Public health management of pandemic (H1N1) 2009 infection in Australia: A failure!
Article first published online: 27 DEC 2009
© 2010 The Authors. Journal compilation © 2010 Asian Pacific Society of Respirology
Volume 15, Issue 1, pages 51–56, January 2010
How to Cite
WATERER, G. W., HUI, D. S. and JENKINS, C. R. (2010), Public health management of pandemic (H1N1) 2009 infection in Australia: A failure!. Respirology, 15: 51–56. doi: 10.1111/j.1440-1843.2009.01675.x
The Authors: Prof. Grant W. Waterer, MBBS, PhD, FRACP is head of the Infectious Disease unit at the Lung Institute of WA and his clinical activities undertaken are at the Royal Perth Hospital. He is Professor of Medicine at the University of Western Australia and adjunct Associate Professor of Medicine at Northwestern University, Chicago. His research interests are in host responses to pulmonary infections and the role of genetics in influencing these responses. Prof. David S. Hui, MD, FRACP, FRCP is a respiratory physician and honorary consultant at the Prince of Wales Hospital, Hong Kong, with interests in clinical management of emerging respiratory infections. He is past president of the Hong Kong Thoracic Society and serves on international committees as an advisor on influenza pandemics. Prof. Christine Jenkins MD, FRACP is a thoracic physician with interests in public policy, guidelines implementation and clinical practice. She is the immediate past president of the Thoracic Society of Australia and New Zealand and has been a member of national committees involved in pandemic planning and implementation of best practice during the H1N1 pandemic in Australia.
- Issue published online: 27 DEC 2009
- Article first published online: 27 DEC 2009
- Received 16 October 2009; accepted 21 October 2009.
- pandemic planning;
- public health;
- swine flu;
In April 2009, severe cases of pneumonia preceded by influenza-like illness were noted to occur in Mexico and North America. A novel influenza A (H1N1) virus was identified as the cause and it rapidly evolved into a pandemic, leading to a large number of cases in Australia despite implementation of public health control measures. In this paper, two senior academics discuss the management of pandemic (H1N1) 2009 infection in Australia from the public health perspective.
David S. Hui, MD, FRACP, FRCP
Pandemic (H1N1) 2009 is a new strain of influenza virus that was first identified in Mexico and the USA in March and April 2009, respectively. The pandemic (H1N1) 2009 virus originated from the triple-reassortment swine influenza (H1) virus circulating in North American pigs.1,2 Within several weeks from onset, the novel virus has spread throughout the world through international air travel and resulted in an influenza pandemic.3 The World Health Organization (WHO) has raised the level of influenza pandemic alert from phase 5 to phase 6 since 11 June 2009.4
As of 27 September 2009, there have been over 340 000 laboratory confirmed cases of pandemic influenza H1N1, over 4100 deaths, in 191 countries and territories reported to the WHO.5 Australia was hit hard by the pandemic virus during the winter of 2009 although the number of cases has declined substantially recently.
The pandemic (H1N1) 2009 virus is highly infectious due to lack of background immunity (except for the elderly age group who may have some cross-protective immunity) but the disease is generally mild in the majority of patients.6–8 The overall case fatality rate is not higher than that of seasonal influenza but data from animal studies show that the novel virus caused increased morbidity, replicated to higher titres in lung tissue and were recovered from the intestinal tract of intranasally inoculated ferrets in contrast to seasonal influenza H1N1 virus.9–11 Nevertheless pandemic (H1N1) 2009 infection is different from seasonal influenza in several aspects: higher incidence of critical illness in the younger age groups; and substantial mortality among critically ill cases due to severe viral pneumonitis.12,13
The large number of infected cases in Australia suggested a failure in containing the infection, although the relatively low mortality might be viewed by the authority as a success of the health system in limiting damages from a new and virulent virus. In this paper, two senior Australian academics polarized the issue and debated whether the public health response to pandemic (H1N1) 2009 infection in Australia had failed.
Grant W. Waterer, MBBS, PhD, FRACP
In the past decade, the emergence of severe acute respiratory syndrome (SARS) and then H5N1 (Avian) influenza heightened sensitivity to the possibility of a pandemic influenza outbreak leading to millions of deaths worldwide. The outbreak of pandemic (H1N1) 2009 influenza in Mexico, termed ‘swine flu’ although it appears to be derived from a mix of swine, human and avian influenza A strains,6 presented the first significant challenge to the public health measures adopted in anticipation of just such an event.
