There are many lessons for health officials and governments to learn from the experience of the 2009 pandemic. While Australia’s response showed that being well prepared was important, success depends on a multi-stakeholder cooperative approach, with key elements being effective communications, robust science-based decision making and a flexible public health response system able to respond rapidly to a crisis.
Governance and decision making
Australia was in a good position to respond rapidly to the emerging threat from pandemic (H1N1) 2009 influenza virus in 2009, and moved quickly to implement an appropriate health response. Australian governments had spent considerable time since 1999 developing and regularly updating a series of connected pandemic action plans – health and whole of government; national and jurisdictional – to guide a coordinated response to an influenza pandemic. These plans had been exercised.The Australian response to the 2009 pandemic was guided by the Australian Health Management Plan for Pandemic Influenza 2008 (AHMPPI), which provides the health sector with a nationally agreed strategic framework to guide preparedness and response activities for an influenza pandemic. Coordination between the Commonwealth and the state and territory governments occurred through the Australian Health Protection Committee (AHPC), the peak health sector decision-making body for national health emergencies. There was strong commitment from all public health officials to support teamwork across governments and a consistent national response. Relationships already established between all levels of government in creating and maintaining the AHMPPI allowed for an ongoing cooperative effort when it became necessary to modify the AHMPPI to reflect the response actions needed for the moderate pandemic (H1N1) 2009 influenza virus. The rapid development of a new Australian pandemic phase – PROTECT – demonstrated that Australia has a flexible public health response system.
One of the most important lessons learned was that Australia’s planning must be flexible to accommodate the biological variations in the clinical picture and the potential uniqueness of each pandemic scenario, to enable resources to be effectively directed to achieve optimal outcomes. One of the biggest challenges to decision making and coordination was the variation in timing of stages of the outbreaks across the country, highlighting that Australia’s pandemic plans and governance arrangements need to incorporate responses adaptable to the severity of the disease, disease patterns and geographical differences. While the geographical spread was not inconsistent with seasonal influenza patterns, in the pandemic context this variation made in-unison phase changes, and the subsequent application of consistent public health actions, difficult. While Australia’s pandemic phasing system was useful to guide public communication, aligning the pandemic phases to the operational response nationally did not always work as well, particularly when jurisdictions were disproportionately affected, requiring locally tailored responses. The fundamental purpose of the Australian pandemic phases and the actions that they drive needs to be further considered.
Multi-stakeholder advisory mechanisms provided valuable expert and operational advice during the pandemic. For the future, well-structured expert advice should be developed from well-functioning advisory committees in preference to establishing new or separate pandemic advisory structures. For example, the Australian Technical Advisory Group on Immunisation (ATAGI) was a valuable source of expert advice on the pandemic (H1N1) 2009 vaccine, and its role needs to be included in pandemic planning.
The vital role of the clinical sector in providing early warning of disease severity seen within Australia’s hospitals, in particular in intensive care units (ICU), was not documented in the AHMPPI. Early recognition of this clinical link was established with a clinical expert group. Also, the moderate nature of the 2009 pandemic virus resulted in a larger role for general practitioners (GPs) than had been considered in the planning for a more severe pandemic. The establishment of a General Practice Roundtable (GPRT) was an important initiative to improve communication with the primary health care sector and to enable the government and representatives of the front-line clinicians to work together in a highly effective manner to ensure that policies were realistic, effective and efficient. To rectify an apparent disconnection between the scientific and operational advice provided during the response, meetings of jurisdictional Chief Health Officers (CHO) and key experts were convened at critical decision-making points. There is a need to formalise these processes and groups within the AHMPPI.
Optimal communication between national, state and territory governments, peak bodies, local bodies and primary health care professionals needs to be further addressed in future planning. It is important to enhance communication with the clinical and primary care sectors in planning and during a pandemic, in particular to communicate the role of AHPC and public health objectives in a pandemic. This could include formalising networks and considering ways of enhancing the intersection and integration between the Commonwealth, jurisdictional governments and local networks of peak bodies.
It is also important to ensure broader stakeholder engagement during pre-pandemic planning and early stages of a response on key aspects of the AHMPPI, to allow for discussion of risks and benefits of all actions in a pandemic. Pandemic plans should reflect the rationale for decisions on pandemic activities. Consensus discussions prior to and during a pandemic and clear documentation of outcomes will enable better management of media commentary to key public health objectives during the pandemic.
Due to the moderate severity of this pandemic, more stringent and restrictive actions were not required, and a move from ‘health’ issues to ‘whole-of-government’ issues for decision making was not widely tested. However, there was one opportunity for national governance of a non-health intervention: school interventions. There was tension between the public health recommendation of early school closures to control the spread of infection, and the political and social realities of implementation. The response highlighted the difficulties that will be encountered by all governments in a more severe pandemic to contain the spread of the pandemic by implementing and continuing more extensive and potentially disruptive social distancing measures.
