools that can also be applied throughout the phases, but will be particularly relevant when the pandemic has been declared in Australia (roughly from phases Aus 6a onwards) when the demand for services is high and large numbers of people are being triaged quickly and potential y by people with minimal experience.
Part three contains information resources for health professionals, including the contact numbers for public health units.
Appendix A contains information intended to be used by the general public to guide them in how to look after themselves in the event of pandemic, including some preparative steps and information about pandemic influenza that will also be useful now. When transmission is widespread in Australia and disease is common, people whose il ness is less severe and who are otherwise in good health will be best cared for in the home. Appendix A may be given to patients by health care professionals or it may be accessed directly by the general public.
IV. ETHICAL AND STAFFING CHALLENGES During a pandemic, HCWs are likely to be faced with many chal enging situations because of the large increase in workload. Ethical dilemmas may arise as HCWs balance the responsibilities they have to their patients, their own health and that of their families. All institutions and private practices need to consider how to deal with these chal enges ahead of time and work on solutions to staff concerns or possible shortages (e.g., pooling resources local y for private practices). Clear communications strategies and effective and reliable information flows will be needed for HCWs.
V. PSYCHOSOCIAL AND MENTAL HEALTH ASPECTS All those working in response to a potential or actual pandemic are likely to have concerns. Many wil , quite natural y, feel anxious as they face the joint tasks of limiting and containing the spread of disease, and treating those individuals directly affected. Individuals and families may become quite fearful about the risk of becoming infected, about how they will manage their sickness and the consequences if they INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) do, and the potential threat to life if the condition is severe. It is helpful to acknowledge concerns, to highlight information available, answer queries honestly, and offer supportive advice if this is required.
Strategies that HCWs can utilise in responding to the psychosocial and mental health aspects of pandemic influenza are outlined in Part 1.3.5 Psychosocial and mental health aspects. The information contained in this section may be useful for HCWs, both personal y and in providing care to their patients.
10 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 1.1 EPIDEMIOLOGY AND CLINICAL FEATURES 1.1.1 Aetiology Pandemic influenza is caused by a subtype of the influenza A virus that has not circulated in the human population in recent times, and is capable of causing severe disease and spreading easily from human It is impossible to predict the exact behaviour of a newly emergent virus. The fol owing features are a. Attack rates
For planning purposes, the WHO advises that national plans are based on a cumulative clinical attack rate in the community of 25% but this may vary widely.
Whereas seasonal influenza often more severely affects the very young and the elderly, pandemic strains have the potential to affect all age groups.
For further information on infection control see the latest version of the Interim Infection Control Guidelines for Pandemic Influenza in Healthcare and Community Settings, Annex to the Australian Health Management Plan for Pandemic Influenza.
When influenza viruses pass from human to human, as is the case with the normal human seasonal influenza, they are transmitted by contact with virus-containing respiratory droplets or droplet nuclei, produced by coughing, sneezing, talking or procedures such as suctioning or bronchoscopy.
The three potential modes of the spread of the virus are:1. Droplet: Droplet transmission occurs when large (greater than or equal to five micrometres) droplets are generated, propel ed a distance of about one metre and deposited on the mucous membranes (mouth or nose) or conjunctivae of another person 2. Contact: Direct contact transmission occurs when the virus comes into contact with a person's hand and then that person touches his or her mouth, nose or eyes (self-inoculation). Direct contact transmission can also occur when skin-to-skin contact results in the physical transfer of the virus (e.g., kissing). Indirect contact transmission occurs when the virus is transferred to a person's eyes, mouth or nose after coming into contact with a contaminated object such as a pen or cup 3. Airborne: When smal er (less than five micrometres) droplets or dust particles containing the infectious agent are produced (e.g., from the evaporation of water from larger droplets) they may remain suspended in the air, dispersed by air currents, and may be inhaled by a person who is some distance (e.g., in the same room) from the source patient.
The relative importance of these three modes of transmission are not certain, although it appears that droplet and contact transmission are the most important. There is no evidence to support the notion that influenza can be transmitted through ventilation systems (refer to Part 3.2: reading list).
12 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) The H5N1 avian influenza virus that re-emerged in Asia in December 2003 and has since spread widely, is usual y transmitted to humans via direct contact with infected poultry, or surfaces contaminated by their secretions. It is possible that contact with raw contaminated poultry products, including blood, may be a source of transmission. It is probable that the current H5N1 subtype has been transmitted sporadical y from human to human in a limited manner after very close and prolonged contact with a person suffering from the disease and without the use of appropriate precautions (refer to Part 3.2: reading list).
d. Incubation period
Human influenza usual y has a short incubation period of one to three days. The incubation period for avian H5N1 influenza may be longer; most cases have occurred within two to four days of exposure, although the range has been up to eight days. For the purpose of these guidelines, an incubation period of seven days will be assumed but this may be altered in light of what is learnt of the epidemiology of the disease early in the pandemic.
e. Period of communicability
Approximately seven days from the onset of symptoms for those greater than 12 years, 14 days for school aged children less than or equal to 12 years and 21 days for pre-school aged children. Individuals may be infectious from 24 hours before the onset of symptoms. The risk is greatest during the period that the patient is symptomatic (e.g., coughing and sneezing).
1.1.3 Case definitions When influenza is circulating in the community, the presence of fever, cough and fatigue are good predictors of influenza, especial y when the temperature is greater than 38 degrees Celsius and the onset of il ness is acute.
Box 1: Provisional clinical case definition for phase Overseas 3
(avian influenza affecting humans)
A high index of suspicion should be maintained during the assessment of any patient with an acute, febrile, respiratory il ness who has recently been overseas.
Suspected H5N1 avian influenza: Fever > 38 degrees Celsius, cough and fatigue of acute onset, One of the fol owing exposures within seven days of symptom onset: a. Contact with a confirmed case of influenza A (H5N1) during the infectious period ORb. Visit to a poultry farm or other poultry contact in an area known to have outbreaks of influenza A (H5N1) ORc. Having worked in a laboratory that is processing samples from persons or animals that are suspected to have influenza A (H5N1) infection.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 13 Because the clinical and epidemiological features may vary during the different phases, an accurate case definition for influenza caused by a pandemic strain cannot be made until the pandemic commences. Below is a provisional case definition for pandemic influenza.
Box 2: Provisional clinical case definition when pandemic influenza is circulating
Suspected influenza: Presence of fever, cough and fatigue of acute onset.
Probable influenza: Fever > 38 degrees Celsius, cough and fatigue of acute onset History of exposure to person with pandemic influenza Note that this case definition will be adjusted at the time the virus is circulating in Australia Likewise, laboratory case definitions cannot be determined in advance. However, the laboratory case definition for avian or pandemic influenza is likely to be similar to that used for seasonal influenza which is shown below. Nucleic acid testing on respiratory tract samples for the pandemic strain is likely to be the most widely available test for early diagnosis.
Box 3: Laboratory case definition for seasonal influenza
1. Isolation of influenza virus by culture from appropriate respiratory tract specimen 2. Detection of influenza virus by nucleic acid testing from appropriate respiratory tract specimen 3. Detection of influenza virus antigen from appropriate respiratory tract specimen 4. IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to influenza virus 5. Single high titre to influenza virus.
Note that this case definition will be adjusted at the time the virus is circulating in Australia 14 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 1.1.4 Symptoms of influenza Abdominal pain (mainly Convulsions in children and elderly).
Stuffy or runny nose Meningism (mainly in children).
Muscle and joint pains. Shortness of breath Pleuritic chest pain Retrosternal pain Sputum production and in children).
1.1.5 Signs of influenza• Fever• Tachypnoea• Respiratory distress• Tachycardia• Postural drop in blood pressure• Cyanosis• Chest crackles• Wheeze• Consolidation• Confusion.
1.1.6 Atypical presentations The very young and elderly, pregnant women, or the immunosuppressed, may not present with the usual signs and symptoms of influenza, and require special attention in assessment. They may not necessarily have to meet the provisional case definition to be considered as a possible case of pandemic influenza (see Box 4: Special considerations in the young, Box 5: Special considerations in the elderly, Box 7: Special considerations for pregnant women and Box 8: Special considerations for immunosuppressed individuals). Different strains of influenza may also be associated with different symptoms, as well as varying severity. For example, some human infections caused by the H5N1 strain in 2004–05 have been associated with gastrointestinal and neurological symptoms in addition to the respiratory features.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 15 Box 4: Special considerations in the young
Uncomplicated influenza in children may be similar to that experienced by adults. However, there are some age related differences in children and adults:1. Young children usual y develop higher temperatures (often over 39.5 degrees Celsius) and may have febrile seizures.
2. Unexplained fever can be the only manifestation of the disease in neonates and infants.
3. Influenza viruses are an important cause of laryngotracheobronchitis (croup), pneumonia and pharyngitis-bronchitis in young children. Both influenza types, A and B, are significant causes of lower respiratory tract infections.
4. Gastrointestinal manifestations, such as nausea, vomiting, diarrhoea and abdominal pain, are found in 40–50% of patients, with an inverse relation to age (mainly three years or younger).
5. Otitis media and non-purulent conjunctivitis are more frequent in younger ages.
6. A variety of central nervous system findings, including apnoea and seizures may appear in as many as 20% of infants. Children may also present with symptoms suggestive of meningitis or encephalitis, e.g., headache, vomiting, irritability and photophobia.
7. Myositis is a common complication in young children, especial y with influenza B.
In adolescents and children over five years of age, the most frequent symptoms are fever, cough, non-localising throbbing headache, chil s, myalgia and sneezing. The temperature range is usual y 38–40 degrees Celsius and a second peak of fever, without bacterial superinfection, may occur around the fourth day of il ness. Backache, sore throat, conjunctival burning with watery eyes and epistaxis may be present, but gastrointestinal symptoms are infrequent. Chest auscultation is usual y normal, but occasional y coarse breath sounds and crackles may be heard.
Respiratory il ness cause by influenza is non-specific and difficult to distinguish from il ness caused by other respiratory pathogens on the basis of symptoms alone. Many viral infections (e.g., respiratory syncytial virus, parainfluenza viruses, adenovirus and rhinovirus), as well as other pyrexial diseases, can cause il nesses clinical y indistinguishable from influenza.
16 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Box 5: Special considerations in the elderly
All people over the age of 65 years, particularly those in residential care facilities or who are immunosuppressed, are at increased risk of complications from influenza. Aboriginal and Torres Strait Islander people are at increased risk from the age of 50 years.
Although viral pneumonia and bacterial pneumonia fol owing influenza are considered the main causes of influenza-related hospitalisation in the elderly, many hospitalisations are attributed to the exacerbation of chronic obstructive pulmonary disease or congestive heart failure. It is therefore important to consider influenza in someone presenting with exacerbations of underlying diseases.
The symptoms and signs seen in older adults are similar to those in younger individuals, but most cases are characterized by the presence of dyspnoea, wheezing, sputum production and temperatures of 38 degrees Celsius. In addition, any unexplained acute deterioration in health status associated with fever may be a manifestation of influenza in elderly individuals.
Influenza-like il ness in older adults can also be caused by other viruses, mainly RSV or parainfluenza. RSV infections are an important cause of hospitalisation and death of elderly individuals and it is impossible to distinguish between RSV and influenza on the basis of clinical 1.1.7 Risk factors/exposures It is also important to assess whether a patient has been exposed to pandemic influenza in the seven days prior to the onset of their symptoms, as this increases the likelihood of the diagnosis and may also determine subsequent public health management.
Prior to the pandemic reaching Australia, and before the virus with pandemic potential is transmitting effectively from human to human, a history of travel to an affected country and contact with poultry or contact with a person with avian influenza would be important in determining the likelihood of infection.
If effective human to human transmission is occurring overseas, then merely having been in an affected area would be a sufficient history of exposure.
In a person who has travel ed overseas it is important to also consider other diseases that present with a febrile il ness such as malaria and typhoid.
Once there is widespread transmission of the pandemic strain in the general population in Australia, then anyone presenting with symptoms and signs of influenza would be considered a suspected case.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 17 Box 6: Taking an exposure history
Dependent upon the phase of the pandemic, the fol owing exposures occurring in the seven days prior to the onset of symptoms, should be asked, in taking a history from the patient:• Overseas travel to an affected area• Contact with poultry in an affected area• Contact with a person with a respiratory il ness• Occupation: (e.g., laboratory worker handling respiratory tract specimens or HCWs with direct patient contact.) 1.1.8 Complications of influenza• Primary viral pneumonia• Secondary bacterial pneumonia• Exacerbation of cardiorespiratory or other underlying health conditions• Middle ear infection• Reye syndrome (rare).
In assessing a patient who has already been diagnosed with pandemic influenza or may be presenting late in the il ness, be alert for these complications.
Primary viral pneumonia and secondary bacterial pneumonia
To ensure the appropriate use of antibiotics it is important, where possible, to differentiate between primary viral pneumonia and secondary bacterial pneumonia. The fol owing descriptions of primary viral pneumonia and secondary bacterial pneumonia may assist, although the pattern of pneumonia associated with a new pandemic strain may be different.
