Influenza and gastro outbreaks in Residential Aged Care Facilities



A case of ARI is sudden onset of any of the following

  • respiratory symptoms (e.g. cough, sore throat, shortness of breath) OR
  • during the COVID-19 pandemic, loss of taste and smell

Any case of ARI or unexplained fever (≥37.5) or history of fever (e.g. night sweats, chills) in a RACF should be treated as suspect COVID-19, isolated and swabbed.

An influenza-like illness (ILI) is defined as sudden onset of at least one of the following three respiratory symptoms:

  • Cough (new or worsening)
  • Sore throat
  • Shortness of breath

AND at least one of the following four symptoms

  • Fever
  • Malaise (feeling unwell)
  • Headache
  • Myalgia (muscle pain)

Any case of ILI in a RACF should be treated as suspect COVID-19 or influenza, isolated and swabbed.

A suspected influenza outbreak

  • 3 or more cases of influenza-like illness (ILI) in residents or staff within 3 days (72 hours)

 A confirmed influenza outbreak                                                                            

  • 3 or more cases of influenza-like illness (ILI) in residents or staff within 3 days (72 hours)

AND           at least one of the cases has had a positive laboratory test for influenza
OR             at least two of the cases have tested positive to influenza using a point-of-care test

A suspected COVID-19 case

Any resident with ARI, unexplained fever (≥37.5) or history of fever (e.g. night sweats, chills),  or ILI will be treated as a suspect COVID-19 case until testing has been undertaken to confirm or exclude. The RACF should contact the Public Health Unit to advise of suspect COVID-19 cases. The Public Health Unit will assist in management and testing advice. If the case is excluded the Public Health Unit will continue to monitor until 8 days have passed with no further symptomatic residents.

A confirmed COVID-19 case

All suspect cases will have a swab taken for PCR testing. If this test is POSITIVE the person becomes a confirmed case. A single confirmed case of COVID-19 in a RACF is treated as an outbreak.

It is important to systematically monitor all residents and staff daily for ARI, fever or ILI symptoms that could be related to COVID-19 or influenza. When people have these symptoms, seek testing immediately and isolate the affected person.  Whilst testing is in progress, we recommend infection control measures are implemented immediately and before test results are available.

As soon as you have a case of ARI, unexplained fever or ILI please phone your local Public Health Unit on 1300 066 055. It is important to phone the Public Health Unit as soon as possible so we can support you in managing the situation. You should also immediately implement infection control measures, see the NSW Health Poster How to identify respiratory outbreaks and what to do next

No, please do not wait for laboratory confirmation. Phone your local Public Health Unit on 1300 066 055 as soon as possible cases arise, so that we can support you with outbreak management.

A single confirmed case of COVID-19 in a RACF is treated as an outbreak. The Public Health Unit should be notified immediately and an outbreak management team created. The response will be as per the Communicable Diseases Network Australia national guidelines for COVID-19 outbreaks in a Residential Care Facility.

If symptomatic residents with ARI or ILI return a negative test for COVID-19 they should still be managed as a case of infectious respiratory illness. The RACF should continue to isolate the person and use infection control measures to limit spread. Enhanced surveillance for newly symptomatic residents should continue and testing implemented immediately for any new cases.

Initial testing should include influenza and other common respiratory viruses to assist in identifying the cause of the illness. If there are 3 or more cases of ILI (with negative COVID-19 tests) the RACF should manage as per the Influenza outbreak guidelines for RACFs in consultation with the Public Health Unit, but maintain monitoring and testing of new cases to ensure COVID-19 is excluded.

If you have 3 or more cases of ILI and at least one tests positive for influenza, this is considered an influenza outbreak. The PHU should be immediately contacted and the situation managed as per the CDNA guidelines. Influenza and COVID-19 can potentially occur at one time in the same facility so any new cases must still be treated as suspect COVID-19 until test results are returned.

The level of restriction required will depend on the situation. Consultation with the Public Health Unit is advised on 1300 066 055.

1. When there is a suspected or confirmed COVID-19 case

A single confirmed case of COVID-19 in a RACF is treated as an outbreak. Admissions and transfers will be restricted as per the latest NSW Health advice for RACFs with a COVID-19 case.

2. If there is a confirmed influenza outbreak (COVID-19 negative)

Management of admissions and transfers will be as per the Guidelines for the Prevention, Control and Public Health Management of Influenza Outbreaks in Residential Care Facilities in Australia. Generally this will include the following:

  • Restrict new admissions to affected areas of the facility
  • When transferring residents to hospital during an outbreak advise the ambulance service and hospital admitting officer of the nature of the outbreak.
  • A transfer form can be provided with the patient notes. This is available on page 34 of the NSW Flu Info Kit.
  • Residents with influenza who have been transferred to hospital may return to the facility providing there is appropriate accommodation and infection control measures in place.
  • Re-admission of residents who have been transferred to hospital without influenza (for another medical reason) is not generally recommended during an outbreak; however, in practice this may not be feasible. Therefore if there is no alternative, the resident may be re-admitted providing infection control measures are in place

3. When there are ongoing cases of ARI all testing negative for COVID-19 and influenza

When a facility has a case of ARI, but test results are negative for influenza and COVID-19, the PHU will continue to monitor the facility for 8 days from the last onset of symptoms. New admissions are allowed provided infection control measures are in place. Please discuss with the Public Health Unit.

