Urgent Information from the AMA on Swine Influenza for Medical Practitioners
30 April 2009 - 12:30pm
URGENT INFORMATION FOR MEDICAL PRACTITIONERS
ON SWINE INFLUENZA On behalf of medical practitioners, the Australian Medical Association has sought specific advice from the Chief Medical Officer on a number of important questions that doctors have been asking us in relation to Swine Influenza. I am pleased to provide the information below which sets out clear, formal advice from the Chief Medical Officer in response to the AMA’s questions as well as other related useful information. Please note that this advice is relevant and appropriate for the circumstances and conditions as at 1 May 2009. Further advice and updates will be provided through the AMA website when available from the government if/when the situation changes. Contact details for each state and territory are set out at the bottom of this advice. Further links to other relevant information are available from the AMA website at http://www.ama.com.au Yours sincerely Dr Rosanna Capolingua President 1. What is the current availability of, and distribution arrangements for, masks for GP staff & patients? Masks and other Personal Protection Equipment (PPE) are available as part of the National Medical Stockpile (NMS). These will be made available on the advice of the Australian Health Protection Committee (AHPC), based on the risk of exposure and availability of supply. Supplies in both NMS and in jurisdictions are limited. In the current DELAY phase, the NMS will not be accessed, to preserve supply for later phases, if the disease becomes established in Australia. 2. What is the availability of prophylaxis for GP staff & doctors? Supplies of both oseltamivir and zanamivir are available both from jurisdictions and NMS, as well as through community pharmacies. Neither drug is on the PBS. Initially, advice should be sought from local Public Health Units (see state contact details below) on the indications and availability of prophylaxis at a local level. Stocks in the NMS will be made available on the advice of AHPC. In the current DELAY phase, the NMS will not be accessed, to preserve supply for later phases, if the disease becomes established in Australia. 3. What advice is available for GPs and staff about how to protect their families? At this stage, protection of families of health care workers (HCW) is dependent on risk. If a HCW has been exposed to swine influenza, depending on the risk, they may be placed on an antiviral medication, which would confer protection against both contracting the illness and infecting others. Apart from this, no other protection would be deemed necessary. Apart from this, general “social distancing” measures would be appropriate, such as maintaining a minimum of 1 metre distance away from others, regular hand hygiene and avoiding touching the face. PPE would not be indicated for family members. 4. What are the likely statistics on expected mortality? At this stage, we do not have accurate enough data (particularly from Mexico) to able to advise on expected mortality. Only a small proportion of deaths in Mexico have been tested, and then only a limited number of them are confirmed swine influenza cases. 5. Will fever centres be established at strategic locations as an alternative venue for patient diagnosis? The establishment of fever centres (flu clinics) is included as part of the Australian Health Management Plan for Pandemic Influenza (AHMPPI). These will be established by jurisdictions, at the request of AHPC. Generally, this will be when the caseload of the outbreak justifies it. 6. What arrangements should be made to reduce infection in GP & Specialist waiting rooms? Measures to reduce the risk of infection in practice waiting rooms include the following:
AMA Note: The AMA also advises that medical practices implement appropriate practice cleaning arrangements including wiping over surfaces with alcohol based preparations including waiting room chairs, bench and counter tops and door handles. Further advice on infection control within the practice is set out in the RACGP Pandemic Flu Kit available at the following website: http://www.racgp.org.au/pandemicresources. 7. What arrangements are being made to ensure quick access to diagnostic tests and results – what are the timeframes for test results and what advice should be given to patients about the availability and timeliness of results? The government is currently relying on Public Health Laboratory Network (PHLN) laboratories for testing. These laboratories can do the initial testing, which establishes if it is influenza A or not. It then may need to go to one of four viral reference laboratories (2 in Sydney, 1 each in Melbourne and Perth) for further subtyping. These tests are done by Polymerase Chain Reaction (PCR) testing, or by viral culture. If it cannot be subtyped further, it will then be sent to the WHO Collaborating Laboratory in Melbourne for gene sequencing. Therefore, it is difficult to give a clear timeframe, as the absolute confirmation that a sample is swine influenza A (H1N1) may take up to 72 hours, though lower level exclusion tests may help in a shorter time frame. As laboratories get busier with more testing, it may take longer. 8. If diagnosis is negative - what are the next steps? If a case were shown not to be swine influenza, they would be referred back for usual care. It is of course possible that they may still have a seasonal influenza strain. 9. What are the current recommended protocols for prescribing Tamiflu and Relenza - only those who have a positive diagnosis or also to those who may have been exposed and/or others? The current indications for the use of antiviral medications are: Close contacts of confirmed or suspected cases (as defined below in question 16 and diagnosed in consultation with the local Public Health Unit) within 48 hours of contact Adults and adolescents. The recommended oral dose of Tamiflu for prevention of influenza following close contact with an infected individual is 75 mg once daily for ten days. Therapy should begin within two days of exposure. The recommended dose for prevention during a community outbreak of influenza is 75 mg once daily. Safety and efficacy have been demonstrated for up to six weeks. The duration of protection lasts for as long as dosing is continued. Paediatric patients. Children weighing > 40 kg, who are able to swallow capsules, may also receive prophylaxis with a 75 mg capsule once daily or one 30 mg capsule plus one 45 mg capsule once daily for ten days as an alternative to the recommended dose of Tamiflu suspension (see below). The recommended prophylactic oral dose of Tamiflu suspension for children greater than or equal to 1 year of age is shown in Table 8. Please refer to table 8.  