During an outbreak of influenza many cases are observed that do not clearly fit into either of these two categories, making differentiation difficult. Indeed, a patient with primary viral pneumonia may have a superimposed bacterial pneumonia and non-influenza community-acquired and nosocomial-acquired pneumonia may occur.
Primary viral pneumonia Primary viral pneumonia involves the typical onset of influenza fol owed by rapid progression within a few days of fever, cough and cyanosis. If severe bilateral chest findings are revealed on physical examination and chest X-ray (CXR). Similar to adult respiratory distress syndrome (ARDS), consolidation is not evident on physical examination or CXR. Blood gas analysis shows marked hypoxia. Gram stain of the sputum does not reveal significant bacteria and bacterial culture yields sparse growth of normal flora, whereas viral testing yields high titres of influenza A virus. Such patients do not respond to antibiotics and have a high mortality.
18 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Secondary bacterial pneumonia Secondary bacterial pneumonia usual y develops fol owing a classic influenza il ness and a period of improvement lasting four to 14 days. Recurrence of fever is associated with the classic symptoms and signs of bacterial pneumonia such as cough, sputum production and an area of consolidation evident on physical examination and CXR. Gram staining and culture of the sputum reveal a predominance of bacterial pathogens, usual y Streptococcus pneumoniae, Staphylococcus aureus or Haemophilus influenzae. Such patients usual y respond to specific antibiotic therapy.
See also Part 1.3.1 for information on the use of antibiotics.
1.1.9 The effect of co-morbidity The fol owing are associated with increased morbidity and mortality with seasonal human influenza:1. Age < 5 yrs or ≥ 65 yrs, ≥50 years for Aboriginal and Torres Strait Islander people2. Pregnancy (2nd or 3rd trimester)3. Chronic lung disease4. Chronic cardiac disease • congenital, rheumatic, or ischaemic heart disease• congestive cardiac failure• (not hypertension alone) 5. Diabetes6. Renal failure7. Malignancy8. Immunosuppression9. Haematological abnormalities10. Hepatic disease11. Long term aspirin therapy (rare association with Reye syndrome in those less than 18 years of age).
1.1.10 Severity of il ness/prognosis There is wide variation in influenza severity, from asymptomatic infection to fatal disease (frequently associated with viral or secondary bacterial pneumonia). Previous exposure to an antigenical y related virus is associated with less severe disease. Therefore, in a pandemic situation when a novel virus is circulating, the severity and length of il ness may be greater than with seasonal influenza. Age, pregnancy and pre-existing disease also influence outcomes. In addition, viral factors have been implicated in the severity of disease. For example, the high case fatality rate associated with human H5N1 influenza virus infections may be related to viral proteins inducing ARDS.
The three pandemics of the last century had varying case fatality rates. The 1918–19 ‘Spanish' influenza pandemic had a case fatality rate of approximately 1% whereas the ‘Asian' influenza pandemic of 1957–58 had a lower case fatality rate, ranging from 1 in 2,000 to 10,000.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 19 Pregnant women, especial y those in their second and third trimesters of pregnancy, are particularly vulnerable to the consequences of influenza infection. See below Box 7: Special considerations for Box 7: Special considerations for pregnant women.
Women with influenza infection in their second and third trimesters of pregnancy are at increased risk of hospitalisation for cardiorespiratory disorders. This is probably due to the increase in heart rate, stroke volume, and oxygen consumption observed in these months, as well as decreases in lung capacity and changes in immunological function.
Fatal influenza in pregnant women is characterised by the rapid development of cardiovascular and/or pulmonary insufficiency after several days of classic influenza-like il ness. Fulminating viral or bacterial pneumonia may fol ow the initial il ness.
An increase in mortality of pregnant women, miscarriages, premature births and stil births was documented during the 1918–19 and the 1957–58 pandemics. The reported mortality rate of pregnant women admitted to hospital with influenza in 1918 was 51% compared to 33% in hospitalised influenza patients from the general population. Influenza deaths in pregnant women represented 50% of all deaths in women of childbearing age, and 10% of deaths from influenza during the epidemics of 1957–58 in New York City and Minnesota. A review of 30 deaths from pneumonia and influenza in pregnant women in Massachusetts between 1954–74 showed more fatalities towards the last trimester and early puerperium (no deaths occurred in the first trimester), and the risk was higher with increasing maternal age. Only four of the 30 women had underlying pulmonary or cardiac conditions.
See Box 8: Special considerations for immunosuppressed individuals.
Box 8: Special considerations for immunosuppressed individuals.
Seasonal influenza may cause more severe disease in immunosuppressed individuals, depending upon the underlying disease or immunosuppressive medication (e.g., corticosteroids, chemotherapy, immunomodulation) and the degree of immunosuppression (e.g., asymptomatic HIV seropositivity versus AIDS). Clinical presentations may be atypical (e.g., reduced fever) and viral shedding more prolonged. Responses to antiviral medications may be slower and require longer courses of therapy (raising the possibility of the development of antiviral resistant virus). Complications may be more common, and convalescence longer. The effects of pandemic influenza infection in immunosuppressed individuals are currently unknown, and management of such cases may require 20 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 1.1.11 Differential diagnosis Below are some of the conditions that may be misdiagnosed as influenza. The list is not intended to be al -inclusive.
1. Any other upper respiratory tract infection.
2. Bacterial or non-influenza viral pneumonia.
3. Sepsis syndrome and ARDS.
4. In a returned travel er, diseases such as malaria and typhoid.
1.2 INVESTIGATIONS In the early phases of a pandemic where pandemic influenza is suspected, it is important to discuss specimen col ection and transport, and appropriate tests with the local public health unit (PHU) initial y. The specific specimens to col ect and laboratory tests for pandemic influenza are addressed in Annex 5: Laboratory guidelines in the Australian Management Plan for Pandemic Influenza (June 2005).
Additional tests for assessing severity and ruling out other diagnoses or complications should be ordered as needed. For example:• CXR – Features include diffuse, multifocal or patchy infiltrates, interstitial infiltrates, and segmental, multifocal or lobular consolidation with air bronchograms – These may be apparent within one week of the onset of fever– There may be progression to the features of ARDS.
• Arterial blood gas (ABG)• Sputum sample for Gram stain and bacterial culture• Blood cultures• Full blood count (FBC); electrolytes, urea, creatinine (EUC); liver function tests (LFT) – Features may include leucopenia, lymphopenia, thrombocytopenia and elevated aminotransferase levels general y in the first week. Multiorgan failure may develop.
• Acute and convalescent serology for atypical pneumonia pathogens.
In the later phases, when the pandemic is spreading in Australia, the necessity for highly accurate laboratory testing for pandemic influenza may diminish. Other tests that detect the pandemic strain, even if sensitivity is sub-optimal, may play an important role in reducing the demand on reference laboratories. In an area of known high pandemic activity, laboratory confirmation may not be needed at al . However, highly accurate testing is still necessary in a previously uninvolved area, or when it is critical to the management of individual patients, or in guiding the public health management of the PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 21 1.3.1 General principles The mainstays of management of the affected individual will include:• Attention to infection control immediately the diagnosis is considered, including isolating the patient and avoiding the use of nebulizers (see Part 1.3.3 Infection control) • Maintenance of oxygenation, with assisted ventilation where required• Maintenance of hydration with oral or intravenous fluids• Nutrition• Bed rest• Antiviral therapy with neuraminidase inhibitors if presentation has been within 48 hours of disease onset and if available (see below) • Antibiotics for bacterial complications of influenza, where required (see below)• Public health considerations, including management of contacts.
When to prescribe antibiotics
Whether to prescribe antibiotics will be an individual decision made by the treating physician. The fol owing principles may guide that decision making process.
If the patient is suspected to have viral pneumonia in the absence of bacterial pneumonia, antibiotics should not be commenced. If antibiotics are used inappropriately, potential consequences include the development of resistance, adverse events and wasted resources. Resource considerations may be particularly relevant in the later phases of the pandemic.
Issues to consider in excluding bacterial pneumonia are:• The clinical status of the patient. The threshold for prescribing antibiotics may be lower in a patient with severe il ness • The presence or absence of underlying conditions such as chronic cardio-respiratory disease, which make the distinction between viral and bacterial pneumonia difficult and place the patient at a greater risk of bacterial pneumonia when infected with influenza • The results of early microbiological investigations, including sputum microscopy, to detect bacterial • The clinical and radiological presentation.
If the decision is made to prescribe antibiotics, standard antibiotics for bacterial pneumonia should be commenced. These can be found in the Therapeutic Guidelines Antibiotic (Version 12, 2003. www.
See also Part 1.1.8 Complications of influenza for information about differentiating between primary viral pneumonia and secondary bacterial pneumonia.
22 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 1.3.2 Antiviral medications Availability of antiviral medications
In the very early phases of the pandemic, antivirals may be available in community pharmacies on prescription or through hospital pharmacies. The National Medical Stockpile (NMS) also contains influenza antivirals, for use in both treatment and prophylaxis. The proportion of antivirals from the NMS al ocated for treatment or prophylaxis will depend upon factors such as their clinical effectiveness against the pandemic strain, rate of depletion of the NMS and the delay until a pandemic vaccine is Indications for antiviral treatment Depending upon their availability within the context of pandemic requirements, and provided they can be administered within 48 hours of symptom onset, the indication for antiviral treatment is patients fitting the clinical or laboratory case definition of pandemic influenza.
Whether the clinical or laboratory case definition is used will depend upon the laboratory turnaround time and the phase of the pandemic. For example, in the earlier phases laboratory confirmation would be important whereas later, the clinical case definition would be sufficient. However, in the containment phases, if public health authorities are recommending an aggressive approach be taken to contain the spread of the virus, antiviral therapy may be commenced in a case that satisfies the clinical case definition prior to laboratory confirmation, and then ceased if the diagnosis is excluded.
The product information for the antiviral medication should also be reviewed.
Clinical studies during a pandemic Clinical studies are required for the early phases of the pandemic to evaluate the effectiveness of antiviral treatment. This information will be used to modify antiviral strategies. Therefore, HCWs may be involved in col ecting data on patients who are enrol ed in the studies.
Onset, dose and duration of antiviral treatment The neuraminidase inhibitor class of antivirals is recommended for treatment of human H5N1 infections because of the high frequency of M2 channel inhibitor resistance in human isolates of the virus.
As the antivirals for seasonal influenza are only effective if commenced in the first 48 hours, general y they should not be used if they are to be commenced after this time. The earlier treatment can be initiated within the 48 hours the better the patient's outcome is likely to be.
Only consider treatment onset beyond 48 hours if:• The patient is severely ill and hospitalised AND there is clinical evidence of primary viral pneumonia or the person is immunosuppressed. This should be done in conjunction with an infectious diseases • Clinical data emerges that treatment after this period is efficacious.
The recommended dose according to age is outlined in Table 1: Antiviral medications. The usual duration of therapy is five days.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 23 Despite recent case reports of oseltamivir resistance emerging in patients1 treated for influenza A H5N1 infection with the currently recommended regimen of oseltamivir therapy, there is no current evidence to support the use of higher doses, longer durations of therapy or combination therapy. However, this issue will be closely fol owed and the recommendation adjusted accordingly in light of new data related to clinical efficacy and patterns of resistance. Persistent detection of virus may be a marker of the emergence of resistance.2 Based on experience with human influenza, use of neuraminidase inhibitors and amantadine to treat clinical cases will not affect the development of an immune response to the infecting influenza strain.
Indication for antiviral post-exposure prophylaxis The index case should ideal y meet the laboratory case definition before commencing contacts on antivirals, to minimise wastage of limited resources. However, in the early phases, if an aggressive approach is being recommended by public health authorities to contain the spread of the virus, antiviral therapy may be commenced prior to laboratory confirmation of the index case and then ceased if the diagnosis is excluded.
• Close contacts of confirmed cases (see Part 1.3.6) Public health aspects for further information on Onset and duration of post-exposure antiviral therapy The neuraminidase inhibitor class of antivirals is recommended for prophylaxis against H5N1 infections because of the high frequency of M2 inhibitor resistance in human isolates of the virus. However, if the circulating strain was known to be susceptible to M2 channel inhibitors, amantadine may be considered as an alternative.
Post-exposure prophylaxis should be commenced as soon as possible but no later than within the incubation period3. Prophylaxis should be continued for 10 days.
In a setting of ongoing exposure, (e.g., household) the first exposure should be regarded as 24 hours before the onset of symptoms in the index case. Therefore, post-exposure prophylaxis should be commenced within six days of the index case first developing symptoms. If the exposure was an isolated event, post-exposure prophylaxis should be commenced within seven days of the exposure (based on an incubation period of seven days).
If a contact develops clinical features of influenza whilst on prophylaxis, then full therapeutic doses should be administered.
1 Resistance was demonstrated in two patients treated with the recommended regimen of oseltamivir therapy. In one patient however, therapy was initiated on the sixth day of il ness. Partial oseltamivir resistance has been demonstrated in another patient who was initial y treated with a prophylactic regimen despite being symptomatic and probably requiring a 2 It is important to note that antiviral sensitivity testing is not routinely available in Australia at this stage.
3 Note that this is not consistent with the product information for oseltamivir, zanamivir or amantadine. Off label use as outlined above is considered appropriate because of the longer incubation period observed for avian influenza infections in humans than with seasonal influenza. Efficacy is likely to be greater with early (i.e., within 48 hours of exposure) onset 24 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Long-term prophylaxis for seasonal influenza (e.g., for occupational exposure or high risk) has been used for 4–6 weeks; the safety, tolerability and efficacy of longer term prophylaxis is unknown. During a pandemic, it may be necessary to provide long term prophylaxis to those at frequent high risk of exposure or in particular occupations.
