GPs sound alarm over aged-care flu standards

Matt Woodley

9/07/2019 4:58:31 PM

Australia’s horror flu season has resulted in more than 360 influenza outbreaks at residential aged care facilities across the country.

GPs call for standardised approach.
GPs have called for a standardised approach to containing influenza outbreaks in residential aged care facilities.

However, despite the potentially fatal consequences for residential aged care facility (RACF) residents, there are no uniform, evidence-based standards for vaccination or containment.
Concern about the ad hoc approach has been so great that it prompted a group of GPs in South Australia, which has had the highest number of lab-confirmed notifications per capita, to arrange a meeting with SA Health to detail specific issues related to influenza containment within RACFs.
One of the meeting’s organisers, GP and Immunisation Coalition (IC) member Dr Rod Pearce, told newsGP there have been several issues related to managing the outbreaks but that he is hopeful of collaborating with government and RACFs to formulate a standardised approach for next winter.
‘At the moment there’s no predictable response from RACFs that satisfies GPs that their patients are being looked after properly,’ he said.
‘Lots of GPs [are] saying there’s a problem … we think outbreak control should be managed with some sort of evidence base.
‘We are considering putting together a trial in South Australia next year where we actually look at outbreak control, and manage RACFs in a way where we can document the response and get some evidence about the best way to do it.’
Dr Pearce said antivirals are currently being underutilised during outbreaks, and that more collaboration between RACFs and GPs could improve patient safety by helping to increase immunisation rates of both patients and staff. He also called for a more uniform approach to managing the flow of patients and visitors that could potentially introduce infection into the facilities.
‘They’re being done, but they’re being done ad hoc. Each place has got its own way of doing it. So if there was better communication with GPs, then the GPs could support what’s being done,’ he said.
‘Guidelines, the evidence base and the protocols that RACFs use for vaccinations and outbreaks is not standardised in a predictable way, so that creates the opportunity for ad hoc methods to put the whole process at risk.
‘There are about 250 RACFs in SA, and about one-fifth are run by the state. We’re hoping we can work with them next year to look at something that is more consistent and robust, so at least we will have a handle on what’s going on and GPs can be more confident that there is a more uniform response.’
Aged and Community Services Australia (ACSA) CEO Patricia Sparrow told newsGP the peak body would consider any new proposal for universal standards, but would need to see the detail and understand how implementation would work in practice. 
‘There are already various requirements and standards in operation that relate to outbreaks and those would need to be considered as well,’ she said.
‘The Commonwealth has responsibility for aged care and as part of this responsibility prescribes a mandatory influenza management program.  However, this is separate to the responsibility that the states and territories have in relation to the management of health-related outbreaks that occur in their respective jurisdictions.’
Aside from concerns over the ad hoc approach to containing outbreaks and vaccine coverage, Dr Ken McCroary, Vice Chair of the RACGP Expert Committee – Standards for General Practices, told newsGP a standardised approach to administering vaccines is also required to ensure maximum efficacy.
‘The stringency of the cold chain varies through all these different places – I’ve personally walked into nursing homes and seen their fridges at –2⁰ with ice all over the vaccines,’ he said.
‘I’ve also seen [staff] at nursing home wards get them out of the fridge at 9am and then leave them on the trolley for the entire shift until three or four o’clock in the afternoon as they give all the residents their vaccine, which by then is just a complete waste and ineffective.’

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Dr Marisa Gilles   10/07/2019 11:49:54 AM

This is very interesting we have had three outbreaks in RCF, two before vaccination of residents and staff had occurred because of this years early onset of the influenza season. In the third vaccination rates were excellent for staff and residents and the outbreak contained quickly - there are national CDNA guidelines specifically stating the correct response to an outbreak in a RCF which are comprehensive and work, they include the use of Tamiflu for both symptomatic and as a prophylaxis lets not reinvent the wheel.

Dr Christopher David Mitchell   10/07/2019 8:43:56 PM

I'd love some evidence that antivirals make a meaningful difference before I get too excited

Simon Pilbrow   11/07/2019 6:26:45 AM

Two issues raised here: (1) the cold chain, (2) managing the outbreaks.
(1) The flu vax cold chain is the GP's responsibility. I am very surprised at this article's suggestion that RACF nurses are commonly doing the Flu vaccinations. GPs should do all their own vaccinations in RACFs and thereby the problem of the cold chain is completely under the GP's control. (1) should be a non-issue
(2) the RACFs have clear standards and protocols for managing outbreaks via CDNA guidelines, and in the region of Victoria in which I attend four separate facilities, these seem to be implemented well and work well. Nobody can stop the viruses mutating, or early outbreaks, but when but they occur, seem to be responsibly managed and contained in the facilities I visit - patients don't enjoy the restrictions on their movements, the lock-downs might be inconvenient for everyone, but what I observe is being done well. I would believe that the facilities do their best to comply with health dept protocols

Chris D Hogan   11/07/2019 9:20:05 AM

Having been involved in writing them I am happy to inform my colleagues that there indeed are guidelines involved in the management of influenza in nursing homes- they are contained in the pandemic plans from RACGP, state & federal health departments.
There is plenty of evidence especially from trials undertaken in Canada several years ago. The problem lies in having the political will to institute for & enforce them.
Immunisation is the key to control. However , the uptake of a vaccine in the frail elderly is not high, Some studies quote a response of 25%. The key is to immunise EVERYONE who regularly visits a nursing home during flu season especially all staff who attend the facility.
Influenza may be infectious 24 hours before onset of flu symptoms & 2 days or more after apparent recovery
Quarantine is also critical - NO ONE who is unwell should visit a nursing home at any time- particularly staff.
Oral anti influenza drugs should be used for prophylaxis of unaffected people

Dr Evan Wayne Ackermann   11/07/2019 10:06:18 PM

Thank you Dr Pearce and GPs in SA - and appreciation to you Chris H for writing guidelines for management of influenza in aged care facilities. As a profession we are the only group with a long term focus in this critical area.
I do also agree with Chris Mitchell re the evidence of antivirals, and indeed the effectiveness of, (or lack of) and problems associated with influenza vaccination. It is far more complex than most people realize.
Thank you to all GPs who actually DO something rather than merely whinge.