The level of restriction to visitors will be dictated by multiple factors, including the clinical situation in the facility itself, and the current local and national number and distribution of COVID-19 cases. If there is any concern that COVID-19 is a risk it may be necessary to limit visitors until the situation is clarified. In most cases an assessment will be made based on testing, clinical, and epidemiological information, in consultation with the PHU, with reference to relevant guidelines, as to how to manage the facility and what level of restriction is required. Generally, essential visitors will be able to visit under strict infection control precautions, but in some cases it may be necessary to temporarily cease all visitors to a facility.

Due to the significant risk to elderly people posed by COVID-19 a precautionary approach will be taken which may be restrictive until the situation is fully assessed. We advise against the use of terms like “lockdown” which can be unhelpful when managing the situation and distressing to family members.

Ensure signs are clearly visible throughout the centre. Ask visitors to perform hand hygiene and wear PPE if required.

These resources can be found at the COVID-19 posters webpage of NSW Health, in the NSW Flu-Info Kit and the NSW Health webpage for residential care facilities and influenza.

Antiviral medication can be used for treatment or prophylaxis. 

As treatment

Treatment with influenza antiviral medication (e.g. Tamiflu) should be considered for any resident thought to have influenza, especially if at increased risk of complications, and should be started within 48 hours of onset of symptoms for maximum benefit.

As prophylaxis

In some situations prophylaxis with influenza antivirals may be recommended in addition to other outbreak control measures.

  • This decision must be made in consultation with the Public Health Unit, the facility’s Outbreak Manager and residents’ GPs.
  • Consideration must be given to medication safety issues, compliance, timing and availability of obtaining and administering medication.
  • If prophylaxis with influenza antivirals is recommended, then it should be given to ALL asymptomatic residents (regardless of vaccination status) and ALL unvaccinated staff, AND it must be started within a 24 hour period.

  • Prior to the start of influenza season ensure that you have contacted your pharmacy to check how quickly they can obtain large quantities should antiviral influenza prophylaxis be recommended. 
  • The pharmacy will need to be able to supply smaller amounts for treatment of individual cases.
  • It is the responsibility of the facility to report and manage influenza outbreaks with the assistance of the local Public Health Unit. 
  • In some outbreaks management involves using anti-viral medication (e.g. Tamiflu) as prophylaxis for residents and staff.  Therefore it is the responsibility of the aged care facility to purchase stocks.
  • Phone your local Public Health Unit on 1300 066 055 if you have any difficulties or questions.

The Guidelines for the Prevention, Control and Public Health Management of Influenza Outbreaks in Residential Aged Care Facilities in Australia recommend that all residents and staff of aged care facilities have an annual influenza vaccination.

Influenza vaccination for staff both protects them and provides an additional layer of protection for high risk residents. Best practice targets are 95% vaccination coverage, in both staff and residents, prior to the beginning of the flu season.

Since May 2018, Australian Government-subsidised providers of residential aged care are required to

  • Provide staff and volunteers with access to free flu vaccination each year. Providers are required to cover the cost of the program.
  • Actively promote the benefits of an annual vaccination for their staff and volunteers, and for the health outcomes of care recipients.
  • Keep records of the number of staff that receive a flu vaccination each year (whether or not under the approved provider’s flu vaccination scheme).

During the COVID-19 pandemic any staff or visitors that have not been vaccinated against influenza are not permitted to enter an RACF unless there is a certified medical contraindication or the vaccine is not available to them. More details available here.

Unvaccinated staff are at higher risk of acquiring and transmitting influenza. During a confirmed influenza outbreak, it is recommended that any unvaccinated staff (due to medical contraindications- see above) only be allowed to work if asymptomatic and wearing a mask, or if asymptomatic and taking appropriate antiviral prophylaxis.

Staff members with an ILI should be excluded from work while they are infectious, that is, at least 5 days after onset of acute illness, or until they are symptom free, whichever is longer.

For more information, see the NSW Health Vaccine Storage and Cold Chain Management website and the National Vaccine Storage Guidelines - Strive for 5.

A gastroenteritis outbreak in a residential care facility is defined as two or more people with diarrhoea and/or vomiting in a facility at one time.

  • Commence infection control measures and cleaning
  • Inform the facility Infection Control Practitioner & facility management
  • Inform medical team, collect faecal specimens for laboratory testing
  • Post signs and alcohol-based hand rub at entrance to affected areas
  • Notify your local Public Health Unit on 1300 066 055
  • Distribute information to staff, residents and visitors

For more information see the NSW Gastro Pack for Hospitals and Aged Care Facilities

Under the NSW Public Health Act 2010, residential aged care facilities are legally required to notify suspected outbreaks of gastroenteritis to their local Public Health Unit.