Table 1: Antiviral medications
Drug Class
Generic name Indication
Dose, duration and
(Brand name)
route of administration indications
Neuraminidase Oseltamivir 2mg/kg (up to 75mg) (age  1 year)5 twice daily for 5 days hypersensitivity Prophylaxis (age  13 years: 75 mg once daily for 10 days (may continue to 42 days Prophylaxis (age 2mg/kg (up to 75mg) once daily for 10 days.
[Whilst oseltamivir is currently only registered for post- exposure prophylaxis in people aged greater than 12 years, during a pandemic it may be considered for off label use in contacts over one year of age. Only if the child was less than one year of age would this require consultation with a paediatrician.] *In some countries, oseltamivir is approved for prophylaxis in children over one year of age.
4 A reduction in the dose of oseltamivir is recommended for persons with creatinine clearance < 30 mL/min or weight < 40kg.
5 Whilst oseltamivir is only registered for children over one year of age, it may be considered for off label use by a paediatrician at a dose of 2mg per kg twice daily for five days for those less than one year.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 25 Table 1: Antiviral medications (continued)
Drug Class
Generic name Indication
Dose, duration and
(Brand name)
route of administration indications
Neuraminidase Zanamivir 10mg twice daily for Prophylaxis (age 10mg once daily for 10 days (may continue to 28 days if necessary in [Whilst zanamivir is only registered for post- exposure prophylaxis in young, healthy adults, during a pandemic it may be considered for off label use in contacts aged  5 yrs.] Prophylaxis (age 5–9 years: 5mg/kg/day in 2 divided doses, up to 150mg/day for 10 days 10–64 years: 100mg twice daily for 10 days > 65 years: 100mg once daily for 10 days 6 Zanamivir is administered through inhalation by using a plastic device included in the medication package. Patients will benefit from instruction and demonstration of correct use of the device.
7 The product information should be consulted for dosage recommendations in renal impairment.
26 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Table 2: Side effects of antiviral medications
Side effects
Serious or life-threatening (<1%) Aggravation of diabetes, arrhythmia, confusion, hepatitis, pseudomembranous colitis, pyrexia, rash, seizure, swel ing of face or tongue, toxic epidermal necrolysis, unstable angina.
Central nervous system: insomnia (adults, 1%), vertigo (1%).
Gastrointestinal system: nausea (10%), vomiting (9%). Similar to those reported during treatment, but general y with lower incidence.
More common with prophylactic use: headache (20%), fatigue (8%), cough (6%), diarrhoea (3%).
Serious or life threatening (<1.5%) Al ergic or al ergic-like reaction, arrhythmia, bronchospasm, dyspnoea, facial oedema, rash, seizure, syncope, urticaria.
Central nervous system: headache (2%), dizziness (2%).
Gastrointestinal system: nausea (3%), diarrhoea (adults, 3%; children, 2%), vomiting (adults, 1%; children 2%).
Respiratory system: sinusitis (3%), bronchitis (2%), cough (2%), other nasal symptoms and signs (2%), infection (ear, nose and throat: adults, 2%; children, 5%).
Serious or life threatening Congestive heart failure, arrhythmia, cardiac arrest, psychosis, neuroleptic malignant syndrome, visual impairment, respiratory failure, pulmonary oedema, May also cause Nausea, dizziness, insomnia, depression, anxiety, irritability, hal ucinations, confusion, anorexia, dry mouth, constipation, peripheral oedema, headache, orthostatic hypotension, somnolence, diarrhoea.
Drug interactions with oseltamivir and zanamivir
No clinical y significant drug interactions have been reported in clinical studies to date. Information derived from pharmacology and pharmacokinetic studies of oseltamivir phosphate suggest that clinical y significant drug interactions are unlikely.
The suggestion that supplies of oseltamivir can be extended by simultaneous use of probenecid is not well supported by scientific studies and probenecid is not registered for this indication.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 27 Drug interactions with amantadine:
Caffeine, opiates and central nervous system (CNS) depressants are associated with increased risk of constipation/paralytic ileus. Antihistamines, albuterol, anticholinergics, fluoxetine and olanzapine are associated with increased anticholinergic adverse effects. Hydrochlorothiazide/triamterene combination may increase amantadine levels.
Antivirals during pregnancy
Table 3: Antivirals during pregnancy
Pregnancy
There is no information on the outcome of human pregnancies exposed to zanamivir or on placental transfer in humans. In rats, low level placental transfer was noted after intravenous administration of zanamivir. There were no malformations observed in animals with intravenous or subcutaneous administration. No recommendation given.
Animal studies revealed no teratogenic effect. Because animal reproductive studies may not be predictive of human response and there are no adequate and well control ed studies in pregnant women, it is recommended that oseltamivir only be used in pregnancy if the potential benefit justifies the potential risk to the foetus.
Amantadine related complications during pregnancy have been reported. The use of amantadine during pregnancy is absolutely contraindicated. The benefits and risks of the use of antivirals during pregnancy need to be weighed up and considered on a case by case basis and, if possible, in consultation with an obstetrician. During a pandemic, and because of the increased morbidity and mortality experienced by pregnant women, especial y during the 2nd and 3rd trimester, the potential benefits of zanamivir and oseltamivir may justify the potential risk to 8 Australian categorization of risk of drug use in pregnancy.
28 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Antivirals during breastfeeding
Table 4: Antivirals during breastfeeding
There is no information on secretion of zanamivir in milk in humans. In rats, the drug has been found to be secreted into milk, although this did not appear to affect the perinatal and postnatal development of the offspring.
It is not known whether oseltamivir or the active metabolite are excreted in human milk. In lactating rats, oseltamivir and the active metabolite are excreted in the milk. Offspring development was not affected at maternal doses of 1,500mg/ kg/day. Oseltamivir should only be used if the potential benefit for the lactating mother justifies the potential risk for the breastfed infant.
Amantadine has been demonstrated in human milk. Undesirable effects may occur in breastfed infants. Use of amantadine during lactation is not recommended.
1.3.3 Infection control The use of appropriate infection control measures for pandemic influenza is addressed in the latest version of the Infection Control Annex to the Australian Health Management Plan for Pandemic Influenza. The revised annex will contain detailed information, including recommendations on how to isolate patients in medical practice settings. This section is an outline of the general infection control principles applicable to the care of patients with suspected or confirmed avian or pandemic influenza. Guidelines for seasonal influenza are found in the Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting which are accessible from: The recommendations are different for the early phases of a pandemic compared to seasonal influenza because with a newly emergent pandemic virus, the population will have no immunity, there is unlikely to be a vaccine available and the behaviour of the virus will be unknown. Throughout the phases of a pandemic, general hygiene measures such as hand and respiratory hygiene and cough etiquette will General infection control principles
The WHO recommends strict adherence to standard and additional precautions to minimise contact, droplet and, in some cases, airborne transmission of the disease in the care of patients with known or suspected H5N1 avian or pandemic influenza. These guidelines are accessible from: Airborne precautions include the use of properly fitted high efficiency masks (P2 (N95)) and negative pressure rooms, if available. In the later phases when infection is widespread in the community, full airborne measures may not be feasible or practical.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 29 Further information about the use of appropriate personal protective equipment (PPE), including who needs to be provided with appropriate PPE, will be included in the revised Infection Control Annex of the Australian Health Management Plan for Pandemic Influenza. Appropriate PPE includes:• Gown (fluid repel ent, long sleeved, cuffed)• Plastic apron (if fluid repel ent gown is not available)• Disposable gloves• Properly fitted P2 (N95) mask (if available and appropriate) or surgical mask• Eye protection• Cap (in high risk situation where there may be increased aerosols).
The patient with suspected or confirmed pandemic influenza should be isolated from other patients. The patient should wear a surgical mask when other people are in the same room or if being transported.
Disposable equipment is preferred in the treatment and care of patients with suspected pandemic influenza and, except for sharps, this should be disposed of careful y in the general waste. If equipment is to be reused, it should be cleaned and reprocessed in accordance with the manufacturer's instructions. Furnishings should also be cleaned and disinfected.
The number of different staff caring for the patient should be minimised.
If oxygen is required, nasal oxygen masks should be used and covered with a surgical mask. If high-flow oxygen is required, a non-rebreather oxygen mask should be used.
Nebulizers should not be used in any patient suspected to have pandemic influenza because of the infection control hazards associated with their use, and the increasing body of evidence that spacers are just as effective in delivering the medication. Other high risk activities that disrupt the airway and potential y generate aerosols (e.g., suctioning and intubation) need to be performed with caution and with the minimal number of staff in the room. Full PPE for staff involved in these high risk procedures is of utmost importance.
Institutions should be vigilant in maintaining accurate records of patients with suspected or confirmed pandemic influenza. This information should include the HCWs who cared for the patient and breaches in infection control. The detail that is recorded about breaches in infection control may be affected by the volume of patients and staff workloads. Further information regarding occupational health issues will be included in the revised Infection Control Annex of the Australian Health Management Plan for 1.3.4 Vaccination When assessing a patient with suspected pandemic influenza, enquire about his/her vaccination status, including the currently available pneumococcal and human influenza vaccines.
These vaccines do not have a role in the acute management of a suspected pandemic influenza patient. The vaccines are contraindicated in people with a high fever, and a sufficient immune response may take two to three weeks to develop. Prior pneumococcal vaccination may reduce complications of secondary pneumococcal infection in cases of pandemic influenza. It is unknown but unlikely that prior human influenza vaccine offers any protection against a pandemic influenza strain.
Should pandemic influenza strain vaccines become available during a pandemic, recommendations for their use will be developed.
30 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 1.3.5 Psychosocial and mental health aspects All those working in response to a potential or actual pandemic are likely to have concerns. Many wil , quite natural y, feel anxious as they face the joint tasks of limiting and containing the spread of the disease, and treating those individuals directly affected. Individuals and families may become quite fearful about the risk of becoming infected, about how they will manage their sickness and the consequences if they do, and the potential threat to life if the condition is severe. It is helpful to acknowledge concerns, to highlight information available, answer queries honestly, and offer supportive advice if this is required. The fol owing strategies can be utilised: • Open communication and accurate information
Open communication and accurate information are vital to support psychosocial wel -being. It is helpful to provide a direct response to questions about the il ness, or to refer to government or official websites or other resources. It is useful to explain what is known, what is uncertain, what is in place to deal with the epidemic, and what actions they can take that are likely to be helpful. This should cover both what is important for themselves as individuals, but also to play their part in helping the community to deal with the epidemic.
• Simple anxiety management techniques
Simple anxiety management techniques such as taking ‘time out', slow measured breathing, positive actions and relaxation techniques are all helpful. Anxiety is natural in such circumstances.
• Positive coping strategies
Helping people to identify positive coping strategies that have previously been useful during il ness or adversity, can help them to mobilise these for the present situation.
• Keeping in touch
If people have to stay at home or be isolated because of infection risk, or ‘social distancing' strategies being used to contain the pandemic, suggest they set up phone, text messaging or email/internet support systems to assist themselves and others through this time. This will be particularly important for those who live alone.
• Special support for children
Children/parents are likely to be particularly anxious if il ness affects young children, and may require special support both to deal with their fears and the il ness.
• Support through death
Should death occur from influenza or associated disease it is likely that those bereaved will benefit from support and recognition of their loss.
• Other considerations
HCWs are likely to require particular support both because of their heightened risk associated with their work in response to the pandemic, and because of fears for themselves and their families. Chal enges associated with this circumstance can be supported by information, support programs through their workplace and identifying family support issues that will assist.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 31 People with presenting chronic and enduring mental il ness, people disabled and in institutional care may also require additional psychosocial support in the event of a pandemic.
Post influenza syndromes, such as depression, fatigue even organic conditions may need to be monitored in the aftermath. Depression should be suspected if there are feelings of hopelessness, prolonged negative mood and thoughts, sleep disturbance or even suicidal preoccupation. Organic conditions may be suspected if there is prolonged confusion, memory impairments, disinhibition or major behavioural change. In either case, further detailed assessment can be useful to clarify these potential complications. These conditions should be considered in determining whether a person is fit to return to work.
1.3.6 Public health aspects Highly pathogenic avian influenza in humans is a quarantinable disease, under the Quarantine Act 1908. Clinicians should report suspected and confirmed cases to the local PHU. Laboratories should report laboratory diagnoses of pandemic influenza.
At least in the early phases, the PHU will perform contact tracing. Close contacts are likely to be offered antiviral prophylaxis for seven to 10 days and will be monitored for the development of symptoms.
The definition of a contact is likely to change once the transmission characteristics of the pandemic strain are known and depending upon the phase of the pandemic. A more sensitive definition may be used in the early containment phases and a less sensitive definition in the later phases.
Contacts may include:1. Close contact • People who have had within one metre contact with an infectious case including physical contact or exposure to their respiratory droplets or droplet nuclei.
