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									                        Waikato DHB
                 Novel Influenza A (H1N1) 09
                  Pandemic Response Plan
                      for Primary Care



                                13 July 2009



  THIS IS A LIVING DOCUMENT AND SUBJECT TO
   REGULAR UPDATES AS INFORMATION AND
            CIRCUMSTANCES CHANGE

WDHB Primary Care Pandemic Response Plan: Version 4.0   13 July 2009   Page   1
Table of Contents
1.   Summary of Updates ............................................................................................................................ 4
2.   Introduction .......................................................................................................................................... 4
3.   Abbreviations and definitions .............................................................................................................. 4
   3.1     Abbreviations ............................................................................................................................... 4
   3.2     Definitions..................................................................................................................................... 5
4. Background ........................................................................................................................................... 5
5. Principles, assumptions and concepts ................................................................................................. 6
6. Organisational responsibilities ............................................................................................................ 8
7. Coordination of the Primary Care Response ..................................................................................... 9
   7.1     Primary Care workload monitoring .......................................................................................... 9
8. Facilities ............................................................................................................................................... 10
   8.1     CBACs ........................................................................................................................................ 10
     8.1.1      CBAC functions                                                                                                                                10
     8.1.2      CBAC locations                                                                                                                                11
   8.2     Key practices .............................................................................................................................. 11
     8.2.1      Key practice locations                                                                                                                        12
   8.3     Residential Institutions and Day Centres ................................................................................ 13
     8.3.1      Important considerations                                                                                                                      13
     8.3.2      Action points                                                                                                                                 13
   8.4     School dental clinics ................................................................................................................... 13
   8.5     Community pharmacies ............................................................................................................ 14
9. Personnel ............................................................................................................................................. 14
   9.1     CBACs ........................................................................................................................................ 14
   9.2     Key Practices .............................................................................................................................. 15
   9.3     Security ....................................................................................................................................... 15
     9.3.1      CBACs                                                                                                                                         15
     9.3.2      Key Practices                                                                                                                                 15
   9.4     Health professionals working outside their scope of practice ................................................ 15
10.     Equipment ...................................................................................................................................... 15
11.     Patient flows ................................................................................................................................... 15
   11.1     Patient types.............................................................................................................................. 15
12.     Infection control ............................................................................................................................. 17
   12.1     General infection control information .................................................................................... 17
     12.1.1     Mode of transmission                                                                                                                          17
     12.1.2     Incubation period                                                                                                                             17
     12.1.3     Period of communicability                                                                                                                     17
   12.2     Infection control in the home .................................................................................................. 17
     12.2.1     Hand hygiene                                                                                                                                  17
     12.2.2     Respiratory etiquette                                                                                                                         18
     12.2.3     Specific infection-control recommendations in the home                                                                                        18
   12.3     Infection control in the community ........................................................................................ 19
   12.4     Infection control in healthcare facilities ................................................................................. 19
     12.4.1     Signage                                                                                                                                       20
     12.4.2     Hand hygiene                                                                                                                                  20
     12.4.3     Patient management                                                                                                                            20
     12.4.4     Personal Protective Equipment                                                                                                                 20
     12.4.5     Cleaning and Sterilisation of Patient Care Equipment                                                                                          20
     12.4.6     Environmental Control (housekeeping, laundry, waste)                                                                                          21
     12.4.7     Use of Masks                                                                                                                                  21
   12.5     Infection Control in High Risk Institutions ........................................................................... 21
   12.6     Health workers in the community .......................................................................................... 22
13.     Clinical issues.................................................................................................................................. 22
   13.1     Diagnosis ................................................................................................................................... 23
     13.1.1     Clinical features                                                                                                                             23
     13.1.2     Swab collection                                                                                                                               23


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   13.2     Management ............................................................................................................................. 24
   13.3     Use of antiviral medication ...................................................................................................... 24
     13.3.1     Prophylaxis                                                                                                                                  24
     13.3.2     Treatment                                                                                                                                    25
     13.3.3     Choice of antiviral                                                                                                                          25
     13.3.4     Indications for antiviral drugs                                                                                                              25
     13.3.5     Tamiflu                                                                                                                                      26
     13.3.5     Relenza                                                                                                                                      28
   13.4     Complications ........................................................................................................................... 29
     13.4.1     Pneumonia                                                                                                                                    29
     13.4.2     Bronchitis                                                                                                                                   30
   13.5     Indications for referral to Emergency Department (ED) .................................................... 31
     13.5.1     Adults                                                                                                                                       31
     13.5.2     Modified EWS (MEWS) scale                                                                                                                    31
     13.5.3     Children < 16 years                                                                                                                          31
     13.5.4     Infants                                                                                                                                      33
   13.6     Vaccination ............................................................................................................................... 33
     13.6.1     Extended eligibility for free seasonal influenza vaccine                                                                                     33
     13.6.2     Pandemic influenza vaccine                                                                                                                   34
   13.7     Special groups ........................................................................................................................... 34
     13.7.1     Pregnant women                                                                                                                               34
     13.7.2     Young children                                                                                                                               35
     13.7.3     Infants                                                                                                                                      35
     13.7.4     People aged > 65 years                                                                                                                       37
     13.6.1     Immunosuppressed people                                                                                                                      37
14.     Logistics .......................................................................................................................................... 38
   14.1     Purpose of the national reserve supplies ................................................................................ 38
   14.2     DHB responsibilities................................................................................................................. 38
   14.3     Funding, accounting, and financial arrangements ................................................................ 39
   14.4     Release of supplies .................................................................................................................... 39
     14.4.1     Order of use                                                                                                                                 39
     14.4.2     Authorisation                                                                                                                                39
     14.4.3     Supplies for PHOs, private sector health organisations and other response agencies                                                           39
   14.5     Available supplies ..................................................................................................................... 40
     14.5.1     PPE                                                                                                                                          40
     14.5.2     Antibiotics                                                                                                                                  40
     14.5.3     Tamiflu                                                                                                                                      40
15.     Communications ............................................................................................................................. 41
16.     Data management .......................................................................................................................... 41
   16.1     Clinical ...................................................................................................................................... 41
     16.1.1     Initial assessment                                                                                                                           42
     16.1.2     Further assessment                                                                                                                           42
   16.2     Logistic ...................................................................................................................................... 42
   16.3     Epidemiological ........................................................................................................................ 43
   16.4     Human resources ...................................................................................................................... 43
17.     Financial issues ............................................................................................................................... 43
18.     References ....................................................................................................................................... 44
19.     Appendices ...................................................................................................................................... 45
   Appendix 1. Map of the Waikato DHB area ..................................................................................... 45
   Appendix 2. Position descriptions ...................................................................................................... 46
   Appendix 3. Welfare Referral Form ................................................................................................... 51
   Appendix 4. Modified Early Warning Score (MEWS) ..................................................................... 52
   Appendix 5. SIRS (systemic inflammatory response syndrome) criteria ........................................ 52
   Appendix 6. CBAC Supplies list.......................................................................................................... 53
   Appendix 7. Taking Tamiflu: for people who cannot take medication capsules ............................ 55
   Appendix 8. Process for activation and deactivation of CBACs ..................................................... 56
   Appendix 9. Patient flows during a Pandemic .................................................................................. 57
   Appendix 10. Community Based Initial Assessment / Triage Form ................................................. 58


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  Appendix 11.   CBAC assessment form: Medtech Outbox document ................................................ 59
  Appendix 12.   Instructions for collecting specimens for Influenza A (H1N1) 09 .............................. 60
  Appendix 13.   Order forms for Pandemic Supplies ............................................................................. 61
  Appendix 14.    Infection control in the home: Patient Information ................................................... 67
  Appendix 15.    Sending patient clinical data to other health care providers via MedTech ............. 68
  Appendix 16.    Data flows for patients with ILI presenting at CBACs .............................................. 69


1. Summary of Updates
Date       Change
8/7/09     Addition of sections on extension of period for seasonal flu
8/7/09     Addition of section on pandemic vaccine and changes to current eligibility criteria
12/7/09    Expanded section on antivirals
13/7/09    Indications for antibiotic indications
13/7/09    Expanded sections on infants
13/7/09    Addition of Medtech Outbox CBAC assessment form

2. Introduction
With the recent appearance of a novel strain of Influenza A (H1N1) 09 virus, plans have been
developed to enable the capacity to respond to an anticipated marked increase in those affected by
this virus. This pandemic is not anticipated to be as lethal as the 1918 pandemic, and current
experience is that this is a milder form of the illness with lower mortality rates. Because this virus is
known to be novel, with no persons having immunity, it is expected that infection will be
widespread, affecting possibly 30% of the population.

This document describes the primary care response to this situation for the Waikato region (see
Appendix 1). This response requires coordination between Health Waikato, several community and
rural hospitals, several PHOs, as well as primary health care providers that are not part of a PHO.

3. Abbreviations and definitions
   3.1     Abbreviations

Abbreviation                             Interpretation
BAU                                      Business as usual
CBAC                                     Community-based Assessment Centres
CDEM                                     Civil Defence Emergency Management
EDI                                      Electronic digital identifier
ILI                                      Influenza-like-illness
HML                                      Home Care Medical Limited (Telephone triage services)
KP                                       Key Practices
MOoH                                     Medical Officer of Health
MoH                                      Ministry of Health
NHCC                                     National Health Coordination Centre
PHO                                      Primary Health Organisation
PITAG                                    Pandemic Influenza Technical Advisor Group

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PPCRT                          Pandemic Primary Care Response Team
PPCH                           Pandemic Primary Care Hub
PPE                            Personal Protective Equipment
NZIPAP                         New Zealand Influenza Pandemic Action Plan
WDHB                           Waikato District Health Board

      3.2   Definitions

Confirmed case            Laboratory confirmed Novel Influenza A (H1N1) 09 infection by one or
                           more of the following tests:
                               o real-time RT-PCR
                               o viral culture
                               o four-fold rise in Novel Influenza A (H1N1) 09 virus-specific
                                   neutralising antibodies
Probable case             ILI, AND
                          A strong epidemiological link to a confirmed case or a defined cluster
Close contact             A person having cared for, lived with, or had direct contact with
                           respiratory secretions or bodily fluids of a probable or confirmed case
ILI                       History of fever, chills and sweating OR clinically documented fever >/=
                           38 C, AND
                          Cough or sore throat

4. Background

In 2006, the WDHB developed a document that described the functioning of Community-Based
Assessment Centres (CBACs).1 However, there was limited discussion with primary care providers.
There were subsequent attempts to remedy this, but other priorities prevented significant progress.
With the more recent appearance and spread of Novel Influenza A (H1N1) 09 throughout the world,
the need to develop a workable plan became apparent, and WDHB began meetings with primary
care providers to effect this.

Initially, it was envisaged that the WDHB would manage the CBACs, but primary care management
of these is now considered more appropriate, as they require significant interplay between the
various components of primary care. Therefore, a collaborative process has been instituted that
allows cooperation and communication across the primary care sector. It has been agreed that these
processes are to be led by Pinnacle Incorporated, supported and advised by other primary care
providers, and coordinated by WDHB GP liaison.

This plan is aligned with the NZIPAP Pandemic Action Plan2 and mostly with the WDHB pandemic
plans,1, 3 although some differences exist; mobile CBACs have not been considered and CBACs will
now be largely managed from primary care whereas in the existing guideline, they were to be
administered by the WDHB.

This plan meets ethical and legal requirements, and is intended to address known inequalities and
barriers to care.



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5. Principles, assumptions and concepts
In managing a pandemic situation, there are several underlying principles that guide the response.
    1. The spread of infection needs to be limited or managed. This will limit the strain on health
       and other services.
    2. Complications of influenza can be more serious than the influenza itself.
    3. Identifying those at increased risk of complications, will allow health services to focus on
       those who have the greatest need.
    4. Primary care services are a fundamental part of the health service, but are provided largely by
       small, often financially precarious businesses, and the viability of these providers may be
       threatened by a pandemic. Therefore, every effort will be made to minimise deleterious
       effects.
    5. Cooperation across the primary care sector is considered essential to a coordinated and
       effective response to the pandemic.

This plan has been developed using the following assumptions:
   1. That this form of influenza will not be dissimilar to seasonal influenza and is likely to
       clinically indistinguishable.
   2. That pandemic influenza and seasonal influenza are likely to occur simultaneously in the
       same population
   3. That the spread of infection will occur in pockets, and services may need to respond to this,
       by increasing services on an area-by-area basis
   4. That secondary services will continue with „business as usual‟ as able
   5. That telephone triage will be the preferred first point of call
   6. That public communications will be the method for advising the community about
       CBACs. WDHB Communications staff will liaise with MoH communications staff to ensure
       a nationally consistent approach.
   7. That the MoH will define a minimum data set for documenting all cases of influenza.

Primary care services have been conceptually divided into three groups:

   1. CBACs. These were initially considered to be facilities that were separate from usual health
      care services, and were to be staffed by temporary, possibly semi-clinical persons. However,
      this was in the context of a pandemic that was associated with a high morbidity, and high
      mortality rate. The current pandemic does not appear to have these characteristics. Therefore,
      CBACs have been set up adjacent to, or part of existing 24-hour GP-led clinics in Hamilton,
      and in available facilities in the rural hospitals in Te Awamutu, Morrinsville, Tokoroa,
      Thames, and Te Kuiti. In some locations, CBACs will be set up non-medical facilities
      (Matamata, Whangamata and Huntly).

   2. Key practices. These are primary care facilities that have the capacity to separate influenza
      patients from non-infected patients in the course of providing care. These are larger practices
      which are strategically placed to reduce the need for infected persons to travel.

   3. Business-as-usual practices. These comprise the remainder of general practices. Potentially
      infected persons will be discouraged from attending these practices, to minimise the spread
      of infection.



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In the Waikato region, these distinctions have become somewhat blurred. In Hamilton City, the two
nominated CBACs provide emergency primary care services which will continue, and so may carry
out a dual role of both CBAC and KP status. In the outlying areas with local hospitals, the CBACs
will be located in/adjacent to these local hospitals, and may not have medical staff attached. In other
locations, they will be separate.




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6. Organisational responsibilities
The structure of health services responsible for managing a pandemic situation need to address
several aspects:
   1. Strategic decisions
   2. Communication
   3. Logistics
   4. Personnel management
   5. Data management

The responsibility lies with the WDHB for the overall management of the response. The
organisational structure is intended to be mirrored at the strategic and operational levels. The
following diagram depicts the roles and lines of responsibility for the response with primary care
management in context of the larger organisational structure.




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7. Coordination of the Primary Care Response

Management of the complexities associated with providing primary care in a pandemic is considered
to preferably lie with current primary care organisations. The initiation of the opening of CBACs
will be approved by the NHCC via the DHB Incident Control Team. Once this has happened, the
management of CBACs will be provided by the Pandemic Primary Care Response Team (PPCRT)
based at the Pinnacle Incorporated Office in Victoria St, Hamilton, where a „Primary Care Pandemic
Hub‟ (PCPH) will be located. The team will include a Primary Care Pandemic
Coordinator/Operations Manager, as well other personnel representing non-Pinnacle PHOs, DHB
logistic, planning, public health and liaison personnel, and administrative support from Pinnacle
staff.