To decide whether the public health measures used against the pandemic were successful or not, we have to establish the goals they should be measured against. The Centers for Disease Control and Prevention defined its primary goals as slowing the spread of disease and reducing the severity of illness in people.14 The Australian Health Management Plan for Pandemic Influenza states that its primary objective is to reduce the impact of a pandemic on social function and the economy.15 It further outlines four key operational objectives: to communicate the best available information to decision-makers, health professionals and the public; to minimize transmission; to optimize the health system to reduce mortality and morbidity; and to work in partnership across all sectors of government to reduce the impact of the pandemic.16
Despite the above, the primary goal of any public health response must be to prevent entry of any new infection into the country, or if it does enter then to prevent spread beyond identified index cases at the point of entry into Australia. At the time the current pandemic was recognized in Mexico,17 the infection had already spread to the USA.18 However at the time the novel infection was declared a quarantinable disease on 28 April 2009, no cases had been documented in Australia, with the first case being confirmed on 9 May in a patient who had arrived from Los Angeles.19 The subsequent move to the ‘protect’ phase of response to the pandemic just 20 days after the start of the public health response on 17 June was a tacit acknowledgement that attempts to contain the virus had failed and it was then widespread in the Australian community.20 There is no question that, unlike SARS in 2003, the Australian public health response failed to prevent pandemic (H1N1) 2009 from gaining rapid and widespread entry into all areas of Australia. That Australia did not see mass casualties and a complete collapse of the country's health system is attributable to the relatively benign course of the pandemic (H1N1) 2009 infection in most patients, not due to any public health success.
Failure of the public health response to contain the pandemic does not represent a failure of government and public health authorities to respond properly, nor that the resources expended to contain it were misspent. Had we been able to limit the entry of the pandemic (H1N1) 2009 virus into the general Australian community by several months until the end or after the peak winter transmission months, the social and financial impact would have been greatly ameliorated and the newly manufactured vaccine21 would have had a much greater impact.
Several factors combined to overwhelm the ability of the public health response to contain the pandemic. Despite its relatively low virulence compared with normal endemic seasonal influenza A, pandemic (H1N1) 2009 infection is highly transmissible,22,23 possibly due to higher viral load in the lung and gut than seasonal influenza strains.9 Complicating efforts to reduce transmission, much of the screening for potential carriers and the use of antiviral prophylaxis was predicated on the presence of typical influenza-like symptoms. Unfortunately many patients infected with the pandemic (H1N1) 2009 virus are asymptomatic or have mild, non-specific symptoms and respiratory symptoms are also frequently absent. Then absence of a clear clinical phenotype to identify patients at risk of spreading pandemic (H1N1) 2009 infection was compounded by long delays in processing screening tests by overwhelmed laboratories, limiting the effectiveness of antiviral prophylaxis and causing a large amount of anger and concern particularly among general practitioners.24 Increasing the capacity of the health system to rapidly process and communicate screening test results should be a key outcome of any review of our response to the pandemic.
Also undermining the public health response were a number of decisions that in retrospect had substantially accelerated the spread of the novel H1N1 infection throughout Australia. The failure to isolate individuals with a high risk of developing pandemic (H1N1) 2009 infection as a result of their exposure on board the cruise ship Pacific Dawn, including those with active symptoms, led to widespread dissemination of the virus, particularly in Victoria. This single event underlined the problems of communication between state health authorities, with widespread anger in Victoria over the decisions made in New South Wales.25 Allowing the cruise ship to embark new passengers while there were likely infected crew and a contaminated environment had led inevitably to further infection and dissemination of the novel H1N1 infection.
Also accelerating the spread of pandemic (H1N1) 2009 was the decision to allow a number of national school sporting events to continue in Victoria despite the infection being established in the community. School children subsequently brought back the novel influenza infection from Victoria to most Australian states. To stop the spread of epidemics, difficult decisions have to be made and that means inconveniencing large numbers of people, including those with long-standing travel and holiday plans. Prohibition of such travel also has economic implications, particularly for airlines and the travel industry. Arbitrary, ‘on the run’ decisions are likely to magnify the political fall out of any restrictions placed on the public and future planning needs to be much more explicit in terms of these measures and the compensation that will be available for those affected.