OR2. Enclosed space • People who have spent more than 15 minutes in a confined space with the infectious patient. This time period may be adjusted fol owing consideration of the room's size, ventilation, humidity and the number of people in the room. For example: • People living in the same house as patient• Day care centre co-inhabitants• Schools—classmates/teachers/playmates• Nursing home co-inhabitants• Contacts in an aeroplane• Potential y, some work mates.
For contacts, consider widespread use of pneumococcal vaccine in high risk groups and the inter- pandemic seasonal influenza vaccine (if still in production).
32 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 1.3.7 Where to manage the patient This will be a decision of the treating clinician based on factors such as the severity of the patient's il ness and the presence of pre-existing co-morbidities.
If hospitalisation is required, some areas may have dedicated influenza hospitals. The aim of designating certain hospitals as influenza hospitals during a pandemic is to reduce the overall risk of hospital- transmitted infection as well as al owing others to continue caring for patients with il nesses other than influenza.
‘Staging facilities'9 may be used to accommodate patients when:• Patients are not unwell enough to require acute hospital care but are unable to be managed at home because of lack of adequate social supports (e.g., travel ers or the frail elderly) • When hospitals are ful , in which case the facility can be regarded as an ‘overflow' facility• When convalescing patients need a higher level of support than they can receive at home, in which case the facility can be regarded as a ‘step-down' facility.
When transmission is widespread in Australia and disease is common, people whose il ness is less severe and who are otherwise in good health will be best cared for in the home.
Additional considerations for those being managed in the home will include:• Assistance with activities of daily living to al ow the patient to stay in the home during the • The patient will need to be educated about infection control measures to reduce the spread of the virus to other household members or visitors • Fol ow-up of the patient and, in the early phases, his/her contacts.
1.3.8 If discharged home Advice to patients who are sent home The fol owing measures may help relieve symptoms:1. Paracetamol or ibuprofen to treat myalgia and arthralgia.
2. Fluids.
3. Bed-rest.
4. Decongestants.
5. Avoid smoking/smoke.
6. Institute infection control measures.
7. Seek help if you experience: • Increasing shortness of breath• New chest pain• New yel ow/green sputum 9 ‘Staging facility' is a general term for a facility to accommodate patients where it is impractical to manage them at home or in a hospital. The role will vary according to the size of the pandemic but would, in general, have a supportive role for patients rather than an interventional one.
PART ONE: GENERAL APPROACH TO ASSESSMENT AND MANAGEMENT OF PATIENTS 33 • Persistent vomiting• Inability to eat or drink• Severe weakness• Inability to cope at home.
Appendix A: Information for the general public—looking after yourself during a pandemic should be given to patients who are discharged home, and their household contacts.
34 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) ASSESSMENT AND MANAGEMENT TOOLS These assessment and management tools are designed to be used throughout the phases of a pandemic, but wil be particularly useful during the pandemic period (from phase Aus 6a onwards), when large numbers of patients are presenting to general practices and emergency departments and the people assessing them may be unfamiliar with usual triage practices. Assessment centres for pandemic influenza patients may be set up in particular hospitals and mobile assessment teams may be evaluating patients in their homes. The guidelines may also be useful in assessing patients in these settings. During the later phases, the demand for hospital beds wil be very high, and where possible patients wil need to be managed at home. Appendix A: Information for the general public—looking after yourself during a pandemic information should be given to patients who are discharged home, and their household contacts.
In the earlier phases, when there is more uncertainty about the clinical presentations and outcomes of pandemic influenza, the fewer patients that are presenting to hospitals and GPs will probably be more closely monitored and investigated. During these phases, infection control, isolation and quarantine will be absolutely crucial to try to contain the spread of the emerging pandemic. There is likely to be greater use of antivirals for treatment of cases and prophylaxis of contacts. Case definitions will require a history of travel to an affected area and possibly even a history of exposure to poultry or a person with a respiratory il ness.
2.2 SCREENING IN GENERAL PRACTICE The fol owing sample screening questions may be useful in the general practice setting when the pandemic is occurring in Australia (from phase Aus 6a onwards). The aim of screening over the telephone is to detect suspected pandemic influenza patients and prevent them from coming into contact with patients who do not have pandemic influenza, thereby minimising transmission. It will also al ow the patient to be directed to the most appropriate assessment location and al ow people who attend to the patient to wear PPE. If used in the earlier phases, the exposure questions will have to be modified.
If pandemic influenza is suspected, the location of the subsequent assessment will depend upon whether the area has established an ‘influenza clinic'. Influenza clinics are discrete facilities for assessing and triaging symptomatic individuals during an infectious disease emergency.
36 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Checklist for telephone enquiries in general practice during a pandemic
Screening questions by receptionist:1. Do you have fever, cough and tiredness of sudden onset? If yes:2. Check patient's telephone number and inform the patient that the GP or practice nurse will call back.
Screening questions by GP/Practice nurse:1. Do you have fever?2. Do you have cough?3. Do you have extreme weakness or tiredness? If yes to the above questions (1 to 3):4. Did your symptoms come on suddenly? If yes ?5. During the seven days before your symptoms began did you have contact with a person with a respiratory il ness? Was the diagnosis pandemic influenza? ACTIONS TO BE TAKEN
If answers suggest possibility of pandemic influenza, offer either10:• Assessment at GP's practice early in the course of pandemic when cases are few (with attention to separation of the possible pandemic influenza patient from others) • Referral to hospital emergency department• Later in the pandemic, referral to a designated hospital emergency department or designated influenza clinic, if established in local area • Assess patient at home.
If severely unwel :• Refer to hospital and inform by telephone the hospital concerned of the possible diagnosis.
10 The location of the subsequent assessment will depend upon whether the area has established an influenza clinic.
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 37 2.3 SCREENING IN AMBULANCE SETTING 2.3.1 Screening at point of cal (i.e. cal s received at 000)
It is important to note that Ambulance Services should implement their locally developed
policy and procedures in the event of a pandemic. Information below should be seen as a
guideline to the policy and procedures of each ambulance service.
If possible screening should commence at phase 3 (Australia) of the pandemic but definitely should be implemented when there has been effective human to human transmission overseas (phase Overseas 4–5).
Questioning by ambulance call takers should occur early in the call after the location information and the main presenting problem of the patient has been ascertained. As the clinical and epidemiological features may vary during the different phases, questions to identify possible cases of pandemic influenza may need to change. Below is a provisional call taking definition to aid in identifying possible cases of avian or pandemic influenza.
Questions should be:• Does the patient have any influenza-like symptoms (e.g., fever, cough and fatigue)?• Has the patient been overseas to an affected country in the seven days before the symptoms started? If the answer to these questions is yes then the information should be referred to the appropriate person in the communications centre who will notify the appropriate authorities, hospitals etc.
If an ambulance is dispatched to this event then the information should be referred to the appropriate person in the communications centre who will notify ambulance crew and to al ow them to apply PPE and implement local management plans. It should be noted that for the patient to be considered a suspected case, a travel history is unlikely to be sufficient exposure. Further assessment of exposure to influenza will be required when the patient is attended to, and the assessment will depend upon the current case definition.
38 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 2.3.2 Screening when attending a patient This screening should be carried out from phase Overseas 3. It is important to note that because the clinical and epidemiological features may vary during the different phases, the clinical case definition If Ambulance Paramedics attend a patient with influenza-like symptoms they should, once they have completed their primary survey of the patient, ask the fol owing questions:1) Do you have a fever?2) Do you have a cough?3) Do you have extreme weakness or tiredness? If yes to the above questions (1 to 3):4) Have you had contact with a person affected by avian or pandemic influenza?OR5) Have you visited a poultry farm or had some other poultry contact in an areas with outbreaks of avian OR6) Have you been working in a laboratory that is processing samples from persons or animals that are suspected to have avian or pandemic influenza? If the answer to these questions is yes then the crews must continue with the use of appropriate PPE
and inform the receiving institution as early as possible to al ow them time to prepare.
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 39 Actions to be taken if the patient meets the suspected case definition:
Further infection control guidelines are found in Interim Infection Control Guidelines for Pandemic Influenza in Healthcare and Community Settings. Included below are some general infection control principles:• Paramedics should be diligent in their use of PPE and adherence to infection control precautions• The patient should be given a surgical mask to wear• The paramedic should notify his/her communications centre• The hospital the ambulance will attend should be notified; if there is a designated influenza hospital then the patient should be taken there • Disposable equipment is preferred in the treatment and care of patients with suspected avian or pandemic influenza and this should be disposed of careful y in the general waste. If equipment is to be reused, it should be disinfected in accordance with the manufacturer's instructions • The number of staff caring for the patient should be minimised. If the patient is to be transferred on then the original crew should be utilised if possible • All officers should wear PPE for the duration of the trip• If oxygen is required, nasal oxygen prongs should be used and covered with a surgical mask. If high- flow oxygen is required, a non-rebreather oxygen mask should be used and covered with a surgical • If the patient has symptoms such as wheezing a nebuliser should not be used. Each Ambulance
Service should refer to their clinical practice guidelines for alternative treatment options.
• Other high risk activities that disrupt the airway, such as suction and intubation need to be performed • On decamping the patient at the hospital, the ambulance should be appropriately cleaned (each ambulance organisation should have appropriate procedures for this, however guidelines for disinfection can be found in Interim Infection Control Guidelines for Pandemic Influenza in Healthcare and Community Settings • Each suspected case of pandemic influenza needs also to be reported to the local PHU. This will be the responsibility of the medical staff • Ambulance services should keep accurate records of any attendances and/or transports of suspected pandemic influenza cases. This information should include the officers who cared for the patient and any breaches in infection control. Further information regarding occupational health is available in the Interim Infection Control Guidelines for Pandemic Influenza in Healthcare and Community Settings.
Effective communication strategies providing up to date information to the work force should be initiated as soon as is practical for each ambulance service.
40 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 2.4 ALGORITHMS FOR USE IN ASSESSMENT CENTRES, GENERAL PRACTICE AND EMERGENCY DEPARTMENTS 2.4.1 Notes on assessment algorithms The algorithms, in particular those for secondary assessment, will need to be adjusted during the pandemic to take into account the availability of resources (e.g., availability of radiography and pathology services and capacity of health services to fol ow-up patients).
Age limits for algorithms
The algorithms are classified as being applicable to adults or children. A very approximate age limit for use of these algorithms is greater than 12 for the adult algorithms and less than or equal to 12 for the Guidelines for primary/initial assessment of adult patients
This algorithm is designed to be used for making the initial assessment of adult possible pandemic influenza patients. Potential settings for the assessment are in the patient's home, general practices, influenza clinics, emergency departments or other locations designated for the assessment of potential pandemic influenza patients. If the evaluation indicates that a further assessment is needed, the Guidelines for secondary/further assessment of adult patients should be used.
Guidelines for the secondary/further assessment of adult patients
This algorithm is designed for making further assessments of patients whose clinical indicator(s) was/ were abnormal on primary assessment. The secondary assessment may occur at the same location as the primary assessment, however because of the likelihood for investigations it may be preferable for them not to occur in the general practice setting or in the patient's home.
Guidelines for assessing children in general practice or other primary/initial assessment
This algorithm is designed to be used for making the initial assessment of childhood age possible pandemic influenza patients. Potential settings for the assessment are in the patient's home, general practices, influenza clinics, emergency departments or other locations designated for the assessment of potential pandemic influenza patients. If the evaluation indicates that a further assessment is needed, the Guidelines for assessing children in the emergency department or other secondary/further assessment centre should be used.
Guidelines for assessing children in the emergency department or other secondary/further
This algorithm is designed for making further assessments of childhood age patients whose assessments were not conclusive or have co-morbidities or danger signs present. Because of the difficulties in assessing children and the likelihood for investigations it may be preferable for the secondary assessment not to occur in the general practice setting or in the patient's home.
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 41 Legend for algorithms
a. Influenza serology: acute and convalescent serology can be used to confirm the diagnosis of influenza,
but only retrospectively. If a definitive diagnosis is required, the relevant swabs are essential for confirming the diagnosis at presentation.
b. Consider antiviral treatment if available.
c. Isolate pending confirmation of influenza. Duration of isolation is to be decided in consultation with Infection Control Department guidelines (for hospitalised patients) or PHU (for non-hospitalised patients), based on the infectious period.
42 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Algorithm 1 Guidelines for primary/initial assessment of adult patients Assess patient according to clinical case definition For any patient transfer
Inform ambulance/transporter/hospital concerned that
patient has suspected/confirmed pandemic influenza Suspected case of pandemic or avian influenza Does not meet clinical case definition • Patient to wait in designated area• Patient to wear surgical mask• If mask unavailable, advise patient to cough • Assess in non-influenza area and manage according to accepted clinical Primary assessment

