7.3 Key Issues and Lessons Identified

Pandemic planning processes over the past five years have provided a good framework for laboratory response design and procedures. Infrastructure and expertise already in place in PHLN laboratories allowed the PHLN to be flexible and quickly respond to the pandemic. Nonetheless, important issues and areas of improvement were identified.

7.3.1 Communication and information sharing

Doctors and nurses at the front-line sometimes received contradictory advice about the need for laboratory testing from a variety of sources including government and professional bodies, which caused confusion among health professionals. In any emerging infectious disease outbreak, test results may be required for public health purposes as well as for individual patient management, regardless of the phase.

During the 2009 pandemic, communication to clinicians about the public health aims of testing was poor. Hence, when policies changed relating to the management of patients, and therefore the priorities for testing, the testing recommendations were slow to be implemented at clinical request level. Even if communicated quickly, the rationale behind the changes was unclear. This had a substantial impact on laboratory workloads. There needs to be better understanding of clinical demand for testing as well as better communication of policies and their rationale.

There was also a lack of communication between public health decision-making bodies (the AHPC and its subcommittees and the states and territories) and the laboratories undertaking the testing. National health policies had an impact on the testing load and the sustainability of laboratory services. Laboratory capacity for routine testing for other conditions was stretched, and this should be considered when evaluating diagnosis policies.



In the early stages of the pandemic, communication between laboratories and the public health units that implemented the interventions was generally very good. However, the method used was inefficient, and better use of existing automated electronic communication should be explored. There were reports in some areas of slowness in communicating negative results, which are important for public health management, delaying the cessation of public health countermeasures. This may in part have been due to a lack of understanding of the importance of negative results (for example, quarantine could be lifted when negative results were received), but more often it was because reporting systems had been set up to communicate only positive results to public health units as required for disease notification. These reporting systems proved difficult to adapt to enable rapid communication of negative results or, as was required in some jurisdictions, rapid notification of individuals who were being tested prior to their results being available. A clear process for urgent communications from laboratories to public health units is required.

Laboratories, both public and private, play a major role in diagnosing infections of public health importance, including influenza. As this information is integral in a pandemic, a need to improve information sharing both between laboratories and with public health units and clinicians has been identified. In general, information systems in public health laboratories do not have direct links with public health units. Current laboratory information management systems serve the needs of hospitalised patients and individual clinicians, but are not easily adapted to other purposes. There is no interface that allows laboratories, even within a single jurisdiction, to readily exchange information with one another electronically. This leads to inefficiencies and duplications in entering and reporting data.



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7.3.2 Pandemic diagnostic ability

7.3.2.1 Development of and access to tests

There was rapid development of pandemic (H1N1) 2009 testing methods soon after the virus emerged, facilitated by access to positive control material. Throughout the pandemic, access to testing was appropriate in all jurisdictions.

7.3.2.2 Surge capacity

The ability of laboratories to meet the demand for a large number of tests applies to every aspect of laboratory service, including specimen collection, specimen transport, administrative processing, technical testing and reporting of results. Many laboratories were able to meet the demand for most of the pandemic period and adjusted their systems to deal with increased pressures. However, public health laboratory capacity within Australia was stretched during the 2009 pandemic. Private laboratories played an important role in supporting the public health response. Although involvement differed by jurisdiction, private laboratories provide an important pandemic diagnostic surge capacity.

Laboratories were acutely aware that sustained pressure would ‘burn out’ staff. Some laboratories had to develop their own criteria for rationing testing to protect the workforce once capacity was exceeded. The phase change to PROTECT temporarily alleviated the pressure because diagnostic testing was then directed only towards people with more severe illness or with underlying vulnerability. However, demand did not decline as anticipated. There was still an expectation that testing would be provided for non-critical clinical cases.

There were duplicated processes in the triaging of specimens and matching of request forms and samples. More administrative staff was required to deal with large numbers of telephone inquiries and manually prepare the reports needed for public health units.

In addition, large numbers of testing reagents were needed and most jurisdictions did not have adequate stockpiles of these. Additional equipment was required for the surge in testing and was difficult to access during the 2009 pandemic. Future planning should take into account limited availability of essential supplies during a pandemic and review barriers to the rapid meeting of unforeseen equipment needs.

7.3.2.3 Quality assurance

Laboratories must ensure that their diagnostic results are correct and consistent. Laboratories in Australia are accredited to perform tests by the National Association of Testing Authorities Australia (NATA)/Royal College of Pathologists of Australasia (RCPA) Medical Testing Accreditation Program to standard ISO15189. Ensuring ongoing quality of test results arises from participation in proficiency-testing schemes such as RCPA Quality Assurance Programs. While there are traditional methods of diagnosis for influenza, tests that directly detect the vital genetic material (nucleic acid testing (NAT), including PCR) are useful because they are very sensitive and specific, providing a rapid diagnosis. These were widely used in the 2009 pandemic response. There is currently a proficiency-testing scheme for nucleic acid amplification assays for influenza in Australia, conducted by the Serology Quality Assurance Program of the RCPA; however, this is limited and not adequately resourced for rapid response to newly emerging threats. There is scope to enhance this capacity. Another rudimentary system is provided through the WHO National Influenza Centre in Hong Kong, which needs to be upgraded to be rapidly responsive to the emergence of new pathogens.

7.3.3 Routine influenza diagnostic ability

Aspects of routine influenza testing have been identified that may be able to assist in improving the information available during a pandemic response. Routine reporting of the proportion of influenza tests that are positive gives public health authorities an understanding of the amount of respiratory disease in the community and of the proportion due to influenza which may be controlled by public health action. Consideration could be given to appropriate mechanisms to encourage the wider implementation of routine PCR-based testing for influenza and other respiratory viruses, recognising both individual diagnostic needs and public health requirements. Furthermore, the routine capacity to identify and report influenza A subtypes would enhance the early detection of new pandemic subtypes. Surveillance systems should incorporate laboratory data to enable this analysis.