The PPCRT will provide the following functions:
    Centralised management of communications including distribution of MoH and WDHB
      directives. This will include advice regarding the need for activation of CBACs and KPs in
      consultation with WDHB staff
    Dissemination of clinical guidelines and directives
    Management of practice closures and reopening, and reallocation of primary care staff as
      required, including optimisation of the use of volunteers, DHB staff and others who may be
      available
    Tracking of staff remuneration and (timesheets) where they may be working at sites other
      than their usual location
    Facilitation of clinical communication across the sector
    Managing the fiscal issues that may arise around payments to practices for flu patients, and
      BAU patients where they cannot be seen by their usual provider
    Facilitating the establishment of consistent and reasonable MOUs and contracts, with WDHB
      as appropriate for Pinnacle and other practices, in ways that ensure no provider is unduly
      disadvantaged.

   7.1     Primary Care workload monitoring
All general practices should have by now received an emailed question in regards to „monitoring
your practice workload‟. The PPCRT will be sending this out twice weekly for feedback although
this may need to be more frequent in the event of a rapidly changing situation. Monitoring the replies
to the single question (with its five options) will enable the PPCRT to identify those areas that are
struggling, so as to provide assistance and is the only monitoring strategy for this issue. Accordingly,
a prompt reply from all recipients is essential for ensuring a timely and appropriate response. Use of
antivirals is also being monitored via the community pharmacies.

Note: If at any time, practices or pharmacies become unable to cope, they should contact the
Pandemic Primary Care Response Team via email pandemic@pinnacle.org.nz or Maree Munro 027
204 4386 as soon as the problem is identified.




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8. Facilities
Allocation of facilities has been guided by the following considerations:
    Primary care population served
    Location of potential facilities
    Willingness of facilities/practices to be involved.
Planning has been also been guided by existing arrangements for 24-hour accident and medical
services, but has been varied where high levels of deprivation and lack of transport may be barriers
to care, or where geography demands a local solution.

Generally, pandemic-specific primary care services (CBACs and Key Practices) will provide care
for populations of 12,000 – 16,000 persons. In the event of very large numbers of people being
affected by influenza that cannot be managed by the above facilities, the CBAC component of
Anglesea Clinic and Victoria Central will relocate to larger facilities.

   8.1        CBACs
CBACs are expected to be used in event of a more widespread outbreak, and have been selected for
location and capacity. The purpose of CBACs is to separate patients who have symptoms suggestive
of pandemic influenza, from those who do not have such symptoms, and to provide some primary
care services.4

Opening CBACs is considered an action of last resort, when current healthcare providers can no
longer cope with the numbers of patients being seen with ILI.

         8.1.1 CBAC functions
         These will include:
             Telephone triage
             Triage and assessment for people presenting with ILI
             Provision of advice and information on patient care and infection control
             Dispensing of antivirals and antibiotics according to protocols
             Referral to CDEM Welfare services (see Appendix 3)

         These will NOT include:
             Inpatient, observational or hospital services
             Vaccinations unless directed by the MoH
             Home visits
             Emergency services other than collapse of the sick in the CBAC
             General Practice services
             ED services
             Radiology and diagnostic services
             Social services
             PPE for the community
             Prophylactic dispensing of antivirals




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People will be discouraged from attending CBACs after hours via public messaging (radio,
newspaper), to reduce the stress on facilities and healthcare staff. Where a CBAC is not open 24
hours, after-hours services will be provided as per the non-pandemic arrangement.

         8.1.2 CBAC locations
         Table 1. CBAC Locations in the Waikato Region

         Location                           Facility
         Hamilton                           Anglesea Clinic
                                            Victoria Central A&M
         Huntly                             Parry St Complex
         Matamata                           St John Hall
         Morrinsville                       Rhoda Read Hospital
         Taumaranui                         Taumaranui Hospital Ward 3
         Te Awamutu                         Matariki Hospital
         Te Kuiti                           Te Kuiti Hospital Physio Dept
         Ngaruawahia                        Nga Miro Centre
         Thames                             Thames Hospital Manaaki Centre
         Tokoroa                            Tokoroa Hospital Ward 3
         Whangamata                         Whangamata Area School

The staffing of CBACs will initially be the responsibility of the organisation concerned. However,
staff may need to come from other areas of primary care in the event of increased numbers of
affected people. This process will be managed by the PPCRT.

   8.2       Key practices
At strategic locations within Hamilton, and surrounding areas, Key Practices have been identified
which have a separate entrance, and rooms which can be used separately from „business-as-usual‟
(BAU) patients (see Table 1). These facilities are expected to see high-risk patients, as well as BAU
patients, but will refer low-risk patients to the nearest CBAC (see Appendix 9 for a graphic of
patient flows). Key Practices usually have a pharmacy on-site, or near-by.4




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      8.2.1 Key practice locations
      Table 2. Key practice locations in the Waikato Region (as of 7th July 2009)

      Location         Key Practice                         Organisation
      Cambridge        Leamington Medical Centre            Waikato PHO
      Coromandel       Coromandel Family Health Centre      Waikato PHO
                       Te Korowai Hauora Coromandel         Te Korowai Hauora o Hauraki
                                                            PHO
      Hamilton         Fairfield Medical Centre             Waikato PHO
                       Hamilton East Medical Centre
                       Northcare, Pukete Road only
                       South City Health Ltd
                       Radius Rototuna
                       Westend Health Centre
                       Te Ha O Kiritahi Health              Toi Ora Maori PHO
                       University of Waikato Student        Student Health Services
                       Health
                       Nawton Medical Clinic                Raukura Hauora o Tainui PHO
                       Enderley Medical
                       Clinic/Community Park Centre
      Huntly           Huntly East Medical                  Waikato PHO
                       Waahi Medical Clinic                 Raukura Hauora o Tainui PHO
      Kawhia           Kawhia Health Centre                 Waikato PHO
      Matamata         Matamata Medical Centre              Waikato PHO
      Morrinsville     Morrinsville Medical Centre          Waikato PHO
      Raglan           West Coast Health 2004 Ltd           Waikato PHO
      Te Kuiti         Te Kuiti Medical Centre              Waikato PHO
                       Te Korowai Hauora Whitianga          Te Korowai Hauora o Hauraki
                       Doctors Surgery                      PHO
      Taumaranui       Taumaranui Medical Centre Ltd        Waikato PHO
      Te Aroha         Health Te Aroha                      Waikato PHO
      Te Awamutu       Te Awamutu Medical Centre            Waikato PHO
      Te Kauwhata      Te Kauwhata Medical Centre           Waikato PHO
      Thames           Te Korowai Hauora                    Te Korowai Hauora o Hauraki
                                                            PHO
      Waihi            Te Korowai Hauora Waihi Health       Te Korowai Hauora o Hauraki
                       Centre                               PHO
      Whangamata       Whangamata Medical Centre            Waikato PHO
      Whitianga        Mercury Bay Medical Centre           Waikato PHO




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    8.3      Residential Institutions and Day Centres
Public Health Services must be called in to assist high-risk institutions (residential and day centres)
where one or more ILI cases have occurred.5 All such institutional outbreaks are to be notified to the
Population Health Service.

          8.3.1 Important considerations

           The likelihood of further spread within the particular institution:
                   o How robust are the infection control procedures that are already in place?
                   o What involvement has there already been from GPs, including the prescribing of
                       antivirals?
           The degree of vulnerability of the residents/attendees to influenza complications age,
            immune status, and presence of chronic diseases
           Whether people wish to take Tamiflu, and the risks posed by Tamiflu (for example in
            relation to polypharmacy in elderly or mental health settings)
           Whether residents/attendees can be excluded (managed at home) rather than needing to
            remain within the institution
           Whether business continuity is threatened by staff illness
           In limited circumstances prophylactic treatment may be considered for staff and or
            residents of institutions where disease is present. Prescribing Tamiflu for prophylactic use
            will not be funded unless specifically authorised by the MOoH.

          8.3.2 Action points

         Ensure that the infection control procedures are robust, including the appropriate
          management of staff and residents/attendees who become ill with ILI.
         There should be a low threshold for the collection of nasopharyngeal samples and antiviral
          treatment of people with ILI.
         Treatment with Tamiflu should begin within the first 48 hours of symptom onset:
              o for sick staff, to shorten the infectious period and expedite return of staff to work
              o for residents in isolation in residential institutions
              o for staff caring for a case, and/or other residents, where social
                 distancing/PPE/effective isolation are impracticable (e.g., care for children with
                 behavioural difficulties.
         Quarantine or exclude staff or residents exposed outside of the institution.

    8.4      School dental clinics

   Dental therapists should avoid assessment and treatment for children with flu-like symptoms.
   Standard precautions, which include the use of PPE must be used for assessment and treatment
     of all patients
   For emergency care for a child with flu-like symptoms :
           o Aerosol generating procedures should be kept to a minimum
           o Ventilation needs to be considered by opening doors or windows, or using an
               extraction fan (if fitted)



WDHB Primary Care Pandemic Response Plan: Version 4.0              13 July 2009             Page    13
          o PPE must be used by all staff, parents and caregivers in the surgery during and
              immediately following any dental procedure until the child leaves and the surgery is
              fully ventilated by opening all doors and windows
          o Standard precautions continue to apply
     Should any required PPE not be available on ordering, staff should contact their team leader.

    8.5    Community pharmacies
Waikato Community Pharmacy Group‟s chief executive Cath Knapton is keeping a database of
pharmacies and prescribers, which has already identified several „outlier‟ prescribers. These
practitioners have been contacted directly and asked to review their prescribing decisions with
colleagues.

As set out in the MoH‟s latest guidance, prophylactic use of Tamiflu is currently very limited, and
may not be initiated without the specific approval of the Medical Officer of Health. Pharmacists
should contact the MOoH before dispensing Tamiflu for prophylactic use to ensure their stock will
be replaced.

9. Personnel
    9.1    CBACs
Staff working in a CBAC may manage a number of functions such as telephone triage, referrals,
people flow, triage, reception, assessment and information as per designated pathways. These
facilities are expected to be nurse-led, with support from administrative, reception, cleaning and
security staff.

Table 3. CBAC staff roles

Position                 Roles
Administration staff      Register patients and collect demographic data
Reception/Support         Identify people who require information only
staff (trained non-       Identify people who require further assessment and
clinical staff)              treatment at the CBAC by clinical personnel
Clinical Staff            Provide information, triage, observations, assessment, and
                             treatment (antivirals and antibiotics )
                          Identify people who need more complex care at Key
                             practices
Cleaning staff            Perform Enhanced Infection Control Cleaning procedures
Security staff            Monitor traffic flows, parking, security and entry into the
                             CBAC
                          Limit entry into the CBAC where required
                          Manage difficult people and bottlenecks within the CBAC
                          Provide security for medication

Position descriptions for each of the above are provided in Appendix 2.


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   9.2       Key Practices
Patients with ILI seen at these facilities have increased risk of serious complications and require
medical review, usually a GP, although in the event of large numbers of patients being affected,
experienced primary care nurses will be involved as well. There may need to be separate
reception/support staff, with these practices operating a CBAC-like facility adjacent and in parallel
to their BAU functions.

   9.3       Security

         9.3.1 CBACs
Funding for security staff for CBACs has been included on the overall funding arrangements.
Management, including sourcing, of those staff will be the responsibility of the organisation
operating the CBAC.

         9.3.2 Key Practices
It is not envisaged that security requirements will be any different from normal arrangements for
these practices and therefore, will not require specific funding.


   9.4     Health professionals working outside their scope of practice
Registered health professionals should consult their registration organisation before agreeing to work
beyond their registered scope of practice.

10.        Equipment
See Appendix 6 for a list of requirements for CBACs.

11.         Patient flows
The primary purpose of directing patients to specific facilities is to limit the spread of the virus.
There is also a need for care to be provided at the most appropriate location, depending on the risk of
complications. Therefore, low-risk people will be managed primarily by CBACs, and high-risk
people will be managed by Key Practices. Business as usual patients will be managed by BAU
practices unless their usual practice is a Key Practice. These patient flows are depicted in Appendix
9, with the width of the arrows showing the relative expected volumes.

   11.1 Patient types
In an influenza pandemic, patients can be classified into four groups:
1. Influenza symptoms and low risk
2. Influenza symptoms and high risk of serious complications
3. Influenza symptoms and very unwell


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4. No ILI symptoms but other medical problem

The management of these groups is summarised in the following table.

Table 4. Management of patient groups

Patient group           Site of care                 Comments
Influenza symptoms      Home                         If seen at a general
and low risk            CBAC if needing              practice, refer to
                        treatment                    CBAC
Influenza symptoms      Key practices using          If seen at CBAC, refer
and high risk of        alternative entrance         to KP
serious complications   Antivirals +/- antibiotics
Influenza symptoms      ED                           For example chest
and very unwell                                      pain, respiratory failure
No ILI symptoms and     Usual GP
no exposure




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12. Infection control
During the influenza pandemic, adherence to infection control practices is extremely important to
prevent or minimise transmission.

   12.1     General infection control information

       12.1.1 Mode of transmission
Influenza is transmitted by:
     Primarily, from person to person by large respiratory droplets from coughing or sneezing.
       Because these droplets can travel a distance of one – two metres, the risk of transmission is
       highest when people are in close contact, generally less than one metre (or arm's length)
     Contact with hands and articles freshly soiled with discharges of the nose and throat of an
       acutely ill individual
     Possibly by the airborne route (controversial) during aerosolizing procedures.

       12.1.2 Incubation period
The incubation period is one to four days, and may be up to seven days

       12.1.3 Period of communicability
Period of communicability of influenza is 24 hours before the onset of symptoms and three to five
days after the onset of symptoms. Children, especially those who are younger, may be infectious for
up to 10 days.

Note: Influenza A and B viruses can survive on hard surfaces for 24 to 48 hours, on softer, porous
surfaces for 8 to 12 hours and on the hands for up to five minutes.

   12.2 Infection control in the home
Two key measures are hand-hygiene and respiratory etiquette. Additionally, during an influenza
pandemic the transmission of the influenza virus and other pathogens can be further reduced by
distancing ill household members from those who are well.

       12.2.1 Hand hygiene
Hand-hygiene is an important measure to prevent the spread of common communicable diseases
including acute respiratory tract infections (e.g. influenza) and diarrhoeal diseases. Coughing or
sneezing, or contact with faeces or material that contains potentially infectious respiratory or
gastrointestinal pathogens, may contaminate hands, clothes or surfaces (tables, doorknobs/handles,
plates, cups, etc.).

Hands should be cleaned by washing with soap and water for 20 seconds before rinsing, and then
dried. Alcohol-based preparations (60–80% alcohol content), if used and available locally, are also
effective if rubbed on hands until the hands are dry.

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Hand-hygiene must be performed:
    before preparing or eating food
    after defaecation or changing or cleaning a child
    after coughing, sneezing or blowing nose
    before and after all contact with sick patients
    after cleaning or handling the patient's soiled linen and waste
    after handling animals or animal waste.

               12.2.2 Respiratory etiquette
Transmission of community-acquired respiratory infections occurs most commonly through
inhalation of respiratory droplets produced by talking, coughing, spitting and sneezing. Respiratory
droplets may also survive for brief periods (depending on the ambient temperature) on hands, clothes
and surfaces.

Respiratory etiquette, i.e. "control at the source", involves covering coughs or sneezes with a barrier-
like tissue/cloth/mask to prevent the dispersion of respiratory droplets into the air and onto surfaces.
     Coughs and sneezes should be covered with a tissue, cloth or mask. Used tissues should be
         disposed of into a plastic bag, and hands should be subsequently washed.
     Respiratory droplets from coughing and sneezing or talking may land on hands, clothes or
         surfaces. Hands must be washed after direct contact with respiratory secretions and after
         contact with sick individuals (i.e. after contact with hands or potentially contaminated
         surfaces).
     Surfaces should be cleaned regularly with detergent and water (or other disinfection fluids
         such as bleach) to avoid self-contamination (i.e. touching the mouth, nose or eyes after
         touching a contaminated area).
     Masks are not recommended for generalised (community) use.