• Use appropriate PPE • Assess clinical indicators • Assess for co-morbidity • If definitive diagnosis required: – Discuss with local public health unit – Nasal and throat swabs or other relevant samples for detection of influenza virus – Influenza serology (a) Clinical indicator assessment
Co-morbidity assessment
1. Age ≥ 65 yrs, ≥ 50 years for
Clinical indicator Results requiring secondary assessment >38 degrees Celsius 2. Pregnancy (2nd, 3rd trimester) New arrhythmia or pulse >100/min 3. Chronic lung disease.
<100 systolic or dizziness on standing 4. Chronic cardiac disease.
Skin colour (lips, Any abnormality on auscultation or chest 7. Immunosuppression New inability to function independently 9. Haematological abnormalities Persistent vomiting (>2–3 times/24 hours) 10. Hepatic disease Oxygen saturation (if 11. Long term aspirin therapy <90% on room air Clinical indicators normal Clinical indicators normal AND no co-morbidities Clinical indicators abnormal Secondary assessment • Liaise with local public health unit • Isolation (b) (See algorithm 2) • Isolation (b) • Treatment (c) • Treatment (c)• Patient information sheet• Consider reassessment at 48 hours (phone/visit) • Phone/visit at 48 hours *Observation may be in a setting such as a sub-acute observation centre in a hospital, staging facility or in the home PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 43 Algorithm 2 Guidelines for secondary/further assessment of adult patients Location of assessment
For any patient transfer
• If patient is moved to new assessment area: Inform ambulance/transporter/hospital concerned that – Ensure patient is in designated pandemic patient has suspected/confirmed pandemic influenza – Patient to wear surgical mask – If mask unavailable, advise patient to cough Secondary assessment
• Use appropriate PPE
• Clinical evaluation to confirm diagnosis of the primary assessment
• Assess need for investigations:
Possible investigations Arterial blood gas/pulse oximetry Serology for atypical pneumonia Pneumonia and co-morbidity OR Functional Conclusive assessment Assessment Severe pneumonia OR impairment Acute care not required Acute confusion OR (unable to cope) No functional Metabolic derangement OR Respiratory failure OR Acute cardiac deterioration Subacute care • Liaise with local (e.g., staging public health unit • Isolation (b) • Treatment (c) • Patient information • Reassessment at Clinical team to liaise with local public health unit 44 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Algorithm 3 Guidelines for assessing children in general practice or other primary/initial assessment centre For any patient transfer
Inform ambulance/transporter/hospital concerned that
patient has suspected/confirmed pandemic influenza Fever >38 degrees Celsius ORCough +/– rhinitis1 • Put surgical mask on child and isolate child from other patients • Use appropriate PPE• Check for clinical symptoms, signs and • Special care: history of exposure • If definitive diagnosis required:• Nasopharyngeal aspirate (NPA) or swabs for detection of influenza virus; influenza serology Stable (absence of danger signs Assessment not conclusive stated on the right) Stable with co-morbidity ORDanger signs such as: Inability to feed
Liaise with local public health unit Oxygen sats <90%
Home with parental education Send to hospital for secondary assessment(see algorithm 4) Isolation (b)Patient information sheetReassessment at 48 hours (phone/visit)Treatment (c) Fever and sudden cough is commonest presentation in children, but infants may have no cough and may present with apnoea, poor feeding and fever or hypothermia. Current Case Definition may change.
Congenital heart disease, suppurative lung disease, immune deficiency, chronic conditions e.g., diabetes, metabolic disease, long term aspirin therapy PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 45 Algorithm 4 Guidelines for secondary assessment of children in the emergency department or other secondary assessment centre For any patient transfer
Inform ambulance/transporter/hospital concerned that
patient has suspected/confirmed pandemic influenza Fever >38 degrees Celsius ORCough +/– rhinitis1 • Put surgical mask on child and isolate child from other patients • Use appropriate PPE• Check for clinical symptoms, signs and • Special care: history of exposure • Nasopharyngeal aspirate (NPA) or swabs for detection of influenza virus; influenza serology (a) • Assess need for other investigations (e.g., FBC, EUC, chest X ray, ABG, pulse oximetry) Stable (absence of danger Danger signs such as: stated on the right) Inability to feed
Oxygen sats <90%
Liaise with local public Isolation (b)Treatment (c) Home with parental Isolation (b)Treatment (c) Isolation (b)Patient information sheetReassessment at 48 hours Clinical team to liaise with local public health Fever and sudden cough is commonest presentation in children, but infants may have no cough and may present with apnoea, poor feeding and fever or hypothermia. Current Case Definition may change.
Congenital heart disease, suppurative lung disease, immune deficiency, chronic conditions e.g., diabetes, metabolic disease, long term aspirin therapy 46 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 2.5 DRAFT FORMS FOR USE IN ASSESSMENT CENTRES The fol owing material may be adapted for keeping records in assessment centres. They are designed to be used for assessing large numbers of patients and potential y by people with minimal triage experience. The forms will need to be adjusted according to the circumstances at the time the forms are used, including the setting in which they are being used. Feedback is actively sought to assist in refining the draft forms.
2.5.1 Primary/initial assessment centre a) Adults
This form is only to be completed for patients who meet the clinical case definition for Name of patient (surname, first name)Medicare/medical record numberAddressPhone numberOccupationOther household members?Other significant contacts?Other close contact(s) (eg workplace details)Age (years)DOB (day/month/year)Date of assessment (day/month/year)Time of assessment Place of assessmentName of person who completed assessmentName and address of general practitioner
Was definitive clinical
diagnosis and/or laboratory
diagnosis made? (If yes,
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 47 Details of vaccination (day/month/year) <14 days ago.
For pandemic vaccine tick if given <14 days ago or if only one dose received.
Pandemic influenza vaccine within the last 12 monthsSeasonal influenza vaccine within the last 12 monthsPneumococcal vaccine within the last 5 years
Date of onset of symptoms
Symptoms (tick if present)
Aching muscles/joints Runny/stuffy nose Sore throat/hoarseness Sputum, including colour Pain on breathing in In contact with someone with influenza in last 7 days (yes/no)
48 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Details of current medications
Tick if present
Age  65 yrs,  50 yrs for ATSI peoplePregnant (2nd or 3rd trimester)Chronic lung diseaseChronic cardiac disease (hypertension is not enough)DiabetesRenal failureMalignancyImmunosuppressionHaematological abnormalitiesHepatic disease.
Long term aspirin therapy (<18 yrs age) PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 49 Clinical indicator
Tick if result abnormal
assessment or
(one tick indicates
need for secondary
<35 or >38 degrees New arrhythmia or pulse <100 systolic or dizziness Skin colour (lips, hands) Chest signs or symptoms Any abnormality on auscultation or chest pain New inability to function independently or persistent vomiting (>2–3 times/24 hours) Arterial oxygen saturation <90% on room air 50 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Subsequent
Subsequent management
applicable
management
Clinical indicators normal and no co-morbiditiesClinical indicators normal but co-morbidity presentClinical indicators abnormal Give details of antiviral
therapy if commenced
Give details of any other

