Respiratory: Influenza
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals for the prevention and management of influenza.
This CIS covers:
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Influenza
Influenza is transmitted from person to person via respiratory droplets, which contain the virus Influenza A or Influenza B, produced during coughing or sneezing. Outbreaks are more common in Australia between March and September, however may occur at any time throughout the year [1]. Influenza virus causes a wide spectrum of disease from asymptomatic infection to respiratory illness with systemic features, multi-system complications, and death from primary viral or secondary bacterial pneumonia [2, 3]. Due to their vulnerable health status residents of RACF experience a mortality rate between 0-20%, increasing to between 30-55% if there is an influenza outbreak in the facility [1, 4].
Due to their age, chronic illness and close living conditions, residents of residential aged care facilities are at high risk of contracting influenza. Incidence of influenza within RACFs varies from 2-16%, however, this can rise to as high as 40% if the RACF experiences an outbreak of influenza [1].
Prevention
Immunisaton
Influenza vaccination, being 70-90% effective, is the single most important measure to prevent or attenuate influenza infection and to reduce mortality. In RACF populations, the vaccine is 50 to 60% effective in preventing hospitalisation or pneumonia and 80% effective in preventing death [1, 3-5]. Immunising RACF staff reduces the rate of introduced influenza and transmission throughout the facility [1, 2, 4].
Influenza vaccines normally contain 3 strains of virus, two current influenza A subtypes and influenza B, representing recently circulating viruses. The Australian Influenza Vaccine Committee determines the composition of vaccines for use in Australia annually. It takes approximately two weeks for a protective immune response to develop following the administration of the vaccine [1]. To provide continuing protection, annual vaccination with vaccine containing the most recent strains is necessary [3]. The National Immunisation Program (NIP) provides influenza vaccine free for people over 65 years, and for Aboriginal & Torres Strait Islander people over 50 years [1].
Immunisation Recommendation
The NH&MRC Australian Immunisation Handbook recommends influenza vaccination for adults residing or working in RACFs to reduce the incidence of influenza and associated morbidity, and to prevent and control outbreaks in high-risk environments [1, 3].
Annual vaccination, administered between February and April is recommended for individuals who are at increased risk of influenza-related complications [1]. Residents admitted after the administration of annual influenza vaccinations should be offered vaccination if they have not received it prior to admission [1]. At-risk individuals for whom vaccination is recommended include [1, 2, 5-7]:
Those with chronic cardiac disorders, diabetes and metabolic/renal disorders, asthma and chronic respiratory disorders or suppressed immune system due to illness or treatment; Those living in a nursing home or hostel; Adults aged 65 years or older; Koori and Torres Strait Islanders aged 50 years or older; and Those in contact with high risk individuals.
Contraindications
Vaccination is not recommended for [1, 2]:
Individuals with anaphylactic hypersensitivity to eggs should not be given influenza vaccine. This includes persons who, soon after ingesting eggs, develop swelling of the lips or tongue or experience acute respiratory distress or collapse. Individuals with an acute febrile illness (fever > 38.5C) should not be vaccinated until their symptoms have abated. Individuals with a history of Guillian-Barré Syndrome (GBS). Because individuals with a history of GBS have an increased likelihood of developing the syndrome again, the chance of coincidental development of the syndrome following influenza vaccination may be higher than in individuals with no history of GBS. The risk of influenza vaccination should be weighed against the benefits to the individual patient .
Immediate adverse reactions, such as hives, angio-oedema, or systemic anaphylaxis, are a rare consequence of influenza vaccination. Other uncommon adverse reactions may develop within a few hours of vaccination and may last for 1 to 2 days. Following the administration of influenza vaccination, observe for adverse reactions including [1-3]:
Local reactions such as swelling, redness and pain (occur in less than 10% of patients); Fever, malaise and myalgia (occur in 1– 10%).
Immunizing RACF staff
Annual Influenza vaccination of RACF staff is recommended by the NH&MRC [3], but currently is not funded by federal or state governments. We suggest that each RACF have a policy on staff immunisation. Vaccines can be bought by the facility, or by individual staff members on prescription. Vaccines can be administered to staff by their own GP, funded through Medicare. Alternatively, the RACF could employ a medical practitioner to provide mass immunisation for staff at the facility [1].
Vaccine supply, handling and storage
It is important to maintain temperature between 2° - 8°C when transporting and storing vaccines. Vaccinations should be transported in cold boxes with thermometers to prevent breaking of the cold chain. Vaccinations should be stored in refrigerators dedicated to the storage of medications. Regular quality assurance testing of refrigerators, e.g. cleanliness, use, and temperature, is a requirement for residential aged care accreditation. If a vaccination is found to be stored at the incorrect temperature it should be disposed of immediately [2, 3]. Refer to ‘The Australian Immunisation Handbook, 8th Edition, pg 60 –61 for methods of transporting. Further advice is available from DHS cold chain enquiries on 9637 4144
Immunisation Documentation and Administrative Issues
Administration of a vaccination should be clearly documented in the resident’s progress notes and/or health record. Details include:
Date and time of vaccination; Type and batch number of vaccination; and Any adverse effects from the immunisation.