Another factor likely to have hindered the public health (H1N1) 2009 initiatives is the increasing perception in the general public and the media that it was a relatively mild illness and that the official response to it was an overreaction.26,27 The SARS experience in Hong Kong in 2003 was an excellent demonstration of how effective community-based measures could be in reducing respiratory infections, and how quickly the benefit was lost when these measures were dropped once there was no widespread public concern.28 Better strategies for engaging the public in appropriate responses during an epidemic, such as avoiding work or school when unwell, are clearly needed.29
If the public health response clearly failed to stop the spread of pandemic (H1N1) 2009 infection, how did it measure up against its other objectives? Being involved in national and local planning in response to (H1N1) 2009, it was very evident that the multiple layers of national, state and local bureaucracy posed significant problems of communication and coordination. Many of those involved in coordinating the response to pandemic (H1N1) 2009 complained of having to attend multiple meetings at different levels of the health system frequently discussing the same agendas. It is hardly surprising then that despite the best of intentions, the systems in place could not respond quickly to a rapidly changing scenario leading to significant concerns, particularly among general practitioners.24
Indeed the entire public health thrust to shift the burden of screening, prophylaxis and treatment away from hospitals and their emergency departments into the primary care setting did not take into account that many general practitioners felt poorly trained to perform or possibly even unwilling to undertake such a role.30,31 Future planning needs to consider much greater support of general practitioners if they are to fulfil these roles. I received many calls from worried general practitioners asking for advice and modern electronic communication resources including the Internet could be much better used to provide real-time support for all primary care practitioners.
In summary, although the public health effort directed against pandemic (H1N1) 2009 was well intentioned and well funded, it met few of the most important goals. The primary reason for the failure of the prepared public health response was the virus itself, with a high infectivity and a clinical presentation that was different from that anticipated. We have however learnt important lessons for future pandemic planning, particularly the need for faster and more efficient coordination across the various health planning bodies, the need for greater capacity and access to molecular screening tests and much greater engagement and support for the general practitioners.
Christine Jenkins, MD, FRACP
The old adage ‘Those who do not learn from their mistakes are bound to repeat them’ pays respect to the need to review experience and analyse shortcomings in order to make progress. Implicit in this is an assumption that we learn more from understanding where we went wrong than from reflecting on what we got right. In this respect I believe my opponent has a somewhat easier task than I! There is no doubt that it is more challenging to identify the crucial components of initiatives that were well undertaken than the missing or mistaken components of those that were poorly implemented. I can readily identify the areas in which we could have done better in relation to the pandemic (H1N1) 2009 infection in Australia, but it is just as important to know the areas in which we did so well that we hardly noticed it.
The Australian Health Management Pandemic Planning Initiative (AHMPPI)15 is a 147-page document, which was finalized in December 2008 after 2 years of planning, and well before the first cases of pandemic (H1N1) 2009 emerged in Mexico in February 2009. It is a comprehensive document providing background to influenza pandemic planning, a strategy for responding to an influenza pandemic, key actions including communications, minimizing transmission, optimizing health services and working across government. It describes how individuals can help control spread of the virus and details infection control in health-care facilities and the workplace as well as personal hygiene measures. It is based on a set of pandemic planning assumptions, focused on anticipated features of influenza virus infection, communicability, infection control measures, clinical presentations, health impact, neuraminidase inhibitor prophylaxis and treatment. It anticipates the impact on the workforce, transport, general services and public gatherings and predicts likely duration of pandemic disruption. The majority of these assumptions are correct, particularly in relation to incubation period, attack rates, modes of transmission, presenting symptoms, neuraminidase inhibitor treatment and prophylaxis, and immunity following natural infection.
Significantly, however, several crucial assumptions in the AHMPPI are incorrect. Behind many of these is the assumption that the pandemic influenza virus would be a virulent avian-like flu, with a high attack rate and case fatality rate, neither of which proved to be true.32 The case fatality rate was predicted to be 1–2%, in part because of uncertainty about the susceptibility of the novel virus to antiviral therapies. In fact it turned out to be less than a 10th of this. Health impact assumptions were incorrect in many other respects, in particular because it was not anticipated that clinical pandemic (H1N1) 2009 infection would be less common in people over 60 years and hence the huge predicted burden of disease in people with chronic cardiorespiratory illness did not occur. In fact, the largest proportion of affected individuals were children and young adults. This instantly placed schools at the centre of the action and steps were taken appropriately in the Delay phase, to close schools of cases and contacts. Border control however proved particularly problematic, the notion of borders being almost anachronistic in an era of air travel where many thousands of people arrive from other parts of the world every day. Even where a notional border does exist such as at a port or passenger terminal, procedures were not uniform. In one instance, passengers were allowed to disembark from a cruise ship when several unwell individuals were subsequently confirmed as having pandemic (H1N1) 2009 infection. Lack of evidence for the efficacy for some of these interventions33 or inconsistency in applying the principles of the AHMPPI was where things went wrong, rather than in the plan itself.