therapy administered
If public health unit was

contacted give details
If reassessment was

arranged give details
If observation was

arranged give details
If patient was sent for

secondary assessment
give details
A copy of this form should be forwarded to the patient's general practitioner and:• If sent to a secondary assessment centre the form should accompany the patient• If observation was arranged the form should accompany the patient• If the public health unit was contacted for contact tracing or fol ow-up of the patient the public health unit should receive a copy of the form.
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 51 b) Children
This form is only to be completed for patients who meet the clinical case definition for pandemic influenza Name of patient (surname, first name)Medicare/medical record numberAddressPhone numberParents' namesOther household members?Other significant contacts Age (years)DOB (day/month/year)Date of assessment (day/month/year)Time of assessment Place of assessmentName of person who completed assessmentName and address of general practitioner
Was definitive clinical
diagnosis and/or laboratory
diagnosis made? (If yes,
52 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Details of vaccination (day/month/year) <14 days ago.
For pandemic vaccine tick if given <14 days ago or if only one dose received.
Pandemic influenza vaccine within the last 12 monthsSeasonal influenza vaccine within the last 12 monthsPneumococcal vaccine within the last 5 years
Date of onset of symptoms
Symptoms (tick if present)
Aching muscles/joints Runny/stuffy nose Sore throat/hoarseness Sputum, including colour Pain on breathing in Loss of appetite/feeding In contact with someone with influenza in last 7 days (yes/no)
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 53 Details of current medications
Tick if present
Congenital heart disease
Suppurative lung disease
Immune deficiency
Diabetes
Metabolic disease
Other chronic disease
Long term aspirin therapy
Vital signs
TemperaturePulseBlood pressureRespiratory rateArterial oxygen saturation (if available) Danger signs (tick if present)—one tick indicates that secondary assessment it needed
Rapid breathingInability to feedCyanosis (blue hands or lips)VomitingLethargyConvulsionsOxygen saturations less than <90%Full fontanel e 54 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Subsequent
Subsequent management
applicable
management
No danger signs and no co-morbiditiesNo danger signs but co-morbidity present Danger sign present Assessment not conclusive
Give details of antiviral
therapy if commenced
Give details of any other

therapy administered
If public health unit was

contacted give details
If reassessment was

arranged give details
If observation was

arranged give details
If patient was sent for

secondary assessment
give details
A copy of this form should be forwarded to the patient's general practitioner and:• If sent to a secondary assessment centre the form should accompany the patient• If observation was arranged the form should accompany the patient• If the public health unit was contacted for contact tracing or fol ow-up of the patient the public health unit should receive a copy of the form.
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 55 2.5.2 Secondary/further assessment centre a) Adults
A new clinical evaluation should always be performed as part of the secondary assessment.
Name of patient (surname, first name)Medicare/medical record numberAddressPhone numberOccupationOther household members?Other significant contactsAge (years)DOB (day/month/year)Date of assessment (day/month/year)Time of assessment Place of assessmentName of person who completed assessmentName and address of general practitioner
Was definitive clinical
diagnosis and/or laboratory
diagnosis made? (If yes,
56 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) The primary assessment forms, or part of the primary assessment forms may be completed here.
Not all of the investigations listed below may be needed for the patient.
Details of investigations performed
NaKUreaCreatinineGlucoseCK-MB (only if ischaemic chest pain)Troponin (only if ischaemic chest pain)Arterial oxygen saturations Arterial blood gas
pH
Oxygen
Carbon dioxide
CXR
ECG
Sputum samples
Respiratory tract swabs or

nasopharyngeal aspirate
Blood culture
Serology for atypical

pneumonia and influenza
Other investigations:

PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 57 Subsequent
Subsequent management
applicable
management
Pneumonia and co-morbidity Severe pneumonia OR Acute confusion OR Metabolic derangement OR Respiratory failure OR Acute cardiac deteriorationFunctional impairment Assessment not conclusive Conclusive assessment Acute care not required No functional impairment
Give details of antiviral
therapy if commenced
Give details of any other

therapy administered
If public health unit was

contacted give details
If observation was

arranged give details
If subacute care was

arranged give details
If patient was discharged

give details
If patient was admitted, to

which ward?
A copy of this form should be forwarded to the patient's general practitioner and:• If observation or sub-acute care was arranged the form should accompany the patient• If the public health unit was contacted for contact tracing or fol ow-up of the patient the public health unit should receive a copy of the form.
58 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) b) Children
A new clinical evaluation should always be performed as part of the secondary assessment.
Name of patient (surname, first name)Medicare/medical record numberAddressPhone numberParents' namesOther household members?Other significant contactsAge (years)DOB (day/month/year)Date of assessment (day/month/year)Time of assessment Place of assessmentName of person who completed assessmentName and address of general practitioner
Was definitive diagnosis
made? (If yes, provide
PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 59 The primary assessment forms, or part of the primary assessment forms may be completed here.
Not all of the investigations listed below may be needed for the patient.
Suppurative lung diseaseImmune deficiencyDiabetesMetabolic diseaseOther chronic diseaseLong term aspirin therapyFull fontanel e Danger signs (tick if present)
Rapid breathingInability to feedCyanosis (blue hands or lips)VomitingLethargyConvulsionsOxygen saturations less than <90%Full fontanel e 60 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) Details of investigations performed
Arterial blood gas
pH
Oxygen
Carbon dioxide
CXR
Sputum sample
Respiratory tract swabs or

nasopharyngeal aspirate
Blood culture
Serology for atypical

PART TWO: ASSESSMENT AND MANAGEMENT TOOLS 61 Subsequent
Subsequent management
applicable
management
No danger signs and no Assessment not conclusive No danger signs but co-morbidity presentDanger signs Give details of antiviral
therapy if commenced
Give details of any other