           12.2.3 Specific infection-control recommendations in the home

      Shared spaces should be well ventilated. When homes and living areas are well ventilated
       (e.g. windows open), respiratory droplets are better dispersed and the risk of transmission of
       respiratory pathogens is reduced. Thus homes should be kept as open as possible to allow
       good air flow. This is particularly important in crowded settings.
      The number of caregivers in the home should be minimised to avoid further exposure of
       family members.
      Family members should limit close contact with an ill person as much as possible.
      Ill persons should cover their mouth and nose with a tissue, cloth (or cough or sneeze into
       sleeve) or a mask when coughing or sneezing, particularly when receiving care, or while in
       close contact with others.
      In the home, the caregiver of an ill patient should take proper precautions such as safe
       distancing (as much as possible), improved airflow to the patient area, hand-hygiene, and
       minimising overall contact with the ill family member.
      Recommendations for the use of masks for caregivers in the home should be adapted to the
       level of resources and the ability to safely implement, and should be accompanied by training
       on safe use and disposal. Use of masks for caregivers in the home might be beneficial in



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       limiting transmission, but is thought to be less important than the other measures mentioned
       above.
      Persons at increased risk of morbidity and mortality from illnesses should not care for or be
       in close contact with the ill person. These persons include pregnant women, children aged
       under 2 years, persons aged over 65 years, and persons with severe chronic diseases or who
       are immunocompromised.
      Avoid other types of exposure to an ill person such as sharing toothbrushes, cigarettes, eating
       utensils, drinks and linens.
      Cleaning of the environment should include washing shared surfaces and clothes, bed linen
       and scarves that have been in contact with a patient's respiratory secretions or stools. Water
       and detergent should be used for washing, and afterwards hands should be washed
       thoroughly with detergent and water (or alcohol based hand sanitisers).

   12.3 Infection control in the community
To reduce disease transmission, efforts to reduce crowding and close contact and to minimise
gatherings of people are critical. To be most effective, these interventions should be implemented
early, targeted to settings where high transmission is likely (e.g. schools) and layered to provide
multiple levels of prevention activities.
     Ill people should be encouraged to remain at home (voluntary isolation) as soon as symptoms
         develop, and to restrict close contact with others.
     Household contacts of patients with respiratory illness should be encouraged to remain at
         home (voluntary quarantine) and avoid contact with the patient, unless they are the
         designated caregiver.
     Gatherings of children (e.g. schools and child-care facilities) may need to be closed, sporting
         events postponed, etc. Enforced closure requires the input of the MOoH.
     Gatherings of adults, such as in the workplace and places of worship, should be reduced as
         much as is feasible. Large public gatherings should be discouraged, including funerals. If
         funerals and other ceremonial/religious events do proceed, close contact should be
         minimised, and hand hygiene/cough etiquette promoted.
     Population movements to and from communities should generally be discouraged, and
         movement of anyone with symptoms should be avoided.

   12.4 Infection control in healthcare facilities
Table 5. Summary of infection control measures

 Protection measure               Applicability
 Hand hygiene, cough etiquette,   Everyone, all the time
 ventilation
 Social distancing                Everyone, whenever practical
 Disposable surgical mask         Carers in direct contact with the sick
 Mask, eye protection, gloves,    Health care workers participating directly in close
 gown/apron                       contact patient care when there is a high risk of contact
                                  with respiratory secretions, particularly via aerosols




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               12.4.1 Signage
Signs should be posted at all entrances informing patients, residents, clients, visitors, volunteers and
staff of appropriate actions to be taken before or upon entering the facility. These will be made and
supplied by the Visual Communications Unit of the WDHB.

               12.4.2 Hand hygiene
Hand hygiene is an important part of preventing the spread of infectious diseases, including
influenza. Hand hygiene can be performed with soap and warm water or by using waterless alcohol-
based hand sanitisers. Placing alcohol based hand sanitisers at strategic points such as the entrance
of facilities for clients as well as staff to use is useful in preventing transmission.

The strict adherence to HAND HYGIENE recommendations is the cornerstone of infection
prevention and control and may be one of the few preventive measure available during a
pandemic.

Staff, patients and those attending or providing care to a patient should be reminded that hand
hygiene is the most important procedure in preventing and controlling the spread of infection. Hand
hygiene should be performed after direct contact with individuals with suspected or confirmed
influenza and after contact with their personal articles or their immediate environment.

               12.4.3 Patient management
If possible, patients with symptoms of influenza or an influenza like illness (ILI) should be placed in
a separate designated area within the premises. A dedicated toilet area is ideal if possible. Whenever
possible, a distance of at least one metre distance should be maintained between patients and staff
(i.e. avoid overcrowding). Movement/activities of staff and clients should be minimised in the
premises, and staff should avoid contact with patients for whom they are not providing care.

               12.4.4 Personal Protective Equipment
Masks should be worn by staff as outlined in standard precautions when splashes or sprays of blood,
body fluids, secretions or excretions to the mucous membranes of the mouth are possible. Masks
may be useful in the pandemic alert and early pandemic periods during face-to-face contact with
coughing individuals, especially when immunisation and antiviral drugs are not yet available.

               12.4.5 Cleaning and Sterilisation of Patient Care Equipment
CBAC staff should adhere to the previously established policies and procedures for the cleaning,
disinfection and sterilisation of patient care equipment.




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       12.4.6 Environmental Control (housekeeping, laundry, waste)
Special handling of linen or waste contaminated with secretions from patients suspected or
confirmed to have influenza is not required. Enhanced cleaning and disinfection of common touch
surfaces (handrails, door knobs, and sink/toilet) is desirable as resources permit.

       12.4.7 Use of Masks
Patients presenting with influenza type symptoms are to be masked as soon as they present, ideally
before coming indoors. All masks must be disposed of after use, in an appropriate waste receptacle,
and hands must be cleaned after the used mask has been discarded. Provide hand sanitising solution
and rubbish bags at the exit.

Surgical masks are recommended for general use. N95 masks are to be used only for taking swabs,
intubation, etc. If N95 masks are unavailable, surgical masks are still considered adequate.

    12.5   Infection Control in High Risk Institutions

    All staff and residents/attendees should be reminded of the importance of good hand hygiene.
    Ensure that visitors stay away if they are unwell. Consider asking child visiting to be limited.
    All people arriving should be asked to use hand gel before entry and should be asked about
     symptoms on arrival. (Clear information and posters will assist this).
    All areas and items that are more likely to have frequent hand contact (e.g, doorknobs, taps,
     handrails) should be cleaned regularly and also immediately when visibly soiled.
    A sickness log should be maintained to help keep track of the situation
    Residents with ILI:
           o Arrange an urgent medical assessment, with a view to antiviral treatment
           o Isolate the ill person from residents and visitors for at least 72 hours when on antiviral
               treatment or, if not treated, until well.
           o Ensure that staff use masks and hand gel when caring for the ill person
           o Cohort exposed room mates and other very close contacts of sick residents (i.e. keep
               them all together in one place and don‟t let anyone else in to the group)
           o If the person is unable to take antiviral drugs, isolate until the symptoms have largely
               disappeared (usually three – seven days)

    Staff with ILI:
           o Staff should call in sick if they are unwell.
           o If staff become sick at work they should be sent home immediately.
           o Staff of high-risk institutions who have an ILI can receive free antiviral drugs from
              the national stockpile which can be accessed through their GP.
           o Staff must stay off work for at least 72 hours after they have started antivirals. If they
              are not taking antivirals, they need to stay at home until symptoms have largely gone
              (normally around four - seven days). A mask should be considered on return to work
              if the staff member has a persistent cough or coryzal symptoms.
           o Health care workers visiting clients at home should phone ahead if possible to check
              for patients with influenza and carry masks, aprons and hand gel with them.


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    12.6    Health workers in the community

 Ensure one metre of distance from someone who is coughing/sneezing. Droplet transmission
  usually occurs within one metre. One metre is accepted as safe and significantly reduces
  exposure.
 Surgical mask and gloves should be worn when close contact is unavoidable including during
  invasive procedures such as collecting swabs. Masks and gloves must be changed as clinically
  indicated and also removed and disposed of in the yellow hazardous waste bag each time the
  wearer leaves the patient's home.
 Hand hygiene (i.e. hand washing or use of alcohol-based hand gel) should be performed before
  and after contact with a patient being treated for influenza. Hands must also be decontaminated
  after removal of gloves.
 Eye protection should be worn if risk of contamination with secretions or saliva i.e. being
  coughed or sneezed at/on.
 Ensure that all used masks, gloves, and tissues are disposed of and eye protection cleaned after
  use. Bleach cleaning is most effective for killing viruses. Viruses can live for 24 to 48 hours on
  hard surfaces
 Keep windows open if possible
 Encourage patients to have ample supplies of disposable tissues and teach them to cover their
  mouth and nose when coughing or sneezing. Tissues must be handled and disposed of as
  household waste. Decontaminate hands.
 Consider having an influenza vaccination. The closure date for free vaccination for those at risk
  has been extended to 30 September 2009.
 Patient-care equipment
      o When possible, use disposable equipment.
      o Dedicate the use of items such as stethoscope, sphygmomanometer and thermometer to
          the influenza patient.
      o Ensure equipment and supplies necessary for patient treatment, safety and comfort are
          available in the immediate treatment area. Keep storage of supplies and equipment to a
          minimum and replenish often.
 Do not take patient notes and paperwork into the patient's home. Only take necessary supplies
  into the patient's home with you. Any excess supplies at the end of the visit is to be left at the
  patient's home for subsequent visits or discarded into a yellow hazardous waste bag.

13. Clinical issues
There are several areas that require decision support and advice.
 Identification of those at increased risk of serious complications
 Identification of those who are significantly unwell, and requiring measures other than analgesia
   and support
 Investigation guidelines
 Administration guidelines for antiviral medications
 Management of common complications
 Referral guidelines for admission to hospital, including mental health issues

The national GP support number is 0800 111 515

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   13.1      Diagnosis
Diagnosis is based largely on history and clinical presentation. It is not currently possible to
distinguish novel Influenza A (H1N1) 09 infection from seasonal influenza on clinical grounds.
However, management will be the same in most cases, in particular for people with mild to moderate
disease.6

       13.1.1 Clinical features
During influenza season (defined as periods when influenza viruses are circulating in the
community), the diagnosis of influenza should be considered in the following patients, regardless of
vaccination status:
 Immunocompetent and immunocompromised persons (both adults and children), including
   healthcare personnel, with fever and the acute onset of respiratory signs and symptoms
 Persons with fever and acute exacerbation of underlying chronic lung disease
 Infants and young children with fever and no other signs or symptoms
 Elderly persons with new or worsening respiratory symptoms, including exacerbation of
   congestive heart failure, or altered mental status with or without fever
 Severely ill persons with fever or hypothermia
 Hospitalized children admitted without fever and acute respiratory symptoms that subsequently
   develop fever or febrile respiratory illness after admission
 Hospitalized adults admitted without fever and acute respiratory symptoms that subsequently
   develop febrile respiratory illness after admission7

       13.1.2 Swab collection
Testing is for surveillance and monitoring the proportion of ILI due to Novel Influenza A (H1N1)
09, and to identify which subtypes are circulating.8 Clinical testing results are being used to augment
routine surveillance. Testing should be limited to the following:9
     Patients with severe clinical ILI, regardless of whether they are admitted to hospital
     Hospitalised patients with upper or lower respiratory tract symptoms
     People with ILI at high risk of influenza-related complications
     People who live or work in high risk institutions
     For the purpose of cluster identification and control, or infection control. It is likely to be
        sufficient to test a small sample of close contacts in the identification of clusters. The extent
        of testing is at the discretion of the local Public Health Unit. Nasopharyngeal samples are
        appropriate to diagnose Novel Influenza A (H1N1) 09 and inform outbreak control among
        people who work in health care settings and essential services.

Antiviral medication reduces the yield from viral swabs. If an adult case has commenced a twice-
daily treatment course of antiviral medication, do not take swabs. Children excrete a higher viral
load. If a child case has been on a twice-daily treatment course of antiviral medication for >48 hours
do not take swabs. For contacts on once-daily prophylaxis with antiviral medication who develop
symptoms, a swab, if indicated, should be taken within 48 hours of commencing antiviral
medication.



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At Waikato Hospital Laboratory, detection of whether any Influenza A is present is possible (25
samples a day, five days a week can be tested), but samples need to be sent to ESR at Wallaceville to
differentiate a seasonal strain from the Novel Influenza A (H1N1) 09. For the Waikato population,
only 10 swabs/day can be sent to ESR. Priority will be given to:
     Inpatients
     Health Care Workers
     Influenza Surveillance Program GP patients
     Patients of strategic interest, requested by the MOoH.

Per-nasal swabs and Viral Transport Medium are available from the Pathlab Waikato stores
department. All community swabs from the Waikato area should be sent to Pathlab through the
normal courier service and will be forwarded to the Waikato Hospital Laboratory which will
endeavour to test as many general practice patients and outpatients as it can up to the daily capacity.
Specimens unable to tested will be reported as such.

For instructions as to the correct specimen collection procedure, see Appendix 11.

   13.2      Management
Most cases will be able to self manage at home and should be encouraged to do so by being provided
with appropriate health advice. Cough and sneeze etiquette and hand hygiene are paramount (see
patient instructions: Appendix 13).

Symptomatic patients should be treated as for seasonal flu. People with moderately-severe and
severe illness should be referred to hospital (see Section 13.5).

   13.3      Use of antiviral medication

       13.3.1 Prophylaxis

      The MoH does not currently recommend the routine use of antivirals for pre- or post-
       exposure prophylaxis. However, there may be situations where post-exposure prophylaxis is
       indicated e.g. for essential workers and hospital staff where there have been significant
       breaches of PPE, on a case by case basis. If considering the post-exposure prophylactic use
       of antiviral medication (Tamiflu or Relenza), this should be discussed with your local Public
       Health Unit.6 Prophylactic use of Tamiflu is currently very limited, and may not be initiated
       without the specific approval of the MOoH.
      Infants and young children10
           o Pre exposure prophylaxis may be used in settings where a vulnerable individual will
               inevitability be exposed to influenza e.g. an oncology patient attending a ward where
               patients have influenza.
           o Post exposure prophylaxis for asymptomatic individuals is reserved for infants and
               children with medical fragility. It should be used with caution as it is likely to prevent
               immunity developing and recurrent courses may be needed.
      Prophylaxis is generally given for 10 days but longer courses can be used in some settings
       e.g. a child with cystic fibrosis having treatment on an inpatient ward that also manages flu
       cases. In nursing homes when used for outbreak control it is recommended to continue until 7
       days after last known contact with a case.10

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       13.3.2 Treatment

      The MoH recommends the prudent use of antivirals for treatment in those with ILI (see
       below)6

       Adults                           Begin antiviral therapy if symptoms have been
                                         present < 48 hours from symptom onset
                                        Only consider initiating antiviral treatment after 48
                                         hours from the onset of symptoms, for people with
                                         severe clinical illness, where possible in discussion
                                         with an infectious disease physician
       Children < 5 years               Treatment can be initiated up to 5 days from the
                                         onset of symptoms
                                        For children < 12 months, consult your local
                                         paediatrician

       13.3.3 Choice of antiviral

      Tamiflu is the first line antiviral for treatment and prophylaxis
      Relenza is indicated where there is:
          o an inability to take or tolerate Tamiflu e.g. due to vomiting or diarrhoea
          o renal failure.