MBS item 10993 can be claimed by a medical practitioner where the practice nurse, on behalf of a medical practitioner, provides an immunisation for a patient in a RACF. The GP need not be present, but is responsible for clinical outcomes of the patient and for ascertaining nurse competency. If the GP sees the patient prior to the nurse giving the vaccination, they will still be able to claim for professional services provided.
It is recommended that residents be offered annual influenza vaccination. GPs can use reminder systems in clinical software [3]. In addition, the 'RACF Reminder System' under Section 3 can prompt RACF staff when the next immunisation is due and immunisation status of residents.
Assessment
Diagnosis of influenza is made based on the presence of fever (>38 C) with at least one respiratory symptom and at least one systemic symptom [6]. Consideration should also be given to environmental influences, e.g. influenza epidemic, contact with an influenza patient, and confirmation of diagnosis [1, 4].
Signs and Symptoms
Signs and symptoms of influenza include respiratory and/or systemic symptoms. Signs and symptoms usually have a sudden onset (<12 hours) [1, 4] and last approximately 10 days [5]. The best predictors of influenza are presence of cough and fever [1]. Common signs and symptoms include [1, 4, 7]:
Diagnostic tests
Diagnosis should be confirmed using diagnostic tests, as clinical symptoms alone are insufficient to confirm or exclude influenza. In Australia there are five types of laboratory testing for influenza, summarised in Table One. Decision regarding most appropriate laboratory testing relates to the environment and circumstances. Rapid point of care (POC) testing is recommended when the results will influence management, e.g. if conducted within 48hrs, antivirals may be considered, or when there is an influenza outbreak within the RACF. POC results should also be confirmed using other laboratory testing [1, 4].
Table One: Laboratory tests available for influenza [1, 4]
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Test
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Type of diagnostic
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Time for results
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Comments
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Rapid point of care testing
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Immunoassay
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15-30 minutes
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80% sensitivity therefore negative result does not rule out influenza.
Confirm cases using other tests.
Does not distinguish between Influenza A and B.
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Antigen detection
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Immunofluorescence (IFA) of respiratory tract specimen
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2-4 hours
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Distinguishes between influenza A and B.
Sub-typing of influenza A strains.
Lower sensitivity than PCR.
Optimal result if specimen collected within 48hrs of symptom onset.
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Nucleic acid detection
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Polymerase chain reaction (PCR) of respiratory tract specimen
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4-5 hours
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Distinguishes between influenza A and B.
Sub-typing of influenza A strains.
Optimal result if specimen collected within 48hrs of symptom onset.
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Viral culture
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Culture of respiratory tract specimen
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1-4 days
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Optimal result if specimen collected within 48hrs of symptom onset.
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Serology
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Seroconversion or significant rise in antibody level detection in blood sample
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10-14 days
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May not receive results until illness is over.
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Management
Antiviral Therapy
There are currently three antiviral drugs registered in Australia that are effective against influenza infection: amantadine, oseltamivir and zanamavir. Oseltamivir and zanamavir are neuraminidase inhibitors that inhibit the ability of the virus to replicate itself. All are active against influenza A, whilst only the neuraminidase inhibitors are active against influenza B. Antiviral therapy is effective in reducing the severity, e.g. particularly development of lower respiratory tract infection requiring antibiotics, and course of influenza [4-6]. Oseltamivir reduces the course of influenza illness by up to 30 hours whilst zanamivir takes approximately 1.5 days to alleviate all symptoms. Currently antivirals are not included in the PBS for the treatment or prevention of influenza, however, their use in high risk populations such as RACFs has been shown to be effective [1, 4].
To be effective, antiviral therapy must be commenced within 48 hours of the onset of symptoms. Many cases of influenza are not identified within this timeframe, thus precluding the use of antivirals [4-6].
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oseltamivir 75 mg orally, 12-hourly for 5 days [6]
OR
zanamivir 10 mg by inhalation, 12-hourly for 5 days [6]
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Other strategies
Bed rest, fluids and pain relief are the main stay treatments for influenza. Promotion of increased fluids (unless contraindicated) and regular hydration assessment are recommended. Paracetamol is recommended for pain relief due to its analgesic and antipyretic actions. Non-pharmacological comfort measures are discussed in the Clinical Information Sheet on Pain Assessment and Management.
Managing Influenza Outbreaks
Residents are at high risk of contracting influenza and RACFs are at risk of influenza outbreaks, despite a high level of immunisation if the vaccination is not well matched to the influenza strain [4]. In the event of an outbreak, the facility should implement strategies to limit the transmission of the virus to others and to enable early identify and management of new cases [4].