therapy administered
If public health unit was

contacted give details
If observation was

arranged give details
If discharge home was

arranged give details
If patient was admitted, to

which ward?
A copy of this form should be forwarded to the patient's general practitioner and:• If observation was arranged the form should accompany the patient• If the public health unit was contacted for contact tracing or fol ow-up of the patient the public health unit should receive a copy of the form.
62 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) RESOURCES FOR HEALTH PROFESSIONALS 3.1 USEFUL NUMBERS FOR HEALTH PROFESSIONALS 1. Department of Health and Ageing Public Information Hotline: 1800 004 599 The fol owing numbers are for health professionals. Please ensure that the general public are directed towards the numbers in Appendix A: Information for the general public—looking after yourself in a pandemic. Useful numbers.
2. State and Territory public health unit contact details (for health professionals):
Australian Capital Territory Northern Territory a/h Royal Darwin Hospital: (08) 8922 8888 Western Australia New South Wales The reporting of communicable disease cases in New South Wales is facilitated by the individual public health units listed below: Metropolitan areas Northern Sydney/ 02 9477 9400 Greater 02 9382 8333 Greater Sydney South West Camperdown 02 9515 9420 02 9828 5944 Hunter/ 02 9840 3603 North Coast ServiceNSW Department of Health—02 9391 9000 (North Sydney) 64 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) The reporting of communicable disease cases in Queensland is facilitated by the individual public health units listed below: Brisbane Northside Brisbane Southside PART THREE: RESOURCES FOR HEALTH PROFESSIONALS 65 3.2 READING LIST1. Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in health care settings. Healthcare Epidemiology 2003; 37: 1094–1101.
2. de Jong, MD, Thanh TT, Khanh TH, et al. Oseltamivir resistance during treatment in influenza A (H5N1) Infection. The New England Journal of Medicine 2005; 353: 2667–2672.
3. Hall CB, Douglas RG, Gieman JM. Viral shedding patterns of children with influenza B infection. The Journal of Infectious Diseases 1979; 140(4): 610–613.
4. Hall CB, Douglas RG. Nosocomial influenza infection as a cause of intercurrent fevers in infants. Pediatrics 1975; 55(5): 673–677.
5. Hayden F, Klimov A, Tashiro M, et al. Neuraminidase inhibitor susceptibility network position statement: antiviral resistance in influenza A/H5N1 viruses. Antiviral Therapy 2005; 10: 873–877.
6. Kilbourne ED (ed). The influenza viruses and influenza. London: Academic Press, 1975.
7. Lindsay MI, Herrmann EC, Morrow GW, et al. Hong Kong influenza clinical, microbiologic and pathologic features in 127 Cases. The Journal of the American Medical Association 1970; 214(10): 8. Mandell GL, Bennett JE, Dolin R (ed). Mandel , Douglas and Bennett's Principles and Practice of Infectious Diseases 4th Edition. New York. Churchill Livingstone, 1994.
9. MIMS Online database. MIMS Australia, HCN (vendor), bimonthly updating, viewed 29 November 10. Moscona A. Neuraminidase inhibitors for influenza. The New England Journal of Medicine 2005; 11. Munoz FM, Campbell JR, Atmar RL. Influenza A virus outbreak in a neonatal intensive care unit. Pediatric Infectious Disease Journal 1999; 18(9): 811–815.
12. National Health and Medical Research Council. The Australian immunisation handbook. 8th edn. Canberra: National Health and Medical Research Council, 2003.
13. Salgado CD, Farr BM, Hall KK et al. Influenza in the acute hospital setting. The Lancet Infectious Diseases 2002; 2: 145–149.
14. Ungchusak K, Auewarakui P, Dowell SF, et al. Probable person to person transmission of avian influenza A(H5N1). The New England Journal of Medicine 2005; 352(4): 333–340.
15. World Health Organization. Avian influenza: assessing the pandemic threat. World Health Organization, January 2005, viewed 12 September 2005 <http://www.who.int/csr/disease/influenza/ 16. World Health Organization. Influenza A (H5N1): WHO interim infection control guidelines for health care facilities. World Health Organization, updated 10 March 2004, viewed 12 September 2005, 17. Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5. Avian influenza A(H5N1) infection in humans. New England Journal of Medicine 2005; 353(13): 66 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) 3.3 USEFUL WEBSITES 1. Department of Health Pandemic Influenza homepage: http://www.health.gov.au/pandemic 2. Department of Health and Ageing Infection Control Guidelines: http://www.health.gov.au/internet/ 3. World Health Organisation Infection Control Guidelines for avian influenza: http://www.who.int/csr/ 4. World Health Organisation Clarification document on the use of masks by healthcare workers in a 5. World Health Organisation Website: http://www.who.int/en/ 6. Centres for Disease Control Website: http://www.cdc.gov PART THREE: RESOURCES FOR HEALTH PROFESSIONALS 67 68 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) INFORMATION FOR THE GENERAL PUBLIC—LOOKING AFTER YOURSELF A.1.1 Be informed about influenza a) What is influenza?
Influenza, or ‘the flu', is a viral infection of the lining of the lungs and airways (the respiratory system). In Australia it usual y affects people during the winter months from June to September. The influenza viruses that circulate every winter are often only slightly different to those from the preceding winter, meaning that there is already a level of immunity (‘body defences') in the community. During these annual epidemics, influenza most commonly affects the very young or the elderly.
At unpredictable intervals, a total y new influenza virus appears in the human population. If this virus can spread easily from person to person and cause severe disease, then a worldwide epidemic (in other words, a pandemic) may occur.
If the pandemic is caused by an entirely new influenza strain, no-one in the community will have immunity to it. Some pandemics have been due to the reappearance of viruses which had not circulated in humans for many years. In these circumstances, people who were alive at the time that the virus previously circulated had some immunity. When population immunity is lacking, the virus can spread very quickly before a vaccine becomes available, affecting a greater number of people and likely causing greater sickness and death than the usual winter outbreak of flu.
b) How is influenza spread?
Influenza is very contagious. Adults can spread the virus for up to seven days, primary school aged children for up to 14 days and pre-school aged children for up to 21 days. People are most infectious when they are still coughing and sneezing. In some people, the contagious period can begin the day before symptoms develop. People breathe in the virus from particles in the air when they are around others with the flu who have been talking, coughing or sneezing. The virus can travel in droplets in the air, and can live for several minutes on your hands and for many hours on surfaces. People can also become infected when they touch respiratory secretions from those who are ill or objects on which viruses have landed, and then touch their own nose, mouth or eyes. It is especial y easy for the virus to spread where there are crowds or where people live or work/study close together.
c) What are the symptoms of influenza?
A person usual y develops symptoms of the flu within one to three days after becoming infected with the virus. They suddenly develop a fever, and possibly chil s, and may have a headache and aching muscles. They usual y have a dry cough and feel weak and tired. Some people have a sore throat and a runny or stuffy nose, and don't feel like eating. The fever usual y subsides in three to five days, and the person begins to feel better. The tiredness and cough may however, persist for a few weeks. Sometimes, usual y in young children and the elderly, flu is associated with vomiting and diarrhoea.
The flu is often confused with the common cold. The flu is different from a cold, as a cold comes on slowly, and rarely causes a fever or muscle aches. A cold is general y milder than the flu, and people can usual y carry on with their usual activities. People with the flu feel very sick and want to stay in bed.
70 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) d) How serious is influenza?
Most healthy people recover from influenza without any serious problems. However, there are certain groups of people who are ‘at risk' of developing complications which can be very serious, and even cause death. It is also difficult to predict who will be affected the most severely in a pandemic, as it is a ‘new' Some people, such as very young children and the elderly, are ‘at risk' because they have weaker body defences (immune systems). Pregnant women, particularly those who are in the second and third trimester of their pregnancies, have an increased risk of complications and death after influenza infections. Similarly, those with diseases such as cancer and HIV/AIDS, people who have had organ transplants and persons who take certain medications frequently develop complications.
People with chronic medical conditions such as heart disease, lung disease (e.g., asthma, cystic fibrosis), kidney disease and diabetes, are also ‘at risk' from influenza. This is because when the body is affected by other conditions, it is easier for bacteria to invade the cel s that have been damaged by the flu virus and cause other il nesses such as pneumonia. Influenza can also stress the body so much that the underlying il ness may worsen.
Children under the age of 18 years with influenza should avoid taking aspirin containing medications. This is because they can develop a very serious il ness affecting the nervous system and liver, cal ed Reye syndrome. It is important for parents of children who need to take aspirin containing medications on a regular basis for a health problem to discuss with their regular doctor the possible complications associated with influenza, and find out what they can do to reduce the risk.
e) For more information
If there is an outbreak of pandemic influenza in your community, watch the television or listen to the radio for more up to date information, or access the Australian Government Department of Health and Ageing website at http://www.health.gov.au. You can also call the Department of Health and Ageing Public Information Hotline: 1800 004 599.
If you have questions about somebody in your household that may have the flu, call your General Practitioner. If you have specific enquiries about whether your local area has set up dedicated influenza clinics or pandemic vaccination centres call your state/territory information line (see Part II . Useful numbers at the end of this document).
A.1.2 Protect yourself against influenza There are a number of measures that individuals can take to protect themselves and others a) Hygiene
Practising good hygiene is always important, regardless of whether an influenza pandemic is occurring. Getting into good habits now is worthwhile.
Handwashing is one of the most important measures to prevent the spread of infection. Wash your
hands often, especial y after being in contact with someone who has a respiratory infection, particularly children. In the event of a pandemic, it is recommended that you avoid shaking hands. It is good for everyone to get into the habit of washing their hands before meals, after using the toilet, and after they cough, sneeze or blow their nose. Tissues should be disposed of in the waste immediately after use. APPENDIX A: INFORMATION FOR THE GENERAL PUBLIC—LOOKING AFTER YOURSELF IN A PANDEMIC 71 The sooner children are taught this the better. It is best to wash your hands with soap and warm water, scrubbing your wrists, palms, fingers and nails for ten to fifteen seconds. Rinse and dry with a clean, dry Be aware of the times you rub your eyes or touch your nose or mouth, and try to avoid these habits as it can bring the virus into your airways or eyes.
Cough hygiene is important. This means turning away from other people and covering the mouth
with tissues when coughing or sneezing, disposing of the tissues afterwards and washing hands after disposal of the tissues.
Don't visit people who have the flu unless it is absolutely necessary. If a member of your family has the flu, keep their personal items, such as towels, separate from the rest of the family. Clean surfaces (such as bathroom sinks and taps, kitchen sinks and counters) after the ill person has handled them. Remember not to share eating utensils, food or drinks.
Maintain good health and look after yourself. Taking good care of yourself physical y and mental y
may strengthen your overall wel -being and the ability of your body to fight off infections and to stay healthy. Not smoking is particularly important for the health of the lungs and airways. Maintain hydration by drinking plenty of water. Stay up to date with recommended vaccinations such as all of the childhood vaccinations and the pneumococcal vaccination for those in high risk groups.
You should also try to stay one metre or more from sick people to reduce the spread of il nesses.
For more information about preventing spread to others see the Interim Pandemic Influenza Infection Control Annex in the Australian Health Management Plan for Pandemic Influenza and the Department of Health and Ageing's website.
The pandemic vaccine will be different from the seasonal flu vaccine that you can obtain every year. The seasonal flu vaccine will not protect you against the pandemic virus. Vaccination with the pandemic influenza vaccine is advised once it is available. Australia has contracts with two influenza vaccine manufacturers who will supply sufficient pandemic vaccine to vaccinate all Australians. As the pandemic strain cannot be predicted in advance, there will be a time delay of about three months before production can commence, and a further delay before there is sufficient vaccine for all Australians (probably about another two months).
i. Who should get the flu vaccine? Supply of a pandemic influenza vaccine may be limited during the early stages of the pandemic, therefore priority groups need to be defined and will be confirmed at the time of the pandemic.
During the pandemic, to find out about vaccine availability and where the vaccine will be administered, call your state/territory information line (see Part II . Useful numbers). Some areas may be holding special pandemic flu vaccine clinics and others may be administering the vaccine through local General i . Who should not get the flu vaccine People who have a severe (anaphylactic) al ergy to eggs should not be given the flu vaccine. This includes persons who, soon after ingesting eggs, develop swel ing of the lips or tongue, or experience acute respiratory distress or col apse. Individuals with severe (anaphylactic) al ergy to any of the product 72 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) components should also not be vaccinated with the flu vaccine. Ask your doctor if you may be al ergic to the product components.
People with minor il nesses can still get the flu vaccine. However, those with a fever (temperature greater than or equal to 38.5 degrees Celsius) should wait until their symptoms have abated.
The risk and benefits of vaccination should be discussed with your doctor, especial y if you have had significant reactions to other vaccines in the past.
i i. What reactions do people have to the flu shot? The most common reaction to the flu shot is some redness, swel ing and pain at the site of the injection. Some people may develop fever, tiredness and muscle aches within a few hours of the vaccination and may last for one to two days. More serious reactions are rare. You cannot get influenza from the vaccine.
c) Influenza antiviral medications
Antiviral medications are effective in preventing and treating acute influenza infection, and during a pandemic there will be a great demand for these medications. The Australian Government has purchased a large stockpile of the antivirals, and they will be used to minimise the overall il ness and death in the population. In the early phases of a pandemic, you may be given the medication (a short course of capsules) if you are sick with pandemic influenza or if a member of your family or work/school place develops influenza to prevent you from contracting the infection. People whose work places them at high risk of contracting influenza (e.g., HCWs) may be given the antivirals for longer periods of time. When the pandemic vaccine is available, preventative antivirals will not be necessary, except to cover the period until the vaccine produces immunity, or for people who are unable to receive the vaccine because of the al ergies mentioned above.