Decision making in a complex environment could be enhanced with the provision of a decision support document to guide decision makers in identifying all the public health actions available in a pandemic and their risks and benefits.
Early and accurate information to guide decision making is important. While urgent research grants were tendered and awarded rapidly, the time frame for the studies generally did not provide research outcomes to guide the real-time public health response. Consideration should be given to developing a set of key research questions in advance of a future pandemic.
Top of Page
Communications
More can always be learned about effective communication in an environment of national threat, rapid change and multiple players, particularly with respect to the need to convey factual, up-to-date information both to the public and to healthcare professionals.A national public information campaign was important, complemented by jurisdictional public communications activities, for the community to develop an understanding of the importance of hygiene in reducing transmission of influenza. While there were clear messages about which groups were at high risk of severe outcomes and about the promotion of self-identification, there was a need for more targeted communication with vulnerable groups. The 24-hour news cycle emphasises the importance of shared and coordinated messaging across jurisdictions. To enhance national coordination and timeliness of message delivery, consideration should be given to implementing an appropriate process to enable early sharing of materials across jurisdictions.
Communication resources were stretched in ensuring that current information was available to government, the media and the public. The intense media demand was difficult to manage when the spokespeople on health issues at both the national and jurisdictional levels were also involved with managing the pandemic response at the most senior levels. A media strategy for pandemic influenza that includes principles and protocols of media engagement is necessary to manage expectations and workloads. Also, clear guidelines identifying Commonwealth and jurisdictional functions and responsibilities, including agreed spokespeople and the objectives, actions and target audiences for various stages of an influenza pandemic, should be developed for the health sector.
Surveillance
Accurate and rapid pandemic surveillance data are of paramount importance in understanding the nature of the disease and ensuring an appropriate response. While all levels of government in Australia worked well together to ensure that a national surveillance picture was readily available to inform decision makers and to keep the public informed, an early thorough and systematic study of the initial cases of disease, and investigation of their contacts, could be further optimised to aid the decision-making process. Epidemiological modelling in pandemic planning provided valuable insights into the effectiveness of response measures such as home isolation (for people who are unwell) and quarantine (for individuals who may have had contact with people who are unwell). High priority should be placed on the early identification and documentation of the true clinical picture, including Australian and overseas data and including identification of the vulnerable, to inform an appropriate health response.The collection and reporting of data are resource-intensive exercises, and more consideration needs to be given to cessation of some elements once they are no longer needed to inform decision making. The draw on resources to report the number of cases each day affected the capacity to analyse the data to produce a synthesis of the situation. Also, the information needed to inform public health policy is not necessarily the information needed to inform the public about the impacts of the disease. Communication with the public needs to include a synthesis of the situation, acknowledgement of what remains uncertain about the outbreak, and plans for what will be undertaken next.
Completion of a surveillance plan for the collection, analysis and reporting of data at national level would enhance national capability. Also, continued development of routine seasonal influenza surveillance to include standard indicators of severity, including emergency department presentations, hospitalisations, ICU admissions and deaths, would enable easy escalation during a pandemic.
Border measures
While border measures were rapidly implemented in Australia’s international airports and seaports, the effectiveness of various border measures to delay entry of the virus into Australia is difficult to measure, and their public health benefits are not clear. Border measures continued beyond the establishment of local transmission in Australia, which varied by jurisdiction.1 There were no restrictions on domestic travel, and state border closures were not considered in Australia. Maintaining border measures was resource intensive with considerable opportunity costs that should be understood when reviewing the effectiveness of border measures. Their effectiveness also needs to be considered relative to the rationale outlined in the AHMPPI, being a short period of delay in the entry of the disease and the raising of awareness among the travelling public. It is likely that the intensive containment measures employed beyond the borders of Australia had a much greater impact in terms of delaying the establishment of the virus in the community than border measures, particularly arrival screening.The management of cruise ships during the early stages of the pandemic was an issue that was not foreseen. During the response, a National Protocol for Pandemic (H1N1) 2009 on Cruise Ships was rapidly developed through consultation with the Australian Quarantine and Inspection Service, state and territory health agencies and the cruise ship industry. At the peak of concern, successful contact tracing was undertaken across Australia for one entire cruise complement of thousands of passengers, but this extensive level of contact tracing would not be possible for the large volume of international air arrivals. Contact-tracing activities related to international flights placed a heavy burden on national and jurisdictional public health resources.