For the oral suspension a dosing syringe marked with 30, 45 and 60 mg dosing levels is provided. Suspected cases (as defined below in question 16 and diagnosed in consultation with the local Public Health Unit) if started within 48 hours of onset of symptoms, until influenza A is excluded or an alternative diagnosis is made Adults and adolescents. The recommended oral dose of Tamiflu capsules in adults and adolescents 13 years of age and older is 75 mg twice daily for five days. Adults and adolescents 13 years of age and older who are unable to swallow capsules may receive the appropriate dose of Tamiflu suspension. Paediatric patients. The recommended oral dose of Tamiflu for paediatric patients 1 year and older who cannot swallow a 75 mg capsule is shown in Table 7 below  For the oral suspension, an oral dosing dispenser with 30, 45 and 60 mg graduations is provided; the 75 mg dose can be measured using a combination of 30 and 45 mg. It is recommended that patients use this dispenser. Paediatric patients weighing > 40 kg who are able to swallow capsules may also receive treatment with a 75 mg capsule twice daily or one 30 mg capsule plus one 45 mg capsule twice daily as an alternative to the recommended dose of Tamiflu suspension. AMA Note: further RACGP advice on the use of antivirals in pregnant women: Always consult with a medical specialist before giving antiviral medication to a pregnant woman. Pregnant women are known to be at higher risk for seasonal influenza complications and during prior pandemics. Pregnant women may be at higher risk for swine influenza complications. Oseltamivir (TamiFlu®) and zanamivir (Relenza®) are “Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. To date no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women. The drug of choice for prophylaxis is less clear. Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications e.g. bronchospasm and medication delivery system challenges that may be associated with zanamivir, because of its inhaled route of administration, need to be considered, especially in women at risk for respiratory problems. 10. When will the antivirals in the stockpile be made available, how will they be distributed and to whom? The distribution of antiviral medication in the National Medical Stockpile (NMS) will be on the advice of AHPC, and at their discretion. The actual method of distribution will depend on needs and circumstances at the time it is to be done. In the current DELAY phase, the NMS will not be accessed, to preserve supply for later phases, if the disease becomes established in Australia. 11. What are the protocols for issuing prescriptions to patients who request prescription for Tamiflu and Relenza for personal stockpiling purposes? At this stage we do not recommend personal stockpiling of antiviral medication, as this may threaten supplies for treatment or prophylaxis where indicated. We are recommending that any prescription of antiviral medication should be on the recommendation of the local Public Health Unit (see contact details below). 12. What advice is available for doctors on access to, and use of, precautionary equipment in GP surgeries: new gloves for every patient treated; masks; timers; theatre like drapes (when will they need to be changed), quick disinfecting of flat surfaces? Standard respiratory, droplet spread and infection control precautions should be undertaken. AMA note: as per the answer to question 1 above, at this stage, all required equipment, including masks, would need to be provided by the medical practice. Masks and other Personal Protection Equipment (PPE) in the National Medical Stockpile (NMS) will not be accessed at this stage in order to preserve supply for later phases, if the disease becomes established in Australia. RACGP advice on use a P2/N95 mask Patients who are suspected of having influenza should be encouraged to wear a surgical mask at all times. Practice staff and other patients in the clinic are required to wear a surgical mask if they are within a one metre distance from the patient. Masks should always be applied correctly ensuring that correct hygiene and handwashing procedures are followed. If P2/N95 masks are unavailable, ensure that the mouth and airways of the clinician are covered with a surgical mask or gauze. However, if the patient has to remove the surgical mask for examination purposes (e.g. taking of throat and nasal swabs) and the GP will therefore be within 1 metre, they will need to wear a P2/N95 mask, goggles, long sleeved gown and gloves (Personal Protective Equipment – PPE). Ensure that PPE is removed in the correct order:
13. What questions should the GP receptionist ask patients on the phone? The following questions are relevant: Have you had a recent acute febrile respiratory illness - a measured temperature of 38 degrees Celsius (or a good history of fever) and recent onset of at least one of the following: rhinorrhea or nasal congestion, sore throat, or cough? If so, have you travelled through Mexico, USA or Canada within the last 7 days? (The list of countries will change as time goes on). 14. At this stage, should the GP do home visits, or will the GP need to stay at the clinic where it may be more efficient to see the patients? This is at the discretion of individual GPs. 15. Do GPs need a dedicated room at this stage to be used for isolation or separation of a possible infected patient from others in the waiting room? Whilst not absolutely necessary, a separate room for suspected cases is recommended, in order to limit exposure to other patients and staff. 16. What is an undiagnosed fever? As GPs rarely seek microbiological confirmation of every cough and cold, will they need to swab everyone with a fever? Are the path companies able to supply enough swabs or enough transport media? At this stage, the definition of a suspected case as provided in the latest advice from the Chief Medical Officer is the indication for further investigation. Obviously, practitioners should exercise their own clinical judgement. AMA note: the latest advice from the Chief Medical Officer on case definition is as follows: A suspected case of swine influenza A (H1N1) is a person with an acute febrile respiratory illness with onset:
17. What should a GP do if patients ring from home concerned about symptoms and over the phone sound high risk? Who will do testing? If a patient calls from home and meets the definition of a suspected case, GPs should do the following:
Swine Influenza Outbreak – Contact Details
For doctors only:
For public inquiry there is a National Commonwealth Health Hotline for Swine Influenza on 180 2007 (this number is correct) For further information please visit the AMA website. If you are not a member of the AMA and would like to receive this type of information directly in the future, contact your state branch to join the AMA. If you are a member please check your details at the AMA member details page. |
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