ASID (HICSIG) position statement: infection control guidelines for patients with influenza-like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities

Rhonda L Stuart, Allen C Cheng, Caroline L Marshall and John K Ferguson
Med J Aust 2009; 191 (8): 454-458. || doi: 10.5694/j.1326-5377.2009.tb02886.x
Published online: 19 October 2009


Standard and Droplet Precautions are considered adequate to control the transmission of influenza in most health care situations. Vaccination of health care staff, carers and vulnerable patients against seasonal and, eventually, pandemic influenza strains is an essential protective strategy.

Management principles include:

The emergence of the novel pandemic (H1N1) 2009 strain has had a significant impact on Australian health care facilities. At the start of the pandemic, there was uncertainty about the modes of transmission. Infection control measures were designed to protect the vulnerable against a disease in which transmissibility was reported as substantially higher than that of seasonal influenza.1,2 Initial evidence from animal transmission studies has now shown comparable transmissibility between the pandemic and seasonal strains.3,4

On 17 June 2009, the Australian Government announced a new pandemic response phase — “Protect” — and issued a new technical annex to the Australian Health Management Plan for Pandemic Influenza (AHMPPI) for this phase.5 This annex included updated infection control advice replacing some of the recommendations in the original AHMPPI Interim infection control guidelines for pandemic influenza in healthcare and community settings 2006.6

The primary goal of infection control is to protect health care workers (HCWs), other patients and community members from acquiring a potentially serious disease. However, the Protect phase guidance on infection control has been considered not entirely workable, and has been inconsistently applied by some jurisdictions. The most serious technical concern is the recommendation that the adoption of Droplet Additional Precautions is required only in an area within 1 metre of an infectious patient, an approach that we believe does not achieve an appropriate level of safety and that is inconsistent with international recommendations. In addition, other infection control recommendations regarding the use of surgical masks during some aspects of clinical care differ from accepted Droplet Precautions, causing further confusion.

The purpose of this position statement from the Healthcare Infection Control Special Interest Group (HICSIG) of the Australasian Society for Infectious Diseases (ASID) is to propose standard measures for adoption across Australia that are practical and consistent with available evidence. The process of developing these guidelines is outlined in Box 1.

How is influenza transmitted?

Influenza may be spread by aerosols, large droplets and contact. The relative importance of these modes is still debated.

Droplet transmission

Droplet transmission occurs via large droplets (> 5 μm diameter) generated from the respiratory tract. Droplet transmission involves direct deposition of large droplets onto the nasal mucosa, conjunctiva and, less frequently, the mouth of the new host. The maximum distance for droplet transmission is unresolved. Historically, the area of risk was defined as a distance less than 1 metre around the patient, based on epidemiological and simulated studies of selected infections. Investigations during the 2003 outbreak of severe acute respiratory syndrome (SARS) suggest that droplets could reach individuals located ≥ 2 metres from their source.7 The distance droplets can travel depends on the velocity and mechanism by which they are produced, the density of respiratory secretions, and factors such as temperature and humidity.8 From a sneeze or cough, large droplets may be propelled up to 6 metres or 2 metres, respectively, before settling or evaporating.8 The US Centers for Disease Control and Prevention (CDC) recommend donning a surgical mask within 2–3 metres (6–10 feet) of the patient, or on entry into the patient’s room or bed space.9 Although evidence suggests that surgical masking of patients reduces the potential for transmission by filtering out virus,10 in practice these masks become saturated after 10–15 minutes of use and lose their efficacy. In terms of HCW protection, a recent evidence review indicates that particulate (P2) masks are more effective than surgical masks and may be preferred in high transmission-risk settings.11

Contact transmission

Influenza is also transmitted by direct and indirect contact via inoculation of the respiratory mucosa by hands. The virus survives on surfaces for extended periods: up to 48 hours on non-porous surfaces and 30 minutes on unwashed hands.12 Contact transmission can be controlled by use of Standard Precautions, particularly hand hygiene, respiratory hygiene and cough etiquette, and environmental controls.9 These measures specify the use of protective eyewear during close contact to avoid direct contamination by respiratory secretions.

Infection prevention and control recommendations

The 2007 CDC evidence review and guideline9 is acknowledged internationally as the primary reference for Infection Control Precautions. Patients with suspected or laboratory-confirmed seasonal or pandemic (H1N1) 2009 influenza should be managed with Standard Precautions plus Droplet Additional Precautions (Box 2).9,15

Vaccination of patients and HCWs against seasonal influenza is an essential preventive measure; vaccination is expected to be available for pandemic (H1N1) 2009 influenza later in 2009.16

Droplet Additional Precautions (Box 2)
Health care workers’ personal protection
Contact tracing
  • Rhonda L Stuart1
  • Allen C Cheng2,3
  • Caroline L Marshall4,5
  • John K Ferguson6,7

  • 1 Department of Infectious Diseases, Monash Medical Centre, Melbourne, VIC.
  • 2 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC.
  • 3 Infectious Diseases Unit, Alfred Hospital, Melbourne, VIC.
  • 4 Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC.
  • 5 Department of Medicine, University of Melbourne, Melbourne, VIC.
  • 6 Department of Microbiology, John Hunter Hospital, Newcastle, NSW.
  • 7 University of Newcastle, Newcastle, NSW.


We would like to acknowledge the following people for their helpful advice (in alphabetical order): Anthony Allworth, Tara Anderson, Paul Armstrong, Sandy Berenger, Craig Boutlis, Kate Clezy, Peter Collignon, Andrew Daley, Dominic Dwyer, Lyn Gilbert, Massimo Giola, Rod Givney, Tom Gottlieb, David Holland, Jon Iredell, David McGechie, Alistair McGregor, Mary McLaws, Colin McLeod, Sally Roberts, Karen Rowland, Ramon Shaban, Tanya Sorrell, Marc Tebruegge, Sean Tobin and Irene Wilkinson.

Competing interests:

None identified.


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