Case Identification and notification
A respiratory disease outbreak is said to occur when three or more cases of a newly-acquired respiratory illness occur within a period of seven days in residents or staff in the same facility. In an outbreak, a confirmed case requires a positive result from at least one diagnostic test. A suspected case is when a resident or staff member has onset of symptoms from a defined point in time, characterized by fever (>38 C); PLUS one or more respiratory symptoms PLUS one or more systemic symptoms [1].
To maintain effective control of an influenza outbreak within the facility, prompt identification of new cases is imperative. Implementing rapid diagnostic testing is important, as antivirals are effective if commenced within 48 hours of symptom onset [4].
In the event of a case of Influenza (Group B disease) or an influenza outbreak identified within the RACF, the state Public Health Unit (PHU) must be notified in writing within five days of laboratory confirmation [7]. The PHU have a role in monitoring the outbreak and directing management, particularly the use of prophylactic antivirals [1, 4]. The PHU is also responsible for declaring when the outbreak is over – usually after a period of 8 days from the onset of symptoms in the last resident influenza case [1].
Vaccination
If the RACF has an outbreak of influenza all unvaccinated residents, staff members, and regular visitors should be offered immunisation [1, 4, 7].
Prophylactic Antiviral Therapy
In Australia, Public Health Units have the role of directing the decision to use antivirals in the event of an outbreak of influenza in a RACF [4, 6, 7]. Neuraminidase inhibitors have been recommended for use in the management of influenza outbreaks RACFs. Amantadine should not be used for treatment or prophylaxis of influenza due to high rates of resistance [4].
Antivirals are most effective in controlling an influenza outbreaks when [1, 4, 5]:
The selected antiviral is effective against the strain(s) of influenza virus; Other outbreak prevention measures such as vaccination, additional infection control precautions, and isolation of symptomatic patients have been implemented; and Antivirals are administered to all asymptomatic residents (regardless of their vaccination status) and unvaccinated staff, until the outbreak is declared over.
To reduce risk of antiviral resistance, contact between residents and staff taking antivirals for treatment and those taking antivirals for prophylaxis should be minimised. Strict infection control strategies should be implemented [1].
Infection control
RACF residents have high rates of resistant pathogens, and infection from these conveys a higher risk of death [8, 9]. Basic infection control policies reduce the spread of infections through institutions, and limit the impact of outbreaks when they occur. RACF staff should be provided with regular education on standard infection control principles [10].
The most important strategies to reduce the spread of infection are [1, 4]:
Regular handwashing, particularly between care of residents and after contact with respiratory secretions;
Good respiratory hygiene such as covering nose/mouth when sneezing or coughing, use of appropriate surgical masks to contain respiratory droplets of residents coughing and use of tissues to contain respiratory secretions; Use of surgical masks by staff when attending residents with respiratory infection, particularly those with fever; Regular cleaning of the facility with detergents and water or chlorine solutions to remove influenza virus that can survive up to hours on surfaces; and Isolating infectious residents.
Isolation
It is recommended that symptomatic residents be restricted to their room for 5 days after initial onset of the illness or until symptoms have resolved, whichever if shorter. If there are separate sections, units or wings of the facility, residents from areas experiencing influenza outbreak should avoid contact with those in unaffected sections of the RACF. It is recommended that new admissions or return of residents who have been absent from the facility, e.g. in acute care, be avoided during an influenza outbreak. Where this unavoidable, use strict isolation and infection control measures to prevent disease spread [1].
Staff with symptoms should be excluded from work for 5 days from the onset of illness or until symptoms have resolved, whichever if shorter. It is recommended that all staff members working within a RACF with an influenza outbreak be vaccinated or receive antiviral medication. Unimmunised staff members should wait 3 days from the last day they worked in a RACF with influenza outbreak before working in an unaffected facility [1].
Visitors to the RACF should be discouraged if they have fever or symptoms of respiratory illness [1, 4]. If the RACF is experiencing an outbreak of influenza, visitors should be informed of the risk. If they choose to visit, restrict visits to only the resident they have come to see, and do not allow groups to visit [1]. Visitors should be encouraged to practice infection control principles including washing of hands and wearing surgical masks to present disease spread [1].
Sources of Information
Where to go for more information
Victorian Public Health Services (including Infectious Diseases and Environmental Health)
The Victorian Public Health Services provide information on management of all infectious diseases and infection control practices. A register is kept of all cases of infectious diseases at:www.health.vic.gov.au/ideas/bluebook/influenza.htm
For notifying of a case or outbreak of influenza telephone: 1300 651 160 or Fax: 1300 651 170.
For general enquiries relating to infectious diseases telephone: 9096 0350.