       See medicine data sheets:
      http://www.medsafe.govt.nz/profs/Datasheet/t/Tamiflucapsusp.htm
      http://www.medsafe.govt.nz/profs/Datasheet/r/relenzarotadisk.htm

       13.3.4 Indications for antiviral drugs
1. All patients with severe clinical influenza-like-illness, regardless of whether they are
   admitted to hospital
    A sepsis assessment tool, such as the SIRS (see Appendix 5), may be useful in deciding who
       to treat with Tamiflu. A score of ≥ 2 supports the use of antiviral medication. This should not
       replace clinical judgment but rather support and/or confirm it.

       Note: the CRB-65 was provided in version 1 of this advice but has been removed as it is less
       suitable for this purpose.

2. Hospitalised patients with upper or lower respiratory tract symptoms
    People who are hospitalised for any reason, but who are symptomatic with respiratory
      symptoms that could be due to influenza
    Hospitalised patients who are close contacts of a confirmed case.

3. Symptomatic people at high risk of influenza-related complications
    People who are immune-compromised or suppressed due for example to transplantation,
      haematological and solid organ malignancy on chemotherapy/radiotherapy, HIV,



WDHB Primary Care Pandemic Response Plan: Version 4.0            13 July 2009              Page   25
         autoimmune disorders, taking the anti-psychotic drug clozapine (because of white cell
         suppression), etc.
        Pregnant women (see section 13.6.1)
        Anyone over 12 months of age with a chronic medical condition, such as:
             o Severe or poorly controlled congestive heart failure
             o Severe chronic respiratory disease
             o More severe asthma (e.g. on oral steroids, high dose steroid inhalers, or steroids and
                long-acting beta-agonists)
             o Renal replacement therapy.

4. Symptomatic people who live or work in high risk institutions, where appropriate
    Antivirals should not be used prophylactically in these groups.
    The following groups of people may warrant antiviral treatment if symptomatic.6
        o Health care and other care providers in facilities and community settings who,
            through their activities, are capable of transmitting influenza to those at high risk of
            influenza complications
        o People who provide services within closed or relatively closed settings to persons at
            high risk (e.g. prisons, early child care centres)
        o People of any age who are residents of a nursing home or other chronic care facility

5. Infants and children
    With complications that result in admission to hospital
    With medical fragility such that they are at higher risk of influenza complications.

   Note: Although safety data for infants under one is limited, CDC supports use with caution.11
   This use should be restricted to those admitted to hospital, or who are otherwise under the
   supervision of a paediatrician.

         13.3.5 Tamiflu
            13.3.4.1    Dosage

Table 6. Tamiflu Dosage

Group                                                  Treatment
Adults                                                 75 mg twice daily for 5 days
                              >40 kg                   75 mg twice daily for 5 days
                              24–40 kg                 60 mg twice daily for 5 days
Children > 12 months
                              16–23 kg                 45 mg twice daily for 5 days
                              15 kg or less            30 mg twice daily for 5 days
                              12-14kg                  30 mg twice daily for 5 days
Children < 12 months          9-12kg                   24 mg twice daily for 5 days
                              6-9kg                    18 mg twice daily for 5 days


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                              4-6kg                    12 mg twice daily for 5 days
                              3-4kg                    9 mg twice daily for 5 days
                              </= 3kg                  6 mg twice daily for 5 days
Note:
    For children aged <12 months, consult a local paediatrician
    For children < 3 months, prophylaxis is not recommended unless the situation is deemed
      critical, due to limited data in this age group12

           13.3.4.2    Adverse effects

       Similar adverse event rates when used for treatment and prophylaxis13
       Nausea and vomiting are the most common adverse effects, less severe if taken with food
           o Assuming patient is taking Oseltamivir with food:12
                    If a patient vomits:
                           within 30 minutes of administration, a repeat dose should be given
                           after 30 minutes of administration, repeat dose if capsule visible in
                              vomitus.
                    If the patient vomits after a repeat dose:
                           confirm the patient is taking the medication with food (which may
                              reduce N&V)
                           consider antiemetic therapy to assist completing the antiviral course
                           consider Zanamivir (Relenza) inhalation as alternative antiviral.
       Abdominal pain, insomnia, headache, fatigue, and conjunctivitis12
       Rarely, anaphylaxis and severe skin reactions12
       Transient neuropsychiatric events (self-injury or delirium) have been reported postmarketing
           o Majority of reports were among adolescents and adults living in Japan
           o FDA advises that persons receiving oseltamivir be monitored closely for abnormal
               behaviour

           13.3.4.3    Interactions

Limited clinical data are available regarding drug interactions with oseltamivir.13 Because
oseltamivir and oseltamivir carboxylate are excreted in the urine by glomerular filtration and tubular
secretion via the anionic pathway, a potential exists for interaction with other agents excreted by this
pathway; e.g. coadministration of oseltamivir and probenecid resulted in reduced clearance of
oseltamivir carboxylate by approximately 50% and a corresponding approximate twofold increase in
the plasma levels of oseltamivir carboxylate.

           13.3.4.4    Contraindications

   Creatinine clearance <10 ml/min, routine haemodialysis or continuous peritoneal dialysis: wider
    spacing of doses may be required
   Hypersensitivity to Oseltamivir or components, fructose intolerance (oral suspension)




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           13.3.4.5   Use during pregnancy

Tamiflu is a "Pregnancy Category C" medication.13No clinical studies have been conducted to assess
the safety of these medications for pregnant women. No adverse effects have been reported among
women who received oseltamivir or zanamivir during pregnancy or among infants born to such
women (see section 13.6.1).

           13.3.4.6   Breast feeding

The UK Health Protection Agency has recommended the use of Oseltamivir as the antiviral of first
choice for the treatment and prophylaxis of pandemic influenza in women who are breast feeding.
Seek specialist advice.12

           13.3.4.7    Use in young children

Children less than one year of age are at higher risk for complications associated with seasonal
human influenza virus infections compared to older children, and the risk of influenza complications
is especially high for children less than 6 months of age.11 Children less than 1 year old are also
known to be at increased risk of complications during previous pandemics. Limited safety data on
the use of oseltamivir (or zanamivir) for treatment of seasonal influenza in children less than one
year of age suggest that severe adverse events are rare. The basis of precautions for Tamiflu comes
from data on weaning rats given the equivalent of 1000 mg/kg with evidence of greater CSF
penetration and potential neurotoxicity.12

Oseltamivir use for treatment of children less than 1 year old with Novel Influenza A (H1N1)09
infection was recently approved by the FDA under an Emergency Use Authorisation, and dosing for
these children is age-based.11 However, the Paediatric Society of New Zealand has yet to make a
comment on this issue. Local advice is to consult with a paediatrician if there are concerns about a
particular child, especially if there is chronic respiratory disease (Personal communication, Dr David
Graham, 6 July 2009).

           13.3.4.8   Suspension

Tamiflu suspension is indicated for those who are unable to swallow capsules, and for children
where lower doses are required. See Appendix 7, for instructions for preparation.

           13.3.5 Relenza
           13.3.5.1   Dosage

Adults and children aged >5 years
 Treatment: 2 x 5mg inhalations twice-daily for 5 days
 Prophylaxis: 2 x 5mg inhalations once-daily for 10 days




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           13.3.5.2   Contraindications

   Concerns exist regarding bronchospasm and decreased pulmonary function after inhalation of
    zanamivir in paediatric and adult patients with underlying airways disease, including asthma and
    COPD.7
   History of allergic reaction to lactose12

           13.3.5.3      Adverse effects

   Very rare: allergic reactions, angioedema, urticaria, bronchospasm, and dyspnoea12
   Neuropsychiatric events reported

           13.3.5.4    Use in pregnancy

The UK Health Protection Agency has recommended the use of Zanamivir as the antiviral of first
choice for the treatment and prophylaxis of pandemic influenza during pregnancy, 12 but the CDC
recommends Tamiflu because of its systemic activity.14 Seek specialist advice.

    13.4 Complications
Complications are similar to those that occur with seasonal influenza and include:
   Exacerbation of underlying chronic medical conditions
   Upper respiratory tract disease (sinusitis, otitis media, croup)
   Lower respiratory tract disease (pneumonia, bronchiolitis, status asthmaticus)
   Cardiac problems (myocarditis, pericarditis)
   Musculoskelatal problems (myositis, rhabdomyolysis)
   Neurological problems (acute and post-infectious encephalopathy, encephalitis, febrile
      seizures, status epilepticus)
   Toxic shock syndrome

       13.4.1 Pneumonia
Pneumonia is one of the commonest causes of morbidity and mortality in both adults and children,
with the burden of disease greatest in those aged <5 years.15 A severe influenza pandemic will be
associated with viral, mixed viral/bacterial, and secondary bacterial pneumonias. Antibiotics can be
a life-saving intervention for bacterial pneumonia secondary to influenza or community-acquired
pneumonia. The goal of providing rapid community-based antibiotic treatment is to reduce the
number of cases of severe secondary bacterial infection requiring treatment in hospital. Data from
past pandemics show that the majority of secondary bacterial pneumonias were associated with
Gram positive cocci such as Streptococcus pneumoniae and Staphylococcus aureus, and Gram-
negative rods such as Haemophilus influenzae. Therefore the suggested antibiotic of choice is
amoxicillin/clavulanic acid, OR when beta-lactam antibiotics are contraindicated or not tolerated,
roxithromycin for adults and older children, or erythromycin for children aged < 8 years.16
Treatment should be continued for 1 week.17

During an influenza pandemic, patients who present with cough or difficulty breathing and who also
have fast breathing or chest indrawing (children), can presumptively be classified as pneumonia and
managed in a standardised way.15

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Adults and children
1.     Those people with ILI without important comorbidities, do not require antibiotics.17
2.     Those people with ILI without important comorbidities who are seen later in the course of
       illness and who have developed significant worsening of symptoms (particularly
       recrudescent fever or increasing breathlessness) should be considered for antibiotics.17
3.     Those people with ILI without important comorbidities, and who have cough or difficulty
       breathing and also have an increased respiratory rate or chest indrawing (children), should be
       commenced on an antibiotic, unless there are any indications for referral to ED.
4.     Those people with ILI and important comorbidities, and who have cough or difficulty
       breathing and also have an increased respiratory rate or chest indrawing (children), should be
       referred to ED.
5.     Those people with ILI and important comorbidities but who have no difficulty breathing or
       increased respiratory rate or chest indrawing (children), should be seriously considered for
       antibiotics.17

 Infants between 1 month and 1 year with mild or moderate pneumonia18
 Amoxycillin 15-30mg/kg/dose three times daily for 3-5 days
    o Use the higher dose if there is severe infection or any risk factors for resistant streptococcus
        i.e. daycare attendance, or previous antibiotics in the past three months
 Erythromycin 10mg/kg/dose four times daily for 5-7 days is recommended if there is an allergy
    to penicillin (rare in infants less than 1 year of age).

Administer oxygen when the oxygen saturation is below 92%. If oximetry cannot be done, give
oxygen if the following signs are present:18
    Restlessness or severe chest indrawing
    respiratory rate >70/min or cyanosis

       13.4.2     Bronchitis

  Clinical features of productive cough with purulent sputum and a clinically clear chest
  Pathogens involved: Strep. pneumoniae, Haemophilus spp, Mycoplasma pneumoniae, Chlamydia
   pneumoniae, and rarely, Staph. Aureus
Adults           Amoxycillin or augmentin is appropriate as the first line antibiotic16
                 Alternatives:
                        o Roxithromycin (preferable to erythromycin as it has better activity
                           against Haemophilus spp)
                        o Doxycycline
                        o Cotrimoxazole
Children         Amoxycillin or augmentin is appropriate as the first line antibiotic16
                 Alternatives:
                        o Roxithromycin
                                Preferable to erythromycin as it has better activity against
                                   Haemophilus spp
                                Macrolides are appropriate to use in children, but 30% develop
                                   adverse GI effects (nausea or vomiting)
                        o Cefaclor19
                        o Cotrimoxazole19

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   13.5     Indications for referral to Emergency Department (ED)

       13.5.1 Adults
There is a significant risk the emergency departments will be inundated with persons with ILI,
potentially paralysing these facilities, and increasing exposure to people at risk because of other
illnesses. Hospital admission should be considered if there are any of the following:20
             Temperature >38.5C
             Rigors
             Systolic BP <100
             Heart rate >110
             Respiratory rate >25 or oxygen saturation < 92% on air
             Vomiting >1 in 24hrs
             Confusion
             Pleuritic chest pains
             Inability to self care or dehydration

       These criteria are for guidance only and do not replace clinical judgment.

       13.5.2 Modified EWS (MEWS) scale
This score was developed to identify those people being admitted to general medical wards who are
at risk of a catastrophic deterioration.21 Scores of five or more, are associated with a five-fold
increase in death, and an 11-fold increase in the risk of admission to ICU, and therefore people with
a score ≥ five should be referred to ED for assessment (see Appendix 4).

       13.5.3 Children < 16 years
Respiratory failure, overwhelming gastroenteritis, shock, heart failure and encephalitis are the most
likely modes of critical illness in children suffering from Novel Influenza A (H1N1) 09.
Complications such as sepsis and meningitis may co-exist.

Refer children to ED if they have any of the following:22
    Severe respiratory distress (lower chest wall indrawing, sternal recession, grunting, or
       noisy breathing when calm)
    Increased respiratory rate measured over at least 30 seconds
           o < 1 year: RR ≥ 50/min
           o 1 year: RR ≥40/min
    Oxygen saturation ≤ 92% on pulse oximetry, breathing air or on oxygen (absence of
       cyanosis is a poor discriminator for severe illness)
    Respiratory exhaustion or apnoeic episode (≥ 20 second pause in breathing)
    Severe clinical dehydration or clinical shock (sternal capillary refill time > 2 seconds,
       reduced skin turgor, sunken eyes or fontanelle)
    Altered conscious level (strikingly agitated or irritable, seizures, or floppy infant)
    Causing other clinical concern to their own GP or clinical team e.g. a rapidly progressive or
       an unusually prolonged illness.


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Thresholds for admission may be lowered where underlying conditions exist:10
    infants aged < 6 months
    infants with a history of prematurity especially if any ongoing lung disease
    immunosuppression
    children with cerebral palsy or weakness that may impair coughing
    underlying heart disease
    lung disease.

   13.5.3.1 Life-threatening Clinical Scenarios that need special attention

Within the high levels of workload generated related with influenza cases these clinical scenarios
need to be looked for identified early and managed/treated.10

   1. Vulnerable infant developing bronchiolitis

Some infants will develop a bronchiolitis picture with the steady increase in respiratory compromise
over 3-5 days. The development of hypoxia is usually marked by slowing feeds, marked pallor and
lethargy.

   2. Early rapidly progressive respiratory distress

This is likely to be an uncommon symptom and seen in young people and older children. It results
from a dramatic inflammatory response – “cytokine-storm”, which follows very quickly (hours) after
the first epithelial colonization in the respiratory tract. Massive out-pouring of fluid occurs very
early in the flu like illness. Supportive care should be offered, possibly including steroids, as well as
obtaining urgent specialist advice.

   3. Late onset deterioration in respiratory status

Influenza leaves the respiratory tree very vulnerable to secondary bacterial infection because of the
epithelial debris, increased secretions and immune compromise. Secondary bacterial invaders are
typically streptococcal or staphylococcal. Symptoms may include increasing fever, toxicity,
tachycardia, grunting and increasing oxygen requirement, typically 3 – 10 days after influenza
illness starts. Early treatment with antibiotics can be life saving.

