Review of Australia’s Health Sector Response to Pandemic (H1N1) 2009: Lessons Identified

4.3 Key Issues and Lessons Identified

Page last updated: October 2011

4.3.1 Implementation

Airport exercises and training undertaken in the pandemic planning stages enabled rapid implementation of border measures, guided by the Fluborderplan. Border agency officers were flexible and responsive, and airports and airlines were cooperative, which allowed for significant (Commonwealth, jurisdictional and commercial) resources to be activated at short notice.

Developing a formal communication process between Australian Government agencies and between these agencies and the airlines and airports, including establishing a database of key contacts, would enhance timely information sharing in emergencies. Human resource implications for operational personnel also need further consideration. For example, the need to develop consistent cross-agency advice during the response on associated occupational health and safety matters, including addressing deployment and use of PPE by the various types of border personnel, contributed to a delay in disseminating final instructions to operational personnel.

While the Fluborderplan guided the implementation of measures, it was not formally activated during the response. There is a need for future planning to better incorporate strategies and operational arrangements to address logistical issues, such as availability and distribution of HDCs; to counter the public communication challenges, such as ensuring rapid and early availability of professional, large-format advertising; and to establish arrangements for the design, collection and systems used for digital data recognition of HDCs.

Airlines reported significant logistical issues due to the number of different declaration cards required for the various countries they enter. This requirement could have been streamlined if Australia and other countries had chosen to use the universally available WHO Passenger Locator Card. However, while this card contained adequate information to enable contact tracing, it did not contain questions to identify travellers who are unwell. Australian HDCs were found to be useful for contact tracing and raising public awareness, which led to self-reporting of symptoms. As part of future reviews of border measures, Australia should continue to monitor developments with the WHO Passenger Locator Card.

Future pandemic planning, including the Fluborderplan, should incorporate appropriate response measures to address influenza management for ships. This needs to incorporate appropriate communication arrangements with cruise ship operators, methods for management of influenza cases onboard, and reception arrangements for reported cases on arrival into Australia.

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4.3.2 Effectiveness

While public health personnel at borders were successful in supporting the implementation of border measures, there are significant opportunity costs involved with implementing and maintaining border measures that require careful consideration. Inherent in the planned range of border measures is the need for appropriately trained public health staff to assess travellers and to undertake the consequent contact tracing where necessary, which particularly placed a heavy burden on public health resources in 2009. The public health resources required for both these functions are drawn from the same finite pool of jurisdictional resources that is also responsible for other routine public health functions and other pandemic response requirements. As a result, there are competing tensions regarding the most effective use of these limited resources.

The policy approach to implementing border measures affects staffing requirements, for example, targeting particular flights versus all flights, and varying temperature settings on thermal scanners. Continuation of border measures through the CONTAIN phase, and uncertainty over the length of time that border measures would be needed, increased pressure on resources and may have affected their effectiveness. For example, the extensive level of contact tracing undertaken on early flights and for cruise ship arrivals could not be sustained for all arriving air travellers. Triggers for discontinuing border measures need to be well defined and communicated. In this context there is a need to understand the effectiveness of border measures, individually and in general, relative to the level of human resources required. Assessing how best to deploy limited resources for the most effective outcome can only be determined at the time; however, it needs to be decided early.

The rapid international spread of the pandemic shows that there is still a lack of understanding about the extent to which border measures slow the spread of the disease. Understanding and measuring whether border measures were effective in delaying local transmission in Australia is difficult. Detecting early cases of disease at the border, or soon after arrival, still allows entry of the disease into the country. The DELAY attained does not refer to the entry of the disease but to the control of the disease, whereby cases are identified and quarantined (or other measures instituted) to prevent transmission and establishment of the disease. However, it is likely that the intensive containment measures employed beyond the border in Australia had a greater impact on delaying establishment of the virus in the community than border measures, particularly arrival screening. Emphasis should be placed on reviewing the evidence basis for border measure options, and quantifying the opportunity costs, when reviewing policy and operational protocols.

The period between the commencement of border measures and acknowledgement of widespread community transmission in Australia – effectively with the move to the CONTAIN phase on 22 May 2009 – was 24 days. Analysis of international experience also concluded that border screening during the 2009 pandemic was associated with a postponement of community transmission of seven to 12 days, with a range from no delay to 20 to 30 days’ delay, noting a possible overestimate of the impact of border measures where countries had also implemented extensive domestic containment and mitigation measures.<sup>]18 There are now significant data available about the types of measures implemented, the resources needed and the impact these had in different countries. Further international research is needed to identify the most effective and realistic measures that might be available.

In reviewing the need for border measures, consideration needs to be given to the public’s perception of the importance of the disease if Australia does not institute visible border controls while neighbouring countries do so. Research conducted for the Australian Government in June 2009<sup>]19 indicates that travellers responded positively to border measures, as they believed these indicated that the Australian Government was proactively protecting the health of the Australian community. Approximately two thirds of the travellers surveyed in Australia indicated that information provided about border measures had made them think of pandemic influenza since returning home. Travellers identified HDCs as having the highest impact (33 per cent), followed by in-flight announcements (22 per cent), thermal scanners (17 per cent) and posters in airports (14 per cent).20 Most notable is the public’s perception of the use and benefit of thermal scanners compared with their limited effectiveness in detecting possible cases of illness (0.5 per cent of cases identified in Australia). The relative value of thermal scanners needs to be further considered, both within the context of the wider impacts on resources and against their effectiveness as a public awareness tool.

Recommendation 9:
Review the policy, operational protocols and communication of border measures (airports and seaports) for pandemic influenza.


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18 Cowling, BJ, Lau, LL, Wu, P, Wong, HW, Fang, VJ, Riley, S, et al. (2010), ‘Entry screening to delay local transmission of 2009 pandemic influenza A (H1N1)’, BMC Infectious Diseases, 10(82).
19 Parr, V, Gagg, K, et al. (2009), Research on effectiveness of the current border control measures: qualitative and quantitative market research report, GfK bluemoon.
20 The remainder comprises two per cent for in-airport announcements and 12 per cent for ‘other’.


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