References
Interpandemic Influenza Working Group Communicable Diseases Network Australia, Guidelines for the Prevention and Control of Influenza Outbreaks in Residential Care Facilities in Australia. 2005, Communicable Diseases Network Australia and Australian Government Department of Health and Ageing: Canberra. p. 59. Department of Human Services, Influenza and Pneumococcal Pneumonia Immunisation, in www.dhs.vic.gov.au/phd/immunisation/pneumoflu.htm (accessed Feb 2004), Government, Victorian. 2003 National Health and Medical Research Council, . ed. The Australian Immunisation Handbook. 8th ed. 2003, Department of Health and Aging Australian Government. NSW Therapeutic Advisory Group, (NSWTAG). Use of antivirals for treatment and prophylaxis of influenza in NSW hospitals and residential care facilities. 2006, NSW Therapeutic Advisory Group and NSW Health Department: NSW, Australia. p. 24. National Prescribing Service, (NPS). NPS Position Statement September 2006: Role of the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) in seasonal influenza. 2006, National Prescribing Service, (NPS). Canberra. p. 6. eTG, Therapeutic Guidelines: Influenza, in http://www.tg.com.au (accessed August 2006), eTG. 2006 Department of Human Services, (DHS), Infectious Diseases: epidemiology and surveillance: influenza, in http://www.health.vic.gov.au/ideas/bluebook/influenza.htm, Victoria, State Government of. 2006 Furman, D. , Rayner, A., Tobin, E., Pneumonia in Older Residents of Long-term Care Facilities. American Family Physician, 2004. 70(8): p. 1495-1500. Bartlett, J. , Dowell, S. , Mandell, L. , File, Jr., T., Musher, D. , Fine, M., Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases, 2000. 31: p. 347-382. (ICSI), Institute for Clinical Systems Improvement, Community-acquired pneumonia in adults. 2003, Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on influenza immunisation provided in this Clinical Information Sheet is based on Level IV evidence produced by expert opinions in the field, particularly the Australian Immunisation Handbook guidelines developed by the National Health and Medical Research Council (NH&MRC) and the Australian Technical Advisory Group on Immunisations (ATAGI). Information on management of influenza and outbreaks is based on the Interpandemic Influenza Working Group Communicable Diseases Network Australia (IIWGCDNA) guidelines and guidelines produced by NSW Therapeutic Advisory Group.
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|
Reference |
Year |
Level of Evidence |
1. |
Interpandemic Influenza Working Group Communicable Diseases Network Australia, Guidelines for the Prevention and Control of Influenza Outbreaks in Residential Care Facilities in Australia. 2005, Communicable Diseases Network Australia and Australian Government Department of Health and Ageing: Canberra. p. 59. |
2005 |
Level IV B evidence |
2. |
Department of Human Services, Influenza and Pneumococcal Pneumonia Immunisation, in www.dhs.vic.gov.au/phd/immunisation/pneumoflu.htm (accessed Feb 2004), Government, Victorian. 2003 |
2004 |
Level IV C evidence |
3. |
National Health and Medical Research Council, . ed. The Australian Immunisation Handbook. 8th ed. 2003, Department of Health and Aging Australian Government. |
2003 |
Level IV B evidence |
4. |
NSW Therapeutic Advisory Group, (NSWTAG). Use of antivirals for treatment and prophylaxis of influenza in NSW hospitals and residential care facilities. 2006, NSW Therapeutic Advisory Group and NSW Health Department: NSW, Australia. p. 24. |
2006 |
Level IV B evidence |
5. |
National Prescribing Service, (NPS). NPS Position Statement September 2006: Role of the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) in seasonal influenza. 2006, National Prescribing Service, (NPS). Canberra. p. 6. |
2006 |
Level IV C evidence |
6. |
eTG, Therapeutic Guidelines: Influenza, in http://www.tg.com.au (accessed August 2006), eTG. 2006 |
2006 |
Level IV C evidence |
7. |
Department of Human Services, (DHS), Infectious Diseases: epidemiology and surveillance: influenza, in http://www.health.vic.gov.au/ideas/bluebook/influenza.htm, Victoria, State Government of. 2006 |
2006 |
Level IV C evidence |
8. |
Furman, D. , Rayner, A., Tobin, E., Pneumonia in Older Residents of Long-term Care Facilities. American Family Physician, 2004. 70(8): p. 1495-1500. |
2004 |
Level IV C evidence |
9. |
Bartlett, J. , Dowell, S. , Mandell, L. , File, Jr., T., Musher, D. , Fine, M., Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases, 2000. 31: p. 347-382. |
2000 |
Level IV B evidence |
10. |
(ICSI), Institute for Clinical Systems Improvement, Community-acquired pneumonia in adults. 2003, Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). |
2003 |
Level IV B evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [11] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Respiratory: Influenza
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