   4. Influenza encephalitis

Influenza is often associated with irritability, distress and at times simple febrile convulsions. Where
seizures, atypical, prolonged, frequent or difficult to treat or other signs of CNS dysfunction occur,
consideration should be given to the diagnosis of Influenza. Encephalitis a rare complication that
will require specialist advice about management.




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       13.5.4 Infants
Refer ALL infants with:18
    history of apnoea
    oxygen saturation <92% or clinical concern about hypoxia
    dehydration
    grunting
    severe illness.

Other factors to consider:18
    underlying medical condition
    prematurity: (born < 32 weeks gestational age)
    infants younger than two months of age.
    distance to base hospital or medical help if infant should suddenly deteriorate.
    social concerns
    car or phone availability
    home environment
    parental exhaustion or inability to cope
    no response to appropriate oral antibiotics within 48-72 hours
    deterioration in spite of antibiotics.

   13.6     Vaccination

            13.6.1 Extended eligibility for free seasonal influenza vaccine
As part of pandemic planning, the MoH is extending eligibility for free seasonal influenza vaccine to
any individual who wants to receive it from their GP (i.e., to those of all ages and those in good
health). This applies from 1 July 2009 until the end of September, or when seasonal influenza
vaccine supplies run out.23

Pandemic influenza is putting extra pressure on the delivery of health care in the primary care sector.
Extending eligibility for seasonal influenza vaccine is being done to:
    Enable more individuals to be protected from contracting both pandemic and seasonal
       influenza over the coming months
    Ease pressure on the health system by reducing the number of doctors visits and
       hospitalisations and
    Reduce the impact on health providers and businesses from staff illness.

The Ministry purchased an extra 125,000 doses of the seasonal influenza vaccine to manage the
increased demand. Already, the uptake of the vaccine this season is more than 20 percent higher than
last year. This vaccine protects against the strains of influenza expected to be prevalent this season.
No more vaccine will be ordered once this stock has been used. The seasonal influenza vaccine is
not expected to offer any protection against pandemic influenza.

For claiming purposes, enter all those aged > 65 years 65s in the FLU - Flu 65+. All other patients
who don't have a specific condition noted in FL01 - FL05 should be entered under FL06 - Flu Other
eligible.

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            13.6.2 Pandemic influenza vaccine
The Ministry of Health has purchased 300,000 doses of an as yet unlicensed pandemic influenza
vaccine from Baxter Healthcare Ltd in case pandemic influenza becomes more severe.23 The
Ministry also has an agreement for supply of another pandemic influenza vaccine from CSL Ltd.

The vaccine will not be used here before it is licensed by Medsafe. A licensing decision is expected
later this year as more information becomes available. This process could be fast-tracked if the
situation warrants it. Frontline staff in health, emergency and other critical services will be offered
the vaccine first, should it be needed. There is enough vaccine to immunise about 150,000 staff in a
two-dose regime. The Ministry is working out the priority groups within these services who would
be offered the vaccine if an immunisation programme is needed.

At this point there is no plan to offer this pandemic influenza vaccine to the wider community or
people with chronic medical conditions as there is no evidence that this would be effective or
beneficial. For most people, this virus is causing a mild to moderate illness and they recover at home
without the need for any medical intervention. However, this is a new virus and the information
available is constantly evolving.

      13.7 Special groups

            13.7.1 Pregnant women
Pregnant women have higher rates of hospitalisation with influenza for variety of reasons. Influenza
infection in the second and third trimester increases the risk of cardio-respiratory disorders, probably
due to the increase in heart rate, stroke volume, and oxygen consumption in the latter part of
pregnancy as well as a decrease in lung capacity and changes in immunological function.2 Fatal
influenza in pregnant women is characterised by the rapid development of cardiovascular and/or
pulmonary insufficiency after several days of influenza-like illness. Influenza close to the time of
delivery poses extra challenges for maternal and newborn health, as well as challenges to infection
prevention in the delivery suite.

Fever in the first trimester is associated with twice the rate of neural tube defects in the foetus and
may be associated with other birth defects and adverse outcomes. Risk may be mitigated by
antipyretics (paracetamol or preferred) and/or multivitamins that contain folic acid.14

The Ministry‟s Pandemic Influenza Technical Advisory Group recommends early administration
with either Tamiflu or Relenza when indicated. The CDC recommends Tamiflu because of its
systemic activity.14 Although neither Relenza or Tamiflu is contraindicated during pregnancy, there
is limited information related to their use. Preclinical studies suggest that risks are low, but their
potential to cause fetal toxicity or malformations in humans is currently unknown. Therefore it is
recommended that they should be used during pregnancy only if the potential benefit justifies the
potential risk to the foetus. However, pregnant women appear to be at increased risk of severe
complications from novel influenza A (H1N1) 09.14 A local obstetric or infectious diseases specialist
should be consulted where there are concerns.




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Risk of exposure to influenza virus can be reduced by the following measures:14
 Frequent hand washing.
 Minimizing contact with sick individuals.
 Having ill persons stay home (except to seek medical care).
 Having ill persons cover coughs.
 Avoiding, whenever possible, crowded settings in communities having outbreaks of novel
   influenza A (H1N1) virus.
 Using facemasks and respirators correctly (if they are used)

            13.7.2 Young children
Children aged ≤ 5 years (and especially those aged < 2 years), and children who have high risk
medical conditions, are at increased risk of influenza-related complications.11, 12 Illnesses caused by
influenza virus infection are difficult to distinguish from illnesses caused by other respiratory
pathogens based on symptoms alone. Some deaths in children have been associated with co-infection
with influenza and Staph. aureus, particularly MRSA.

Young children are less likely to have typical influenza symptoms (e.g., fever and cough) and infants
may present to medical care with fever and lethargy, and may not have cough or other respiratory
symptoms or signs. Symptoms of severe disease may include:
    apnoea, tachypnoea, dyspnoea, cyanosis
    dehydration, altered mental status, extreme irritability

In neonates and children under two years, fever may be the only presenting feature. Fever can be
associated with non-specific signs of sepsis such as pallor, floppiness, poor feeding, or altered
sleeping patterns. Children under two years are more likely to present with diarrhoea and vomiting
than older children.2

If antiviral treatment is being considered for children aged <12 months of age, consult with a local
paediatrician.

            13.7.3 Infants
The majority of infants with pneumonia present with cough and/or difficulty in breathing, but only a
small number of infants with these symptoms have pneumonia. The majority of the remainder have
bronchiolitis.18 The World Health Organisation has defined 3 key signs that should be used when
deciding whether or not a young child with cough and/or difficulty in breathing has pneumonia.
These clinical signs are:
    tachypnoea
    chest indrawing
    absence of wheeze.

Fever
In infants less than 2 months of age however, the presence of a fever (≥38°C) or of hypothermia (<
35.5°C) is more significant and is likely to be due to a bacterial infection. The presence or absence of
fever is not useful in the assessment of an older infant with pneumonia.



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Focal Chest Signs
Infants aged <1 year commonly develop a bronchopneumonia and it is unusual to find persistent
focal signs on chest examination. Finding focal signs suggests the presence of a lobar pneumonia or
other localised lung pathology. Pneumonia is likely if infant has tachypnoea with any of the
following:
     chest wall indrawing
     nasal flaring
     grunting
     crackles

Pneumonia is unlikely in the absence of:
    respiratory distress
    tachypnoea
    crackles

In the first 3 days of illness, tachypnoea has a lower sensitivity and specificity in predicting the
presence of pneumonia, but is still better than any of the other parameters.

Assessment of severity
The following should be assessed when deciding on severity of illness:18
    general appearance
    oxygen requirement
    respiratory rate
    evaluation of work of breathing
    chest auscultation – crackles increase the likelihood of pneumonia
    pyrexia or hypothermia in infants aged < 2 months.
Note:
    Respiratory rate and indrawing are reliable clinical indicators for assessment of severity of
       lower respiratory tract infections, bronchiolitis and pneumonia.18
    Presence of wheeze in addition to respiratory rate and indrawing indicates bronchiolitis rather
       than pneumonia.18

Table 7. Assessment of severity18

                        Mild                        Moderate                      Severe
Respiratory Rate        < 2 months > 60/min                                       >70/min
                        2-12 months >50/min
Chest wall              None/mild                   Moderate                      Severe
indrawing
Nasal Flare &/or        Absent                      Absent                        Present
grunting
Feeding                 Normal                      Less than usual               Not interested
                                                    Frequently stops              Choking
                                                    Quantity > half normal        Quantity < half normal
History of              Normal                      Irritable                     Lethargic
behaviour
Cyanosis                Absent                      Absent                        Present


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                  13.7.3.1     Infant feeding considerations

Infants who are not breastfeeding are more vulnerable to infection and hospitalization for severe
respiratory illness than infants who are breastfeeding. Women who are not ill with influenza should
be encouraged to initiate breastfeeding early and feed frequently. Ideally, babies should receive most
of their nutrition from breast milk. Eliminate unnecessary formula supplementation, so the infant can
receive as much maternal antibodies as possible.14

Infants are thought to be at higher risk for severe illness from novel influenza A (H1N1) 09 infection
and very little is known about prevention of novel H1N1 flu infection in infants. If possible, only
adults who are not sick should care for infants, including providing feedings. The risk for novel
influenza A (H1N1) 09 transmission through breast milk is unknown. However, reports of viraemia
with seasonal influenza infection are rare, which suggests that the risk of virus crossing into breast
milk is also probably rare. Sick women who are able to express their milk for bottle feedings by a
healthy family member should be encouraged to do so. Antiviral medication treatment or
prophylaxis is not a contraindication for breastfeeding.14

Careful adherence to hand hygiene and cough etiquette is critical, especially for sick women who do
not have anyone to help with infant care while they are ill. Women with ILI are recommended to use
facemasks when providing infant care and feedings.14

Instruct parents and caretakers on how to protect their infant:
 Practice hand hygiene and cough etiquette at all times
 Keep the infant away from persons who are ill, and crowded areas
 Limit sharing of toys and other items that have been in infants' mouths. Wash thoroughly with
    soap and water any items that have been in infants' mouths.

            13.7.4     People aged > 65 years
Frail elderly, particularly those living in residential facilities are more susceptible to infections, and
are at increased risk of complications from influenza.2 Symptoms and signs of influenza are similar
to younger individuals but cases in the elderly are characterised by the presence of dyspnoea,
wheezing, sputum production and temperatures of 38º Celsius (temperatures may be less than this).
During a pandemic any unexplained acute deterioration in health status associated with fever may be
a manifestation of influenza in elderly individuals.

       13.6.1 Immunosuppressed people
People with chronic medical conditions such as renal failure, or those who are taking
immunosuppressive medication such as corticosteroids, or chemotherapy that compromises the
body‟s immune system can experience a more severe disease with seasonal influenza. For example:
    Clinical presentations may be atypical e.g. reduced or no fever
    Viral shedding may be more prolonged
    Response to antiviral medication may be slower and require longer courses of therapy
    Complications may be more common and require longer convalescence.

The effects of pandemic influenza on immunosuppressed individuals are currently unknown.

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14.       Logistics
As part of ongoing planning for the management of the Novel Influenza A (H1N1) 09 virus
pandemic, health providers should be:
    forecasting their needs to ensure sufficient supplies are available in their workplace
    planning with their normal suppliers
    identifying and working with alternative suppliers.

The MoH manages and/or controls a number of national reserve emergency supplies. Some of these
are held in DHB stores and others in bulk stores away from DHB sites. National reserve supplies
will be utilised when normal supplies and supply chains are no longer available.

Table 8. National reserve emergency supplies

National reserve supply items               DHB Stored       Ministry Stored
P2 respirators and general purpose masks         X                   X
Personal Protective Equipment (aprons,
                                                   X
gloves, eye protection)
Clinical equipment
                                                   X
(syringes, giving sets, IV fluids, etc)
Tamiflu
                                                   X                  X
(each DHB holds 200 courses)
Pandemic antibiotics                               X
Vaccination supplies                                                  X
Body bags                                                             X
Not available at this time
Pandemic vaccine                                 N/A                 N/A

14.1   Purpose of the national reserve supplies
A prolonged or very large health emergency may cause supply difficulties for DHBs, PHOs and
private sector health organisations. The National Reserve Supplies Management and Usage Policy
outlines actions that may be taken in this situation.24 National reserve supply stocks have been
developed to ensure that as far as is possible, DHBs and the Wider Health Sector have continued
access to essential supplies during large or prolonged emergencies that generate unusual demands on
normal health service stocks or supply chains.

DHB „business as usual‟ supplies and supply chain capacity should be managed at a level able to
ensure all reasonably predictable local events can be supported without requiring additional
resources from national reserves.

14.2 DHB responsibilities
DHBs are responsible for:
  o Maintenance and turnover of national reserve supplies held in DHB stores
  o Internal DHB supply prioritisation and allocation in emergencies
  o Support of neighbouring or regional DHBs


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   o Local and regional supplies usage reporting and forecasting
   o Applying to the National Coordinator (or designated person) for Ministry release of national
     reserve supplies if or when appropriate
   o All aspects of transport, distribution, and security of supplies within DHB districts
   o Ensuring observation of all relevant clinical guidelines, usage policies or national priorities
     developed by the Ministry
   o Ensuring appropriate and economical use of national reserve supplies in all clinical settings
     in their districts; and
   o Accounting to the Ministry for all national reserve supply, receipt and usage

14.3 Funding, accounting, and financial arrangements
The WDHB will need to account to the MoH for all national reserve supplies drawn from WDHB or
Ministry stores using report templates developed by the Ministry. The Ministry will fund the use of
national reserves as part of overall emergency response funding.

14.4 Release of supplies

14.4.1 Order of use
National reserve supplies will not be released until supplies from other sources have been drawn
down. This means that as a general rule DHB and national reserve supplies will be used in the
following order:
    1. Operational supplies
    2. Supplies available from normal suppliers, or held in supply chains
    3. Supplies able to be sourced from regional DHBs without jeopardising their emergency
       response capability
    4. National reserve supplies held under Ministry control in DHB stores
    5. National reserve bulk supplies held in Ministry bulk stores

This expectation does not preclude the rapid release of national reserve supplies from any source
when appropriate.

14.4.2 Authorisation
Release of supplies will be authorised by:
     The National Coordinator or
     A person specifically designated by the National Coordinator for this role.
All requests for supplies must go through the local DHB, using the appropriate order forms in
Appendix 12.

14.5 Supplies for PHOs, private sector health organisations and other response
    agencies
All health providers are responsible for providing a safe working environment for their employees
(as are all other employers) and should make all necessary provisions to ensure their employees‟
safety in any health emergency.24 A prolonged, unusual, or very large health emergency may cause


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supply difficulties for PHO and private sector health organisations, as well as DHBs. In the interests
of continued emergency response delivery it may be appropriate for support to be provided from
national reserve supplies. Any PHO, private sector health organisation and any other response
agency requesting assistance with supplies must do so through their local DHB.

The general order of priorities for distribution of available national reserve supplies to organisations
such as PHOs, private health practices and/or non-health agencies in emergencies is:

1.     Health organisations essential for the continued delivery of the health service response to the
       emergency, such as those providing CBAC services during a pandemic

2.     Health organisations essential for the continued delivery of non-emergency health service
       responses, such as those continuing to provide day-to-day „business as usual‟ service delivery
       during an emergency

3.     Non-health organisations essential to support the continued delivery of critical services
       during a health emergency.