Public health measures
Pandemic responses include a range of measures that can be implemented as severity increases, balancing effectiveness with societal cost and disruption. For example, measures may range from infection control measures, symptomatic treatment and home isolation, to widespread antiviral prophylaxis, school closures and cancellation of mass gatherings.Comprehensive laboratory testing is important early in a pandemic to describe the disease, but is very resource intensive. There is a need to change to a clinical definition once the virus circulation has been established and there is a clearer clinical picture. Consideration could be given to methods of collecting case data based on clinical diagnosis. The frequent and rapid changes to the case definition as the disease outbreak evolved was challenging and resource intensive, with flow-on effects on laboratory testing capacity. A new process for the development of case definitions during a pandemic response needs to be explored to enable more robust definitions that can avoid too-frequent changes. Consideration needs to be given to whether a clear objective of the definition, including describing and communicating the public health rationale, would assist in the development and acceptance of case definitions.
Quarantine is inconvenient for individuals and difficult to enforce as a public health measure. The purpose of voluntary quarantine was not well understood by the community during 2009. The challenge is to educate the community about what individuals can do after they have been exposed to a case, in terms of social expectations and protecting vulnerable members of the community. The relevance of voluntary quarantine in general needs further consideration once community spread has occurred, including its role in protecting vulnerable population groups such as schools for students with disabilities, remote communities and other groups.
The disruptive nature of school closures was significant. School exclusions, whereby children who had travelled to areas identified in the case definition were requested to voluntarily quarantine themselves, were far less disruptive than whole-of-school or class closures but were sensitive as they suggested bias against particular regions of Australia. Evidence of the effectiveness of school interventions in delaying the spread of a pandemic needs to be further defined.
Infection control is an important control measure in a pandemic. The principles of infection control developed in the health sector can be applied to a range of environments; therefore, consideration should be given to the development of generic infection control messages that cover a multitude of settings, through emphasis of the principles of infection control rather than specific actions and equipment.
The use of antiviral medications was limited in Australia. Areas for future work include understanding the benefits of early versus late use and extensive versus limited-population use, in particular the use of antiviral medication for high-risk contacts such as Aboriginal and Torres Strait Islander peoples and other vulnerable groups when no prophylaxis is provided generally for the well population, and policy for prescribing. The planned provision of antiviral prophylaxis for healthcare workers was not implemented in 2009, and remains an unresolved issue.
Top of Page
Health sector capacity
The 2009 pandemic clearly highlighted the need to develop guidance on strategies that could be employed during a pandemic to enhance the health sector workforce capacity. While the public health workforce and the hospital system were stretched during the 2009 response, it should be taken into consideration that ‘business as usual’ generally continued in both public and clinical healthcare settings during the pandemic.A pandemic places particular demands on the public health workforce. Contact tracing, support for border measures, coordination of support for quarantined individuals and surveillance reporting all placed additional demands on the public health workforce. Further planning for surge capacity in these areas is necessary for a sustained response.
In the hospital system, ICUs were the most significantly affected, experiencing surges of patients requiring ventilation for pandemic influenza. The demand for extra-corporeal membrane oxygenation (ECMO) was unforeseen, but was managed well. This highlighted the requirement for ECMO as a new capability and the need for trained intensive-care staff. Any future surge capacity strategy should address the need to sustain surge capacity in the hospital system for long periods of time.
Laboratory capacity
Australia has a well-established and prepared network of diagnostic laboratories that was able to respond flexibly and quickly to support the public health response. Public health laboratory capacity was stretched during the response, and private laboratories played an important role in supporting the public health response. To maximise laboratory capacity in a pandemic, there is a need to clearly define the roles of the various laboratories and reference centres and the Public Health Laboratory Network.There is a need to improve the communication before and during a pandemic between public health decision-making bodies, front-line clinicians and diagnostic laboratories to ensure that the rationale behind laboratory testing as the pandemic progresses is clear and that resources are used efficiently.
Current laboratory information management systems serve the needs of hospitalised patients and individual clinicians. These systems are not easily adapted to other purposes. There is a need to consider mechanisms to improve the reporting of laboratory results, including negative tests, to enable rapid and easy access by public health units and other local laboratories as well as clinicians.
National Medical Stockpile deployment
While Australia’s National Medical Stockpile (NMS) met the demands of the 2009 pandemic, the moderate nature of the pandemic led to limited demands on the NMS overall. It would be expected that demands would be much higher with a severe pandemic. It would be prudent to review the range and quality of stockpiled goods for an influenza pandemic.Mechanisms in place for the distribution of NMS supplies to jurisdictional receiving facilities were successful, and holding stocks in various Australian Government storage facilities reduced distribution response time.