If you or a member of your household are prescribed these drugs, it is very important to take
them exactly as indicated. This will ensure you receive maximal benefit from your treatment
and reduce the chances of the virus becoming resistant. Antiviral resistance will limit the future effectiveness of these important medications.
A.1.3 Plan ahead Spend a little time thinking about what you will need if you got the flu.
Do you know how to use or read a thermometer correctly? If not, ask someone to show you.
Your local pharmacist or the nurse at your general practice should be able to give you instructions.
Have a plan
• Have a plan for if you and your family have to stay at home for a week or so during a pandemic
• Talk to your family and friends about this
• If you live alone, or are a single parent of young children, or are the only person caring for a frail or
disabled adult, the plan is an especial y good idea APPENDIX A: INFORMATION FOR THE GENERAL PUBLIC—LOOKING AFTER YOURSELF IN A PANDEMIC 73 • Think of someone you could call upon for help if you became very ill with the flu or were unable to leave the home and discuss the possibility with him or her • Think of someone you could call upon to care for your children if their school or day-care was closed because of the pandemic, and you were required to work, and discuss the possibility with them • Your plan needs to include who could help you with food and supplies if you and your family are il• Having a telephone network for you and the people who live close by is a good idea• Have the phone number of your family doctor and state/territory information line in a prominent place• Think about supplies you might need in a pandemic.
Supplies you might need in a pandemic
It is a good idea to:• Have enough fluids (e.g., juices, soups etc) and food on hand to last you and your family a week• Have enough basic household items (e.g., tissues) to last a week• Have some plastic bags—used supermarket bags are good—to put the used tissues in• Have paracetamol and a thermometer in your medicine cabinet.
A.2.1 Is it the flu? The most prominent characteristics of the flu are sudden appearance of a high fever (38 degrees Celsius or more), a dry cough, and body aches, especial y in the head and lower back and legs. Usual y the person feels extremely weak and tired and doesn't want to get out of bed. Other symptoms can be chil s, aching behind the eyes, loss of appetite, a sore throat and a runny, stuffy nose. The flu is even more likely if you have been in contact with someone with the flu, or have had some other type of exposure such as overseas travel to areas where flu outbreaks are occurring.
A.2.2 What can you do for yourself?
Influenza antiviral medications—As there is a limited supply of influenza antiviral medications,
during a pandemic they may not be available to treat every person who has contracted influenza. Information about the availability of the medications will be communicated widely by the Australian Government. When they are available for treatment, because they are only effective if
commenced within the first 24–48 hours of illness, it will be important to seek medical
attention early so that the antivirals can be commenced immediately. Therefore, you should
contact your doctor immediately • Rest—Probably you will feel very weak and tired until your temperature returns to normal (about
three days), and resting will provide comfort and al ow your body to use its energy to fight the • Stay at home—You should stay away from work/school and avoid contact with others as much
as possible while the infection is contagious. The contagious or infectious period for people over 12 years of age is seven days from when the first symptom appears • Drink plenty of fluids—Extra fluids are needed to replace those lost because of the fever (through
sweating). If your urine is dark, you need to drink more. Try to drink a glass of water or juice or an equal amount of some other fluid every hour while you are awake 74 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) • Take simple analgesics such as paracetamol or ibuprofen as recommended on the package to
ease your muscle pain and bring down your fever (unless your doctor says otherwise). Children under 18 years of age should not take any aspirin containing medications. This combination of influenza and aspirin in children has been known to cause Reye syndrome, a very serious condition affecting the nervous system and liver • Antibiotics are not effective against influenza because influenza is a virus and antibiotics fight bacteria. However, your doctor may prescribe them if you develop secondary bacterial infections • Gargle with a glass of warm water to ease a sore throat. Sugarless lol ies or lozenges also help.
Some medications, such as benzocaine, work by numbing the throat. They usual y come in the form of a lozenge or throat spray. Others, containing substances like honey or herbs, work by coating the • A hot water bottle or heating pad may also relieve muscle pain. A warm bath may be soothing
Use saline nose drops or spray to help soothe or clear a stuffed nose. Decongestants help shrink
swol en blood vessels in the nose. There are two kinds—pil s and nose drops/sprays. Nose drops/ sprays act in minutes. They work better and have fewer side effects than pil s. However, they only work for two to three days and then they may make matters worse. If your nose is still stuffy after three days, you may want to switch to the pil s. The pil s take half an hour to work. They may cause dry mouth, sleep disturbances and other side effects. Pseudoephedrine is a decongestant in pill form, but you should talk to you doctor or pharmacist about whether it is OK to take this medication • Wipe your nose with disposable tissues and put them in the waste immediately. Cover your nose and mouth with tissues when you cough or sneeze and throw them in the waste as wel . Wash your • Do not smoke as it is very irritating to your damaged airways
Ask for help: If you live alone, are a single parent, or are responsible for the care of someone who is
frail or disabled, you may need to call someone to help you until you are feeling better • A cough can be helpful if it gets rid of mucous. If a dry cough is keeping you awake, a cough
suppressant (antitussive) may be helpful. If you need help loosening mucous, an expectorant may be helpful. It is not helpful to take a suppressant and an expectorant together • If you buy medicine at the pharmacy to treat your symptoms (‘over-the-counter' medications),
check with the pharmacist to see if it is the best one for you. Mention if you have a chronic il ness or are taking any other medicine. Take into consideration that:– It is better to buy a remedy that treats only one symptom. This way you are not taking in substances that you do not need, or that may trigger an adverse reaction – Read the label to be sure that the ingredient treats the symptom you have– Long acting medications tend to have more side effects than short acting medications– Read the label and note any possible side effects or interactions with other drugs or health – If you have a chronic condition and are taking prescription medications, it is a good idea to ask the pharmacist to suggest a medication that would be safe for you to take, if you have not already discussed this with your doctor.
Older persons are much more sensitive to medications in general and may experience more side-
effects, especial y to the nervous system (e.g., confusion).
If you have any questions at all about medications, don't hesitate to talk to your pharmacist.
APPENDIX A: INFORMATION FOR THE GENERAL PUBLIC—LOOKING AFTER YOURSELF IN A PANDEMIC 75 A.2.3 What to expect Day 1–3: Sudden appearance of fever, headache, muscle pain and weakness, dry cough, sore throat and stuffed nose (but overshadowed by previous symptoms) Day 4: Fever and muscle aches decrease. Hoarse, dry or sore throat, cough and possible mild chest discomfort become more noticeable Day 8: Symptoms decrease. Cough and tiredness may last 1–2 weeks or more.
A.2.4 When to seek medical attention Early phases
In the early phases of the pandemic, before it is widespread in the community, it will be important to seek medical attention as soon as you suspect you may be experiencing symptoms of
pandemic influenza. This will al ow health authorities to take measures to try to contain the spread of
the pandemic.
If appropriate, you may be treated with influenza antiviral medications and your family members and work col eagues may be given preventative antivirals. The influenza antiviral medications are only effective for treatment if started in the first 48 hours of il ness (the earlier the better). If you have specific enquiries about where to access medical care in your local area, you should phone your state/ territory information line (see II . Useful numbers).
If you are experiencing the flu, avoid public places and contact with other people, especial y those ‘at
risk' of severe influenza. When you seek medical care, if possible, ring the practice before-hand in case there are special arrangements for pandemic influenza patients (e.g., assessment in the home). When you attend the practice, alert the receptionist to your symptoms so that you can be seated away from others. You may be asked to wait in a separate area and you may be given a surgical mask to wear. Before you are given a surgical mask, or if they are not available, remember to turn away from other people and cover your mouth and nose with tissues when you cough or sneeze. Wash your hands after disposal of the tissues in the rubbish.
If the decision is made for you to be cared for in the home, you should seek medical attention again in the situations outlined below.
Later phases
In the later phases when it is not possible to contain the spread of the pandemic, antiviral medications may not be available for treatment, and public health units may not have the capacity for contact tracing. Provided you are a normal healthy person, you may only need to seek medical attention if your symptoms worsen or are not improving.
76 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) If you are a normal y healthy person and have developed the flu, you should seek medical care if:• You become short of breath while resting or doing very little• Breathing is difficult or painful• You are coughing up increased or bloody sputum• You are wheezing• You have had a fever for three to four days and you are not getting better or you may be • You have started to feel better, and suddenly you get a high fever and start to feel sick again• It is noted by yourself and others that you are extremely drowsy and difficult to wake up or that you are disorientated or confused • You have extreme pain in your ear.
Seek medical care as soon as possible, in order to prevent your condition from worsening. Bacteria may have invaded your damaged tissues. At this point your doctor may consider giving you antibiotics.
If you have heart or lung disease, or any other chronic condition that requires regular medical attention, if you are frail, or if you have an il ness or are on treatments or medications that affect your immune system, or you are pregnant and you get the flu, call your doctor. If you are living with a long-term il ness, your doctor may suggest changes to your usual management routine and/or provide you with extra help in treating the flu and preventing complications.
A.2.5 When a child is unwel Older children and teens have the same symptoms of the flu as adults. Very young children and infants probably have similar symptoms, but may not know how to tell people they have sore muscles or a headache. These children may be irritable and eat poorly. They sometimes develop a hoarse cry and barking cough (like croup). Younger children, especial y those under six months of age may also have diarrhoea, vomiting and stomach pain.
Some of the things you can do for your child are:• Give paracetamol or ibuprofen every four to six hours for the fever in the dose recommended on the package (unless your doctor says otherwise). Do not give aspiring containing medications. Your pharmacist can provide advice on appropriate ‘over-the-counter' medications for treating fever • Do not expect to be prescribed antibiotics for uncomplicated influenza, as they will have no benefit. Antibiotics may be prescribed for complications of influenza such as pneumonia or ear infection • Dress the child in lightweight clothing and keep the room temperature at about 20 degrees Celsius if • Offer cool fluids frequently when the child is awake• Avoid cold baths• Al ow the child to rest and stay at home until no longer infectious, so the virus isn't spread to other children (currently the infectious period for primary school aged children is about 14 days and for pre- school aged children is about 21 days) APPENDIX A: INFORMATION FOR THE GENERAL PUBLIC—LOOKING AFTER YOURSELF IN A PANDEMIC 77 • Use salt-water nose drops to treat a stuffy nose. Throw away tissues as soon as you have wiped your child's nose. Teach the child to cover their mouth when they cough or sneeze and then throw the tissue away. Wash your hands often and teach your child to do so after wiping their nose.
In the early phases, you should seek medical attention as soon as symptoms develop, as influenza antiviral medications may be available for treatment. If you have specific enquiries about where to access medical care in your local area, you should phone your state/territory information line (see Part I I. Useful numbers at the end of this document).
When you seek medical care, if possible, ring the practice before-hand in case there are special arrangements for pandemic influenza patients (e.g., assessment in the home). When you attend the practice, alert the receptionist to your child's symptoms so that you can be seated away from others. You may be asked to wait in a separate area and your child may be given a surgical mask to wear. Before you are given a surgical mask, or if they are not available, remember to encourage your child to turn away from other people and cover his/her mouth and nose with tissues when he/she coughs or sneezes. Handwashing after disposal of the tissues in the rubbish is important.
In the later phases, antiviral medications may not be available. You should take your child to a doctor if your child:• Has heart or lung disease or any chronic il ness requiring regular medical care; has a disease or is taking drugs or treatment that affect the immune system or takes aspirin regularly for a medical condition • Has trouble breathing• Is less than six months old and has a temperature greater than 38.5 degrees Celsius• Is constantly irritable and will not calm down• Is listless and not interested in playing with toys• Has a fever that lasts more than five days• Drinks so little fluid that they are not urinating at least every six hours when awake• Has vomiting for more than four hours, or has severe diarrhoea.
Note: green or yel ow nasal discharge does not necessarily mean a child has a bacterial infection and needs antibiotics.
Take your child to the hospital emergency department or call 000 if your child:• Has severe trouble breathing not caused by a stuffy nose• Has blue lips• Is limp or unable to move• Is hard to wake up, unusual y quiet or unresponsive• Has a stiff neck• Seems confused• Has a seizure (convulsion/fit)• Has not had a wet nappy in 12 hours.
78 INTERIM NATIONAL PANDEMIC INFLUENZA CLINICAL GUIDELINES (JUNE 2006) A.3 USEFUL NUMBERS FOR THE GENERAL PUBLIC 1. Department of Health and Ageing Public Information Hotline: 1800 004 599 2. State and territory information lines (for the general public): Public information line
Australian Capital Territory Northern Territory a/h Royal Darwin Hospital: 08 8922 8888 1800 671 738.
Western Australia In New South Wales, you should contact the public health unit in your area: Metropolitan areas Northern Sydney/ 02 9477 9400 Greater 02 9382 8333 Greater Sydney South West Camperdown 02 9515 9420 02 9828 5944 Hunter/ 02 9840 3603 North Coast ServiceNSW Department of Health—02 9391 9000 (North Sydney) APPENDIX A: INFORMATION FOR THE GENERAL PUBLIC—LOOKING AFTER YOURSELF IN A PANDEMIC 79

Source: http://www.public.health.wa.gov.au/cproot/2246/2/pandemic-clinical-gl.pdf

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