The prioritisation above should not be interpreted as a guarantee of supply assistance to any agencies
or organisations, but rather indicates the prioritisation hierarchy that will be applied while supplies
remain available.

14.6 Available supplies

14.6.1 PPE
National reserve P2 respirator (N95 equivalent) masks and general purpose mask stockpiles will be
mobilised in health emergencies if or when normal supply chains cannot meet demands.

Other supplies consist of gowns, gloves, IV fluids, giving sets, and associated clinical equipment.
The stockpiles will be mobilised in health emergencies if or when normal supply chains cannot meet
demands. The Ministry does not hold bulk supplies of these items off DHB sites. All national
reserve supplies of these items are in DHB stores.

14.6.2 Antibiotics
In case of an influenza (or other) pandemic, national reserve pandemic antibiotics will be released
for use if or when patient volumes and resulting antibiotic demands make this appropriate and
necessary.

High-volume antibiotic use is not anticipated other than during the „manage it‟ phase of an influenza
pandemic. The Ministry does not hold bulk supplies of antibiotics off DHB sites. All national
reserve supplies of these items are in DHB stores.

14.6.3 Tamiflu
Each DHB holds 200 treatment courses of national reserve Tamiflu. With the exception of some
ready-use supplies held in major centres, all other national reserve supplies are held in bulk stores.

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DHBs generally do not hold significant additional stocks of Tamiflu beyond the 200-course
allocation. Accordingly national reserve stocks were mobilised and made available early in the
course of the current pandemic

CBAC and Key Practices must make supplies request directly to the DHB using the relevant order
template (See Appendix 12).

15.         Communications
The coordination of an effective response which is constantly changing as the pandemic unfolds,
requires a comprehensive, accurate and reliable communication plan that has redundancy built in.
This system will have the following components;
    The WDHB has a system in place that includes a current fax list of all providers, including
       all PHOs, non-PHO providers, pharmacies, community laboratories, St John‟s Ambulance
       Service, and DHB facilities that are part of the primary care response (mainly CBACs
       located in the rural hospitals).
    Pinnacle Inc also has a mechanism for communicating with all practices, including non-
       Pinnacle PHOs, and non-PHO providers.
    The MoH will provide communications via the Ministry website (www.moh.govt.nz ), and
       via the Public Health Unit of the WDHB.
    Once CBACs have been activated, the PPCRT will communicate will all facilities in the
       region informing them of this. HML will also be notified once this has occurred, and will be
       informed of all CBAC and KP locations and contact numbers.

16. Data management
The effective management of a pandemic requires effective and efficient systems to manage the
following data types:
     Clinical
     Epidemiologic
     Logistic
     Human resources
     Fiscal

16.1 Clinical
Clinical data collection is necessary for:
     Identification of those who can be managed at home, and those who require more detailed
       assessment and treatment
     To inform other providers of diagnostic and treatment measures provided to a particular
       patients
     To monitor use of antivirals and antibiotics
     To facilitate claims




WDHB Primary Care Pandemic Response Plan: Version 4.0          13 July 2009            Page      41
16.1.1 Initial assessment
The initial assessment of ILI will occur at the triage points at both CBACs and KPs, using the
assessment form in Appendix 10. The form will be used to:
     Identify those who satisfy the criteria for ILI
     Identify those who need antiviral and antibiotic medication
     Identify those who need referral to ED.

In Appendix 11, there is a version that can be loaded into Medtech as an Outbox document.

For all CBACs and KPs, when the form is completed, it is to be faxed to Health Waikato Regional
Referral Centre, 0800 867333. A copy will be sent to the patient‟s usual GP, and a copy will be
forwarded to Population Health Services (see Appendix 15 for a diagram of clinical information
flows).

Manual data entry is well-known to reduce data quality, and this has implications for identity
management. Transcription errors, variable hand-writing legibility, and variations in use of names
and reported dates of birth, will lead to patient identification problems.

Note: Making sure that details are accurate and legible will reduce claiming and other problems.

16.1.2 Further assessment
If the patient is referred for medical review, either to another area of the CBAC facility, or to another
facility such as a Key Practice, clinical data recording will occur via the usual process for that
provider. Some PMS systems (e.g. Medtech) have the capacity to send a copy of the consultation
note to other providers using HealthLink, and the appropriate EDI for that provider. Instructions for
doing this, as supplied by Medtech can be found in Appendix 14. A list of Provider Healthlink EDIs
for the Waikato region can be found on the Pinnacle website www.pinnacle.org.nz (together with
instructions about how to add EDIs to the address book).

16.2 Logistic
The WDHB has stocks of PPE, and antiviral and antibiotic medications. Tracking of supplies
required and used will be done by the DHB, so as to conserve stock and deploy them in the most
effective manner. These are able to be delivered at short notice (in two hours, for single facilities,
and in six hours, in the event of all providers needing supplies at once). CBACs, KPs and BAU
practices are all eligible. Several forms are available for the purpose, and can be found in Appendix
12.

Monitoring of use of medication stocks will be done via the CBAC assessment form, and community
pharmacy reports of usage. The CBAC Initial assessment/triage form will be faxed to the Population
Health Unit of the DHB by the Regional Referral Centre after it has been received (see Appendix
15). This will be forwarded to the MoH to enable monitoring of national supplies.




WDHB Primary Care Pandemic Response Plan: Version 4.0              13 July 2009             Page    42
16.3 Epidemiological
The spread of the virus, once community spread is established, will be monitored by the Public
Health Unit of the WDHB. However, Novel Influenza A (H1N1) 09 is clinically indistinguishable
from seasonal influenza, which has already begun to occur.

16.4 Human resources
The primary care workforce will be affected by the following factors:
    Provider illness
    Support staff illness
    Illness in dependents
    Childcare/school facility functioning
    Eldercare facility functioning

This is complicated further by the need for a certain critical number of staff to maintain a facility‟s
capacity to function. Once this falls below the level of viability, the facility has no choice but to
close. Should this situation arise, there are precautions and consequences that may be considered:
     Maintenance of communication processes/responsibility for results already ordered
     Availability of patient data for other practitioners
     Redeployment of surplus available staff

The coordination of human resources will be done by the PCPRT, so that staff can be deployed to
the location where they are most needed. It is expected that influenza infection will move through
the region in a patchy fashion, which will reduce the strain on services overall.

Monitoring the impact of the spread of influenza through the region will be done by twice-weekly
reports to the PPCRT that assess both the numbers of patients with ILI being seen, and also the stress
experienced by providers. In the event of a provider being unable to cope, extra staff will be
deployed to assist. Lists of staff that could be available from other services will be maintained and
drawn upon as required.

17.     Financial issues
There are a several financial issues that a pandemic raises for primary care.
    The MOH has stated that services provided by CBACs will be free, but how these facilities
       are to be funded has not yet been made clear.
    Patients with ILI with increased risk, or comorbidities that require medical evaluation should
       not be penalised by virtue of those factors, as this would be discriminatory. Therefore,
       mechanisms for paying for the cost of primary care need to be developed
    Practices may be directed to close, thereby preventing revenue earning, but costs (e.g. labour,
       rent,etc) may remain the same.
    Staff seconded to other facilities which have different pay rates.
    Copayments for patients who are not able to be seen by their usual GP.

These issues are currently being addressed by meetings between the PPCRT, and the Funding and
Planning Unit of WDHB, although details are not yet available.

WDHB Primary Care Pandemic Response Plan: Version 4.0              13 July 2009             Page     43
18.    References
1.    Waikato DHB. Community Based Assessment Centres. 2006.
2.    Ministry of Health. New Zealand Influenza Pandemic Action Plan: Guidance on Care. 2006.
3.    Waikato DHB. Draft Pandemic Plan; Version 2. 2006.
4.    Scoins H. Practice Pandemic Planning Resources (Counties Manukau). 2007.
5.    National Health Coordination Committee. Guidance for Public Health Services Involved in
      Managing Influenza in Residential Institutions and Day Centres. 29 June 2009.
6.    Ministry of Health. Guidance on the diagnosis and management of Novel Influenza A
      (H1N1) 09 in the Pandemic 'Management' phase No 2. 1 July 2009.
7.    Harper SA, Bradley JS, Englund JA, et al, Expert Panel of the Infectious Diseases Society of
      America. Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis,
      and institutional outbreak management: clinical practice guidelines of the Infectious Diseases
      Society of America. Clin Infect Dis 2009; 48:1003-32.
8.    Mansell C. Influenza A Testing Strategy. 19 June 2009.
9.    Waikato Medical Officer of Health. Personal communication. 26 June 2009.
10.   NHCC. Influenza; Clinical guidelines for infants and children. 3 July 2009.
11.   CDC website. Interim Guidance for Clinicians on the Prevention and Treatment of Swine-
      Origin Influenza Virus Infection in Young Children. Available from url:
      http://www.cdc.gov/swineflu/childrentreatment.htm Accessed 27 June 2009.
12.   Curtis N, Hynes K. Antiviral drug doses in children. Available from url:
      http://www.rch.org.au/emplibrary/clinicalguide/Antiviral_drug_doses_in_children_with_infl
      uenza.pdf, 23 June 2009. Accessed 12 July 2009.
13.   CDC website. Antiviral Agents for Seasonal Influenza: Side Effects and Adverse Reactions.
      Available from url; http://www.cdc.gov/flu/professionals/antivirals/side-effects.htm
      Accessed 29 April 2009.
14.   CDC. Pregnant women and novel influenza A (H1N1) virus: considerations for clinicians.
      Available from url: http://www.cdc.gov/h1n1flu/clinician_pregnant.htm. 30 June 2009.
      Accessed 12 July 2009.
15.   World Health Organisation. Reducing excess mortality from common illnesses during an
      influenza pandemic. WHO guidelines for emergency health interventions in community
      settings. Geneva, 2008.
16.   Mills G. Personal communication. 1 July 2009.
17.   Lim WS. Pandemic flu: clinical management of patients with an influenza-like illness during
      an influenza pandemic. Provisional guidelines from the British Infection Society, British
      Thoracic Society and Health Protection Agency in collaboration with the Department of
      Health. Thorax 2007; 62:1-46.
18.   Paediatric Society of New Zealand. Wheeze and chest infection in infants under 1 year: Best
      practice evidence based guideline. 2005.
19.   Meech R. Pandemic antibiotics (personal communication). 10 July 2009.
20.   Meech R. Personal communication. 29 June 2009.
21.   Subbe CP, et al. Validation of an modified Early Warning Score in medical admissions. Q J
      Med 2001; 94:521-526.
22.   NHS. Swine flu paediatric community assessment tool. June 2009.
23.   RNZCGP. ePulse 2009; 11: #35.
24.   NHCC Operations Manager. National PPE reserves: clarification for DHBs. 30 June 2009.
25.   Ministry of Health. Taking Tamiflu: for people who cannot take medication capsules.
      Undated communication.

WDHB Primary Care Pandemic Response Plan: Version 4.0          13 July 2009            Page     44
19. Appendices
Appendix 1. Map of the Waikato DHB area




WDHB Primary Care Pandemic Response Plan: Version 4.0   13 July 2009   Page   45
Appendix 2. Position descriptions

COMMUNITY BASED ASSESSMENT CENTRE – POSITION CHECKLISTS


           1. Cleaning Staff


Reports to:
    CBAC Manager.

Responsible for:
    Ensuring CBAC is cleaned as per schedule and in accordance with current infection control
      measures

Readiness
    Participate in initial CBAC training prior to activation of CBAC facility
    Participate in infection control training prior to activation of CBAC facility
    Participate in induction training and orientation for designated CBAC site

Activation of position and allocation to CBAC site
    Report to CBAC Manager
    Conduct familiarisation for CBAC facility
    Attend updated CBAC and infection control training if required
    Attend initial briefing for specific CBAC procedures for CBAC facility

Duration of shift
   Determine frequency of cleaning required for each CBAC area
   Clean all chairs, tables, benches and surfaces with detergent
   Mop all floors with detergent
   Wipe hard surfaces with detergent
   Clean hand basins, toilets and bathroom facilities
   Empty rubbish bins
   Ensure cleaning audit card is completed after each area is cleaned
   Ensure cleaning stocks are available and regularly replenished in each CBAC area, in
      particular in CBAC Assessment areas (handwash, paper towels, detergent, etc)

Shift change
    Check cleaning and PPE supplies prior to shift changeover and order stocks as required
    Ensure cleaning audit card is up-to-date
    Attend briefing on shift change

Equipment
   Identification card
   Individual PPE
   Mop


WDHB Primary Care Pandemic Response Plan: Version 4.0           13 July 2009          Page    46
      Bucket
      Plastic Bags
      Detergent
      Cloths
      Paper Towels
      Cleaning trolley
      Other stores dictated by infection control measures

This is a generic position checklist that can be adapted to suit individual DHB current cleaning
contractual arrangements and infection control measures. It is recommended that further advice be
sought from infection control prior to activating cleaning staff in a CBAC environment.


           2. CBAC Manager



Reports to:
    Clinical Leader and Nursing Leader
    Primary Care Coordinator

Responsible for:
    Overall establishment and effective operation of CBAC facility including management of
      CBAC non clinical staff and the CBAC facility.
    Overall responsibility for the following staff:
         o Admin staff
         o Volunteers
         o Security
         o Cleaning staff
         o Catering

Readiness
    Liaise with CBAC facility owner
    Oversee the design of the site in relation to access, security and patient and staff flow
    Participate in relevant CBAC training prior to activation of CBAC facility e.g. infection
      control and orientation for designated CBAC site
    Ensure CBAC non-clinical staff is appropriately trained
    Ensure all supporting CBAC resources have been identified
    Ensure familiarisation of CBAC procedures, including patient flow, etc
    Assist with rostering of clinical and non-clinical CBAC staff
    HR requirements for all clinical, non-clinical and volunteers

Duration of operation
   Ensure clinical and non clinical staff complete and maintain contact lists and timesheets
   Ensure volunteer complete and maintain contact lists and timesheets
   Ensure maintenance of appropriate staffing levels
   Monitor CBAC work flow


WDHB Primary Care Pandemic Response Plan: Version 4.0          13 July 2009            Page     47
      Ensure adherence to CBAC procedures by all CBAC Staff
      Ensure maintenance and adherence to infection control procedures by all CBAC staff
      Liaise with local emergency services and Civil Defence personnel
      Manage all staff working in CBAC
      Ensure CBAC staff are receiving regular breaks
      Ensure maintenance of accurate clinical and administration records
      Provide regular reporting to Control Centre as directed including minimum dataset
       information, incident reports, etc
      Ensure appropriate stock levels are maintained for CBAC

Shift change
    Provide shift changeover report
    Provide separate briefing to incoming CBAC Manager
    Forward any incident reports to CBAC Manager

Equipment
   Oversight of non-medical equipment
   Mobile communications
   Maintain adequate pandemic supplies


           3. CBAC Clinical Leader


Reports to:
    CBAC Manager and Nursing Leader
    Primary Care Coordinator

Responsible for:
    Rostering of clinical CBAC staff
    Overall supervision of medical staff in CBAC
    Establish clinical guidelines for assessing and treatment of all patients, especially those in
      high priority
    Provide assistance in all assessment/treatment areas as required
    Oversight of decision making on appropriate disposition of patients in priority assessment
      areas
    Oversight of all clinical decision making