While a clear principle of use of the NMS is that no jurisdiction will be disadvantaged because of its own stockpiling, there was a lack of clarity with respect to the policy and timing of the transition from jurisdictional stockpiles to the national stockpile, and of responsibility for the provision of personal protective equipment (PPE) for use by GPs. There is a need to better communicate the role of stockpiles and to facilitate better understanding of when and how stockpile items are made available.
Vaccination
Australia’s national response plans are premised on delaying the establishment and spread of the disease for as long as possible to allow the production of a pandemic vaccine. The national Pandemic (H1N1) Vaccination Program commenced on 30 September 2009 and concluded on 31 December 2010 when remaining stockpiled vaccine expired. This national program was the biggest vaccination program undertaken in Australian history, contributing to the substantially lower-than-expected levels of circulating pandemic influenza virus during Australia’s 2010 influenza season and the low impact of influenza on the Australian population in 2010.While pre-established contracts with vaccine manufacturers aided the early availability of a pandemic vaccine in Australia, the production of a customised vaccine using current technology takes time and one is unlikely to be available during the first wave of an influenza epidemic. This emphasises the importance of implementing other mechanisms for slowing disease transmission in the early stages of a pandemic. An area for future exploration is in medical technology, in particular innovation in vaccine technologies which could potentially deliver vaccine to Australians even more rapidly than occurred in 2009.
Pandemic planning needs to cover a range of vaccination program scenarios based on disease virulence. A GP-based vaccination program was an appropriate response in 2009 based on the severity of the disease. The need for clinical trials and registration of the vaccine should be considered when planning the objectives of a pandemic vaccination program.
Communication about the purpose of a pandemic vaccination program could be strengthened. Engagement with the primary healthcare sector through the GPRT and Indigenous Flu Network (IFN) worked well to ensure open dialogue between governments and the primary healthcare sector.
While indirect measures of vaccination provided some indication of uptake in the community, comprehensive data on vaccine uptake or wastage were not collected nationally. The national collection of vaccine data during a pandemic needs further consideration.
Top of Page
Aboriginal and Torres Strait Islander peoples
Indigenous Australians were identified early as being vulnerable to severe effects of the disease. Information on indigenous populations of other parts of the world and early recognition of this threat to Indigenous Australians aided Australia’s response. To meet the challenges of the 2009 pandemic, an appendix to the PROTECT Annex specifically focusing on Indigenous Australians was developed, in collaboration with the Indigenous health sector, which clearly outlined issues specific to Indigenous Australians who had underlying medical conditions or who lived in remote communities.The IFN proved to be a useful mechanism to arrange a nationally coordinated response for Indigenous Australians. Consideration should be given to maintaining or establishing a similar forum to inform future planning and response.
Conclusion
Australia’s response to this new threat was proportionate to the threat, appropriate and measured. Australia did not implement all the measures contained in the AHMPPI; rather, it developed a new response approach as understanding of the biology and clinical picture of the pandemic (H1N1) 2009 influenza virus evolved. While lessons from the 2009 pandemic will be critical to further informing health and whole-of-government responses into the future, it is important that future planning not be based solely on the last pandemic. Pandemics are unpredictable and therefore there is a need to remain flexible and adaptable to respond to all levels of threat to the health of Australia’s population.Recommendations
Governance and decision making
- Consider ways of incorporating greater flexibility in pandemic influenza planning to enable responses adaptable to the severity of the disease, disease patterns and geographical differences in spread. This could include reviewing the purpose of Australian phases and assessing the issues on which national consistency is required.
- Develop a decision support document. This could include identifying all the public health control measures available in a pandemic, the objective of each measure (considering severity), the risks and benefits, the resources required, communication processes and relevant legislation.
- Review the number and composition of health advisory groups on pandemic influenza, both in terms of how they operate in the pre-pandemic period and during the response, and how public health recommendations feed into whole-of-government processes.
- Develop a research plan to ensure that rapid investigations meet the immediate needs of a public health response to an influenza pandemic. This could include defining additional studies needed to supplement surveillance data early in a pandemic, processes to rapidly fund investigations of issues of concern and a protocol for learning from early cases in Australia and overseas.
Communications
Top of Page
Surveillance
Border Measures
Public health measures
Health sector capacity
Laboratory capacity
National Medical Stockpile deployment
Vaccination
Aboriginal and Torres Strait Islander peoples
Top of Page
1. Note that the virus gained momentum in Victoria before other states of Australia. Bishop, JF, Murnane, MP, & Owen, R (2009), ‘Australia’s winter with the 2009 pandemic influenza A (H1N1) virus’, New England Journal of Medicine, 361(27), 2591–2594.
Document download
This publication is available as a downloadable document.