Readiness
    Liaise with CBAC leadership team re CBAC site and facilities including patient and staff
      flow
    Participate in relevant CBAC training prior to activation of CBAC facility –e.g. infection
      control and orientation for designated CBAC site
    Ensure CBAC clinical staff is appropriately trained (in collaboration with Nurse Leader)
    Overview of clinical equipment requirements

Duration of operation

WDHB Primary Care Pandemic Response Plan: Version 4.0          13 July 2009           Page    48
      Ensure maintenance of appropriate clinical staffing levels
      Monitor CBAC patient flow
      Ensure CBAC staff are receiving regular breaks
      Ensure maintenance of accurate clinical records
      Ensure appropriate stock levels are maintained for CBAC

Shift change
    Provide shift changeover report
    Provide separate briefing to oncoming CBAC Manager
    Forward any incident reports to CBAC Manager

Equipment
   Oversight of medical equipment and supplies


           4. CBAC Nursing Leader


Reports to:
    CBAC Manager and Clinical Leader
    Primary Care Coordinator

Responsible for:
    Rostering of clinical CBAC staff (in collaboration with Clinical Leader)
    Overall supervision of nursing staff in CBAC
    Establish clinical guidelines for assessing and treatment of all patients, in priority 2 and 3
      areas
    Provide assistance in all assessment/treatment areas as required
    Oversight of decision making on appropriate disposition of patients in priority assessment
      areas
    Oversight of all nursing decision making

Readiness
    Liaise with CBAC leadership team re CBAC site and facilities including patient and staff
      flow
    Develop orientation and training package for all staff
    Participate in relevant CBAC training prior to activation of CBAC facility –e.g. infection
      control and orientation for designated CBAC site
    Ensure CBAC clinical staff is appropriately trained (in collaboration with Clinical Leader).
    Overview of clinical equipment requirements

Duration of operation
   Ensure maintenance of appropriate clinical staffing levels
   Monitor CBAC patient flow
   Ensure CBAC staff are receiving regular breaks
   Ensure maintenance of accurate clinical records


WDHB Primary Care Pandemic Response Plan: Version 4.0           13 July 2009           Page    49
      Ensure appropriate stock levels are maintained for CBAC

Shift change
    Provide shift changeover report
    Forward any incident reports to CBAC Manager

Equipment
   Oversight of medical equipment and supplies




WDHB Primary Care Pandemic Response Plan: Version 4.0        13 July 2009   Page   50
Appendix 3. Welfare Referral Form

                                WELFARE REFERRAL

Date:___________     CBAC Site:______________________________ CBAC Phone:_______________


CDEM EOA:              □ TVEOA                 □ WVEOA                 □ SEOA
Fax Number_________________

Time faxed _______________(24hr format)

Patient ID information

Family Name ___________________ Given Name _________________ Middle name _______________

Address ____________________________________________________________________________

Date of Birth ____________ Male □ Female □ Phone____________ Other Phone _______________

Circle appropriate answer

1. Are you able to care for yourself?…………………………………………………………………… Yes / No

2. Do you have anybody able to care for you? (Family, Neighbours, Friend) ……………………..             Yes / No

3. Do you have food supplies for the next 2 days? …………………………………………………... Yes / No

4. Are you able to prepare your own meals ? …………………………………………………………. Yes / No

5. Are you able to keep warm ? (heater, fire, bed) ……………………………………………………. Yes / No

6. Are you able to replenish supplies? (food, fuel, wood/coal, supplementary financial support) ... Yes / No

7. Do you already receive assistance? From whom? ………………………………………………… Yes /                               No

8. Are you providing assistance to other persons which is likely to cease during your sickness? … Yes / No

9. Other considerations you require assistance on:
     Housing ………………………………………………………………………………………….. Yes /                                                 No
     Transport ………………………………………………………………………………………… Yes /                                                 No
     Animal management …………………………………………………………………………… Yes /                                              No
     Any other concerns …………………………………………………………………………….. Yes /                                           No

10. Do you have a means to contact people in an emergency or if your circumstances change?      Yes / No
(e.g. landline phone, mobile phone, personal alarm, plan with neighbour, family or friend)




WDHB Primary Care Pandemic Response Plan: Version 4.0                13 July 2009               Page    51
Appendix 4. Modified Early Warning Score (MEWS)

           3          2          1           0          1             2            3
SBP        <70        71-80      81-100      101-199                  >200
HR                    <40        41-50       51-100     101-110       111-129      >/=130
RR                    <9                     9-14       15-20         21-29        >/=30
Temp                  <35                    35-38.4                  >/=38.5
AVPU                                         Alert      Reacting      Reacting     Unresponsive
score                                                   to voice      to pain



Appendix 5. SIRS (systemic inflammatory response syndrome) criteria
These signs indicate significant physiologic disruption, including sepsis. SIRS can be diagnosed
when two or more of the following criteria are fulfilled:
    Temperature ≥38 ° Celcius
    Heart Rate >90/min
    Respiratory Rate >20/min




WDHB Primary Care Pandemic Response Plan: Version 4.0           13 July 2009            Page       52
Appendix 6. CBAC Supplies list

                           CBAC Supplies Checklist               Number   Received
Diagnosis and assessment
Thermometers
Sphygmomanometer and stethoscope
Scales
Flashlight
Cleaning and infection control equipment
Tissues
Surgical masks
Eye protection
Paper towels
Plastic Aprons
Alcohol wipes
Latex-free gloves - small
Latex-free gloves - medium
Latex-free gloves - large
Antibacterial hand washing solutions (bottles)
Sterilising liquid for surfaces/cleaning
Adhesive tape (rolls)
Plastic rubbish liner bags
Furniture
Tables and chairs
Examination couch/s
Mobile light e.g. anglepoise
Portable partitions
Rubbish bins
Linen bags
Administration equipment
Lockable cabinet for drugs
Clinical data collection forms
Phone, fax and photocopier
Stapler/staples
Scissors
Clipboards
Filing boxes
Pads of paper
Pens, pencils
Rubber bands
Cellotape and dispenser
Post-it notes
Photocopy paper
Provisions
Tea, coffee sugar, biscuits
Disposable cups, spoons, paper serviettes


WDHB Primary Care Pandemic Response Plan: Version 4.0   13 July 2009      Page   53
Communication
Phone – landline or mobile
Access to fax
Signage
Influenza patient information brochures
CD Welfare Information
Staff information
IC Manual
IT Requirements (optional)
Cell Tops
Lap
Internet links WDHB EOC
Scanner
Cell Phones
Fax




WDHB Primary Care Pandemic Response Plan: Version 4.0   13 July 2009   Page   54
Appendix 7. Taking Tamiflu: for people who cannot take medication capsules
You have been given a course of Tamiflu because you or someone you are caring for has influenza.
Tamiflu can reduce the symptoms of influenza and shorten the course of the illness. The Ministry of
Health recommends that you or the person you are caring for take the capsules you have been given.
The capsules contain the actual medicine, which is a bitter-tasting white powder. If you or the
person you are caring for can‟t swallow capsules, you will need to mix the powder inside the capsule
with something sweet so that the medicine can be taken.

1. You will need
     The contents of one Tamiflu capsule
     A large teaspoon of some strongly flavoured sweet food (the sweeter the better), for example:
           o smooth-textured jam (diabetic jam is fine)
           o fruit syrup (diabetic versions are fine)
           o strongly flavoured runny honey
           o strong sugar syrup (made from table sugar and a small amount of water)
           o golden syrup
           o sweetened condensed milk
       Note: Don’t use chocolate syrup – the bitter taste of the powder comes through.

2. Prepare the mixture
     Wash and dry your hands.
     Place a large teaspoon of the sweet food into a clean dessertspoon.
     Carefully break open the Tamiflu capsule, and pour the contents into the food.
     Stir thoroughly for at least one minute until all the powder is completely mixed in.

3. Give the medicine
     Give the medicine straight away after mixing. If possible, give the medicine at the same time
       as a meal, or some other food.
     For children of 15 kg or less, give one third of the mixture, and throw the rest away.
     For children of 15 kg to 40 kg, give two-thirds of the mixture, and throw the rest away.
     For anybody over 40kg, give all the mixture.
     Give a strongly flavoured drink afterwards to clear any after-taste.

4. Give the full course of medicine
    Prepare and give one dose twice each day for five days.
    It is important to take the full course even if you or the person you are caring for start to feel
      better.


Developed by the New Zealand Ministry of Health and approved by Medsafe, the New Zealand Medicines
Safety Authority. For more information go to www.moh.govt.nz or www.medsafe.govt.nz25




WDHB Primary Care Pandemic Response Plan: Version 4.0            13 July 2009             Page    55
Appendix 8. Process for activation and deactivation of CBACs




WDHB Primary Care Pandemic Response Plan: Version 3   7 July 2009   Page   56
Appendix 9. Patient flows during a Pandemic




WDHB Primary Care Pandemic Response Plan: Version 3   7 July 2009   Page   57
Appendix 10. Community Based Initial Assessment / Triage Form

Community Based Initial Assessment / Triage Form                                Date:_dd_ /_mm_/_yy_
CBAC Location:      Anglesea     Victoria North  Other: (please state)_________________________
* Indicates compulsory information               Fax to Health Waikato Regional Referral Centre, 0800 867333
Section 1 : Patient Details

*Family name:                              *Given name:                         *Middle name:

*DOB: (dd/mm/yyyy)                         *Age:                                NHI (if known):
Usual GP:                                  Practice name:
*Sex:    Male      Female                Weight: (children)                   *Ethnicity
Home Address:                              Next of Kin: (name & address)           NZ European
*No:____*Street:_______________                                                    Maori
*Suburb:______________________                                                     Pacific
                                                                                   Asian
*City/Town:___________________
                                                                                   Other ________________
*Home ph:____________________
Cell:                                      Next of Kin phone:                   *Occupation:


Section 2: Assessment for Influenza-like illness                       Time of assessment:
History of fever, chills and sweating?      yes  no                Sore throat?  yes  no
Temp (>38C)                   Number of days unwell:                Cough?         yes  no
Other symptoms: (Runny nose, sputum, headache, nausea/vomiting, diarrhoea, myalgia, arthralgia,
shortness of breath, chest pain)




Section 3: Risk Assessment                                                Time of assessment:

BP:         _____ /_____            HR: ___/min           RR: ___/min          Comorbidities:
Oxygen saturation:                  Dyspnoea               yes  no            Significant asthma/COPD
Cap refill >3 secs?  yes  no      Chest indrawing        yes  no            Heart disease
Pregnant?  yes  no                                                            Diabetes
                                    Regular medications & dosage:
                                                                                Chronic kidney disease
                                     ___________________________
                                     ___________________________               Liver disease
If yes: ____ /40
                                     ___________________________               Cancer (not skin)
Allergies:                                                                      Immune suppression
                                     ___________________________
 _______________________            ___________________________               Organ transplant recipient
 _______________________                                                       Other ________________
                                     ___________________________

Additional Clinical Features: (Rigors, vomiting, pleuritic chest pains,        SIRS score:
inability to self care, dehydration, alert/drowsy/confused)
                                                                               MEWS score:

Indications for antiviral medication:       Indications for antibiotics:       Indications for swabs:
 Severe ILI                                 Suspected pneumonia               Severe illness
 Pregnancy                                  Risk of pneumonia                 ILI and risk of serious comps
 Significant comorbidity                    Other                             ILI and high-risk institution

Section 4: Treatment and discharge
*Antiviral given?      *Antibiotic given?                Recommendation?                Admin only
 Tamiflu               Augmentin                        Home
                                                                                Data entered
 Relenza               Roxithromycin                    Key Practice
                        Other                            ED                  Date: _________________
 Prescription                                                                 Name:_________________
                                                         Patient review
 Dispensed
                                                         requested in          Signature:______________
Dose: ___________      Dose: ______________
Duration: ________     Duration: ___________             _______days

Clinical assessment         Name:   (print)_____________________________________________________________
completed by:
                            Signature:_________________________________________________


WDHB Primary Care Pandemic Response Plan: Version 3                  7 July 2009                Page       58
Appendix 11. CBAC assessment form: Medtech Outbox document

COMMUNITY BASED INITIAL ASSESSMENT / TRIAGE FORM                                                          DATE: [MIS_DATE]
Key Practice: [LOC_NAME]
*Indicates Compulsory Information                                         Fax to Health Waikato Regional Referral Centre 0800 867 333
Section 1 : Patient Details
*Family name: [PAT_SURNAME]                        *Given name: [PAT_FIRSTNAME]
*DOB: [PAT_DOB]                                    *Age:[PAT_AGE]                                  NHI (if known):[PAT_NHI_NO]
Usual GP:                                          Practice name:
*Sex: [PAT_GENDER]                                 Weight if less than 60kg                        *Ethnicity: [PAT_ETHNICITY]
*Home Address:                                     Next of Kin: [PAT_NOK_NAME]
[PAT_HOME_STREET]                                  [PAT_NOK_STREET]
[PAT_HOME_SUBURB]                                  [PAT_NOK_SUBURB]
[PAT_HOME_CITY]                                    [PAT_NOK_CITY]
Home ph: [PAT_DAY_PHONE] Cell:                     Next of Kin phone:                              *Occupation:
[PAT_MOB_PHONE]                                    [PAT_NOK_PHONE]                                 [PAT_OCCUPATION]

Section 2: Assessment for Influenza-like illness                             Time of assessment:
History of fever, chills and sweating?               yes       no                         Sore throat?       yes      no

Temp (>38°C)                         Number of days unwell:                               Cough?             yes      no

Other symptoms: (Runny nose, sputum, headache, nausea/vomiting, diarrhoea, myalgia, arthralgia, shortness of breath,
chest pain)


Section 3: Risk Assessment                                                  Time of assessment:
BP: _____/_____                                  HR: ___/min              RR: ___/min       Comorbidities:
    2                                                                                           Significant asthma/COPD
SpO                                              Chest Indrawing          yes    no
                                                                                                      Heart disease
Cap refill >3 secs?      yes        no           Dyspnoea                 yes      no                 Diabetes
                                                 Regular medications & dosage:                        Chronic kidney disease
Pregnant?               yes         no
                                                   ___________________________                        Liver disease
If yes: ____ /40                                   ___________________________                        Cancer (not skin)
Allergies:                                         ___________________________                        Immune suppression
   _______________________                         ___________________________                        Organ transplant recipient
   _______________________                         ___________________________                        Other ________________

Additional Clinical features: (Rigors, vomiting, pleuritic chest pains, inability to self          SIRS score:
care, dehydration, alert/drowsy/confused)
                                                                                                   MEWS score:

Indications for antiviral medication:                      Indications for antibiotics:            Indications for N/P swab
   Severe ILI                                                 Suspected pneumonia                     Severe illness
   Pregnancy                                                  Risk of pneumonia                       ILI and risk of serious comps
   Significant comorbidity                                    Other                                   ILI and high risk institution

Section 4: Treatment and discharge
*Antiviral given:           *Antibiotic given:                           Recommendation:            Admin only
   Tamiflu                     Augmentin                                   Home                       Data entered
   Relenza                               Roxithromycin                       Key Practice           Date: _________________
   Prescription                          Other                              ED                      Name:_________________
   Dispensed                                                             Patient review
Dose: ___________                   Dose: ______________                 requested in               Signature:______________
Duration: ________                  Duration: ___________                _______days
Clinical assessment
completed by                        Name: (print)_____________________________________________________

                                    Signature:_________________________________________________


WDHB Primary Care Pandemic Response Plan: Version 3                                       7 July 2009                  Page       59
Appendix 12. Instructions for collecting specimens for Influenza A (H1N1) 09
Collect samples promptly to avoid prolonged exposure of
staff and other patients, so the patient can be transferred or       Nasopharyngeal swabs are the best
discharged home.                                                     specimen.
 Wear mask, gloves and gown.                                        Throat swabs may be taken if nasal
 A standard surgical mask is satisfactory.                          specimens are unobtainable.
 Wear protective glasses if available.

                             Gloves and mask are recommended
                             when obtaining respiratory samples.

NASOPHARYNGEAL SWABS
Do this test first as it is the most uncomfortable.
Rest back of patient‟s head against wall or bed.
Use flexible per-nasal swab.
Insert swab 4-5 cm into nose in horizontal direction.
Rotate swab 3 x each way.
Put swab back dry into its plastic tube.

LOW NOSE SWABS
Use rigid virus swab from green top tube.
Insert swab 2 cm into nose, but not so far as to be uncomfortable.
Rotate 2-3 x each way.
Put swab into virus transport medium e.g. the
green tube.

SWAB TYPE:
Please use green swabs available (viral transport medium)
Alternative swab types must have dacron, polyester or nylon tips and aluminium, plastic or wire
shafts. Examples are: black top Chlamydia swab MW120, flexible wire blue top MW160 and the
Microrheologics plastic flocked swab as used for Influenza surveillance. The sample must be sent
as a dry swab or in a special virus transport medium.

Virus testing cannot be done on swabs sent in a bacterial transport medium such
as Charcoal, Amies, and Gel, nor on swabs with wooden shafts.
ESR and Auckland hospital labs prefer not to process wire shafted swabs (they have to cut each one
with sterilised scissors), so if specimens are sent directly there, a plastic shaft would be preferred.

Waikato Hospital lab processes can use wire swabs. Plastic-shafted swabs that are flexible enough
to use for nasopharyngeal swabbing can be difficult to obtain, but are great if available (some have
orange tops and some are in paper packets).



Chris Mansell, Clinical Microbiologist, Waikato Hospital.




WDHB Primary Care Pandemic Response Plan: Version 3              7 July 2009               Page     60
Appendix 13. Order forms for Pandemic Supplies



ORDER FOR PANDEMIC PERSONAL PROTECTION EQUIPMENT
                 Fax to Waikato DHB Purchasing & Distribution Services on 07 839 8784
            (If submitting order after hours ring Waikato DHB Supply Chain Manager before sending)

  Code #                                Description                         Unit    Qty Reqd     Qty Issued
  134231         DELIVERY - PANDEMIC STOCK                                EACH          1
  134876         APRON SURGICAL DISP STD 11335MM (PK25)                   PAK
  134239         GLOVE EXAM P/FRE DERMAGRIP LARGE (BX100)                 BX
  134874         GLOVE EXAM P/FRE DERMAGRIP MEDIUM (BX100)                BX
  134875         GLOVE EXAM P/FRE DERMAGRIP SMALL (BX100)                 BX
  134877         GOWN ISOLATION YELLOW DISPOSABLE                         EACH
  134873         HANDGEL ALCOHOL 70% V/V ETHYL 150ML                      BT
  134882         HANDGEL ALCOHOL 70% V/V ETHYL 500ML                      BT
  134881         MASK F/SHIELD WITH VISOR TECHNOL (BX25)                  BX
  134880         MASK FLUIDSHIELD PFR 95 PARTICULATE (BX35)               BX
  134879         MASK PROCEDURE W/EARLOOPS (BX50)                         BX
  134878         MASK SURGICAL STANDARD BLUE (BX50)                       BX
  134897         TISSUE FACIAL HYGENEX WHITE (BX100)                      BX
  107667         BAG PLASTIC YELLOW 600X1000X900                          EACH
  134240                                                    BX
                 BOX 405X255X255MM FOR PACKING PANDEMIC STOCK(CTN25




Name of person placing order (print):                         Delivery Address:

Signature of person placing order:

Contact phone number:
Time/Date of order:


                             Waikato DHB Purchasing and Distribution Service use only


Date received:                                            Order Number:
Time received:                                            Despatch confirmation:

USE RC2095-XXX




WDHB Primary Care Pandemic Response Plan: Version 3                                7 July 2009                Page   61
                             ORDER FOR PANDEMIC STORES
                 Fax to Waikato DHB Purchasing & Distribution Services on 07 839 8784
            (If submitting order after hours ring Waikato DHB Supply Chain Manager before sending)

  Code #                                Description                        Unit     Qty Reqd     Qty Issued
  134231         DELIVERY - PANDEMIC STOCK                                EACH          1
  134884         CATHETER IV AUTOGUARD 14GA X 1.75IN                      BX
  134885         CATHETER IV AUTOGUARD 16GA X 1.77IN                      BX
  134886         CATHETER IV AUTOGUARD 18GA X 1.16IN                      BX
  134887         CATHETER IV AUTOGUARD 20GA X 1.16IN                      EACH
  134888         CATHETER IV AUTOGUARD 22GA X 1.00IN                      BT
  134877         GOWN ISOLATION YELLOW DISPOSABLE                         BX
  134881         MASK F/SHIELD WITH VISOR TECHNOL (BX25)                  EACH
  134880         MASK FLUIDSHIELD PFR 95 PARTICULATE (BX35)               BX
  134878         MASK SURGICAL STANDARD BLUE (PK50)                       BX
  134893         NEEDLE BLUNT FILL 18G X 1.5IN (100/BOX)                  EACH
  134894         NEEDLE HYPODERMIC 20G X 1 INCH YELLOW                    EACH
  134895         NEEDLE HYPODERMIC 22G X 1.5 INCH BLACK                   EACH
  134896         NEEDLE HYPODERMIC 24G X 1 INCH RED                       EACH
  134883         SMARTSITE BLOOD SET 20 DROPS/ML                          EACH
  134889         SYRINGE HYPO 20ML N/N CONCEN LUER LOK                    EACH
  134892         SYRINGE HYPO 60ML CONCEN LOK LUER (EA/PK60) EACH
  108544         SYRINGE HYPODERMIC 10ML CONCEN LUER LOK                  EACH
  134890         SYRINGE HYPODERMIC 3ML LUER LOK                          EACH
  134891         SYRINGE HYPODERMIC 5ML LUER LOK                          EACH




Name of person placing order (print):                         Delivery Address:
Signature of person placing order:
Contact phone number:
Time/Date of order:



                             Waikato DHB Purchasing and Distribution Service use only


Date received:                                            Order Number:
Time received:                                            Despatch confirmation:

USE RC2095-XXX




WDHB Primary Care Pandemic Response Plan: Version 3                                7 July 2009                Page   62
                              ORDER FOR PANDEMIC FLUIDS
             Fax to Waikato DHB Purchasing & Distribution Services on 07 839 8784
            (If submitting order after hours ring Waikato DHB Supply Chain Manager before sending)

Code #                                  Description                              Unit   Qty Reqd Qty Issued
 134231 DELIVERY - PANDEMIC STOCK                                                EACH      1
 134898 FLUIDS IV GLUCOSE 10% 500ML                                              EACH
 134899 FLUIDS IV GLUCOSE 4% 0.18% SODIUM CHLORIDE 1000ML EACH
 134900 FLUIDS IV GLUCOSE 4% 0.18% SODIUM CHLORIDE 500ML                         EACH
 134868 FLUIDS IV GLUCOSE 5% 1000ML                                              EACH
 134901 FLUIDS IV GLUCOSE 5% 500ML                                               EACH
 134869 FLUIDS IV SODIUM CHLORIDE 0.9% 1000ML                                    EACH
 134870 FLUIDS IV SODIUM CHLORIDE 0.9% 100ML                                     EACH
 134871 FLUIDS IV SODIUM CHLORIDE 0.9% 250ML                                     EACH
 134872 FLUIDS IV SODIUM CHLORIDE 0.9% 500ML                                     EACH




Name of person placing order (print):                          Delivery Address:
Signature of person placing order:
Contact phone number:
Time/Date of order:



                             Waikato DHB Purchasing and Distribution Service use only


Date received:                                          Order Number:
Time received:                                          Despatch confirmation:

USE RC2095-XXX




WDHB Primary Care Pandemic Response Plan: Version 3                                7 July 2009                Page   63
                        ORDER FOR PANDEMIC ANTIBIOTICS
              Fax to Waikato DHB Purchasing & Distribution Services on 07 839 8784
            (If submitting order after hours ring Waikato DHB Supply Chain Manager before sending)

Code #                                  Description                           Unit     Qty Reqd Qty Issued
 134231 DELIVERY - PANDEMIC STOCK                                             EACH        1
 124611 AMOXYCILLIN/CLAVULANIC ACID 1.2G INJ (PACK/10)                        PK
 105458 AMOXYCILLIN/CLAVULANIC ACID 500MG TAB (PACK/20)                       PK
 110172 AMOXYCILLIN/CLAVULANIC ACID SYRUP 250MG/5ML                           BT
 135893 CEPHAZOLIN 1GM INJ (PK/10)                                            PK
 135896 COTRIMOXAZOLE 480MG TAB (PACK/500)                                    PK
 135895 COTRIMOXAZOLE LIQUID 240MG/5ML 500ML                                  BT
 109988 DOXYCYCLINE 100MG TAB (PACK/250)                                      PK
 135892 FLUCLOXACILLIN 1G INJ (PACK/5)                                        PK
 105691 FLUCLOXACILLIN CAP 500MG (PACK/500)                                   PK
 135894 FLUCLOXACILLIN SYRUP 250MG/5ML                                        BT




Name of person placing order (print):                         Delivery Address:
Signature of person placing order:
Contact phone number:
Time/Date of order:



                             Waikato DHB Purchasing and Distribution Service use only


Date received:                                          Order Number:
Time received:                                              Despatch confirmation:

USE RC2095-XXX




WDHB Primary Care Pandemic Response Plan: Version 3                                  7 July 2009             Page   64
                 COMMUNITY PHARMACY ORDER FOR TAMIFLU
              Fax to Waikato DHB Purchasing & Distribution Services on 07 839 8784
            (If submitting order after hours ring Waikato DHB Supply Chain Manager before sending)

  Code #                                Description                         Unit     Qty Reqd     Qty Issued
  134231         DELIVERY - PANDEMIC STOCK                                EACH          1
  116894         OSELTAMIVIR (PCKT of 10)                                 PCKT




Name of person placing order (print):                         Delivery Address:

Signature of person placing order:
Contact phone number:

Time/Date of order:



                             Waikato DHB Purchasing and Distribution Service use only


Date received:                                            Order Number:

Time received:                                             Despatch confirmation:

Use RC 2095-500




WDHB Primary Care Pandemic Response Plan: Version 3                                 7 July 2009                Page   65
                                 OTHER ITEMS ORDER FORM
              Fax to Waikato DHB Purchasing & Distribution Services on 07 839 8784
            (If submitting order after hours ring Waikato DHB Supply Chain Manager before sending)

  Code #                                Description                         Unit     Qty Reqd     Qty Issued
  134231         DELIVERY - PANDEMIC STOCK                                EACH          1




Name of person placing order (print):                         Delivery Address:

Signature of person placing order:

Contact phone number:

Time/Date of order:



                             Waikato DHB Purchasing and Distribution Service use only


Date received:                                            Order Number:

Time received:                                             Despatch confirmation:

USE RC2095-XXX




WDHB Primary Care Pandemic Response Plan: Version 3                                 7 July 2009                Page   66
Appendix 14. Infection control in the home: Patient Information
Transmission of community-acquired respiratory infections occurs most commonly through
inhalation of respiratory droplets produced by talking, coughing, spitting and sneezing. Respiratory
droplets may also survive for brief periods (depending on the ambient temperature) on hands,
clothes and surfaces. Hand-hygiene, respiratory etiquette, and maintaining a distance of 1-2 metres
(3-6 feet) can reduce the chance of transmission of infection.

Hand hygiene
Coughing or sneezing may contaminate hands, clothes or surfaces (tables, doorknobs/handles,
plates, cups, etc.). Hands should be cleaned by washing with soap and water for 20 seconds before
rinsing, and then dried. Alcohol-based preparations (60–80% alcohol content), if used and available
locally, are also effective if rubbed on hands until hands are dry. Hand-hygiene must be performed:
 before preparing or eating food
 after opening one‟s bowels or changing or cleaning a child
 after coughing, sneezing or blowing the nose
 before and after all contact with sick patients
 after cleaning or handling the patient's soiled linen and waste
 after handling animals or animal waste.

Respiratory droplets from coughing and sneezing or talking may land on hands, clothes or surfaces.
Hands must be washed after direct contact with respiratory secretions and after contact with sick
individuals (i.e. after contact with hands or potentially contaminated surfaces).

Respiratory etiquette
Coughs and sneezes should be covered with a tissue, cloth or mask. Used tissues should be disposed
of into a plastic bag, and hands should be subsequently washed. Masks are not recommended for
generalized (community) use. Use of masks for caregivers in the home might be beneficial in
limiting transmission, but is thought to be less important than the other measures mentioned above.

Social distancing
Family members should limit close contact with an ill person as much as possible. Other types of
exposure to an ill person such as sharing toothbrushes, cigarettes, eating utensils, drinks and linens
should be avoided. The number of caregivers in the home should be minimized to avoid further
exposure of family members.

Other measures
Shared spaces should be well ventilated so that respiratory droplets are better dispersed and the risk
of transmission of respiratory pathogens is reduced. This is particularly important in crowded
settings. Persons at increased risk of morbidity and mortality from illnesses should not care for or
be in close contact with the ill person. These persons include pregnant women, children aged under
2 years, persons aged over 65 years, and persons with severe chronic diseases or who are
immunocompromised.

Cleaning of the environment should include washing shared surfaces and clothes, bed linen and
scarves that have been in contact with a patient's respiratory secretions or stools. Water and soap
should be used for washing, and afterwards hands should be washed thoroughly with soap and
water (or cleaning fluids such as bleach).




WDHB Primary Care Pandemic Response Plan: Version 3             7 July 2009              Page    67
Appendix 15. Sending patient clinical data to other health care providers via
MedTech
For assistance with this, please phone 09 358 0661 for MedTech Support

It is possible to send an electronic copy of a patients consultation notes to another GP. This is
particularly useful after treating casual patients or if you are an A&E.

Sending consultation notes using Healthlink

Press F12 on the keyboard to open a new consultation screen.

When you have completed a patient‟s consultation, refer to the menu bar and click on Consultation
/ Send To.

                                                 If the details of the patient‟s regular GP have been
                                                 included in the patient register F3 (under the
                                                 account tab) then their details will appear in the
                                                 „To’ field automatically.

                                                 If the ‘To’ field is empty, click on the search button
                                                 (A square with 3 dots on it) at the end of the field to
                                                 search your address book for the patient‟s GP. If
                                                 the GP does not exist in your address book, you can
                                                 add their details including their Healthlink EDI.

                                                 You are also able to manually enter the GPs
                                                 HealthLink Mailbox name. Click the ‘RSD’ button
                                                 to send the message. Your message will be queued
                                                 for sending. .




If your MedTech scheduler is set to run, the consultation notes will be sent automatically, if
not follow the instructions below.
On the machine where you have HealthLink installed, use the Message Transfer Utility to queue
your message for sending. Go to Tools / Message Transfer / Message Transfer Utility. Click the
‘Process’ button to send your messages to HealthLink.




WDHB Primary Care Pandemic Response Plan: Version 3              7 July 2009             Page       68
      Appendix 16. Data flows for patients with ILI presenting at CBACs




WDHB Primary Care Pandemic Response Plan: Version 3   7 July 2009   Page   69

								
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