Australia was in the front line of pandemic (H1N1) 2009 infection by virtue of the fact that the northern hemisphere outbreaks occurred just before the Australian winter. We were still learning about this virus when travel and climatic conditions favoured its arrival and continued residence in Australia. At such a time there were crucial opportunities for information gathering and dissemination, which could influence service provision and public health initiatives. The Centers for Disease Control and Prevention and WHO alerts, web-based information and daily updates provided excellent examples and the Australian government was prompt in providing high levels of information, updates and advice for health-care professionals through the Internet.34 There were however critical opportunities for communicating balanced information to the public, and some of these were wasted. Although schools were closed, parents were sometimes not informed about the implications for subsequent socializing and contact with other children. Importantly, however, key messages were communicated, particularly regarding personal hygiene to slow spread in the community. Recent research in the UK suggests these messages are well received.35 The promotion of Department of Health websites, pandemic update bulletins and situation reports, which were issued twice daily from the National Incident Room, enabled health-care professionals to remain fully informed of the rapid evolution of infection in the community. Key messages were conveyed to health-care workers in some but not all settings. Crucially, general practice was at the forefront of patient management but the establishment of fever clinics was slow as was provision of personal protective equipment to general practice.36,37 The potential for infection transmission through general practice could have been minimized to a much greater extent with greater involvement of primary care leaders and professional groups.38 General practitioners may reasonably complain that they were inadequately supported and the community inadequately prepared given they were at the front line and inundated with patients with flu-like syndromes.
On the other hand, at the public hospital level, availability of personal protective equipment, the provision of antiviral drugs through emergency departments and the rapid implementation of testing assisted in prompt management of early cases. Emergency departments rapidly implemented nasopharyngeal swab collection and rapid influenza A assessment, awaiting results from RT-PCR for pandemic (H1N1) 2009. Measures were taken to reduce patient exposure through isolation and minimizing aerosol-generating procedures. Staff fever clinics were rapidly established. Despite the mild nature of clinical disease in most people affected, a very small proportion of people suffered much more severe disease presenting with acute respiratory failure and requiring high-level management in intensive care.39 It became obvious that limited intensive care services would be a serious problem in reducing access to quality care for critically ill patients. The limited number of intensive care beds would have caused a catastrophic bottleneck were this disease more serious, and one of the crucial areas to revisit is the provision of intensive care services, as even with the relatively mild H1N1 and the sparing of the older population, intensive care beds were rapidly filled and life support facilities stretched. In some local contexts, there was conflicting advice to health-care workers about coming to work if symptomatic, perhaps reflecting concerns that a seriously reduced workforce would be an unmanageable consequence.40
The National Health and Medical Research Centre responded very appropriately to the pandemic, announcing timely availability of research funding for studying the novel H1N1 virus and implementing a rapid turnaround for assessment and awarding of grants. Early publications and the results from these studies will inform future planning, establish monitoring processes and be collated and presented in a national research meeting.
The role of the media in a pandemic situation is immensely influential. Initial media focus on the WHO Pandemic Phase step up to Level 6 led the public to believe we were on the brink of a catastrophic and devastating pandemic, rather than by way of explanation informing them that this is a predictable, natural evolution of spread of disease. Media attention was initially intense, but as the disease spread and more people had personal experience of it, it became obvious that it was relatively mild and the community questioned the overcall. Some became complacent, believing the pandemic threat to be completely exaggerated. It might seem in the light of this that the public health responses to pandemic flu, such as school closures, border control measures, quarantine and painstaking testing of suspected cases, were excessive.41 This is an easy position to take in retrospect, having seen this disease to be generally mild. Government would however have received well-justified criticism had it turned out to be more serious, even as serious as was suggested by the early statistics from Mexico. A high level of vigilance was maintained in the control room of the Department of Health and Ageing and state health departments, with multiple daily bulletins, innumerable interviews on radio and TV, engagement of professional colleges, recommendations for case identification, clinical advice for health-care workers, advice to acutely unwell patients and the establishment of hospital triage measures.
How would we know if we had got it seriously wrong? Obvious possibilities include excess mortality, higher attack rates than predicted by experience elsewhere, extreme disruption to health-care delivery resulting in poorer outcomes for those with non-flu illnesses, poor availability or access to antiviral treatment, unnecessary school closures or impositions on the community and loss of public confidence in the management of the many health- and service-related aspects of the pandemic. None of these occurred. Naturally, there are areas for improvement and processes are already in place to ensure deficiencies will be addressed.
The real test of whether we got it right might come with the northern hemisphere winter. This will provide another opportunity to observe the public health initiatives in a range of well-resourced countries as well, of more concern, in developing countries. It will occur in a very different context, where vaccines will progressively become more widely available and at-risk groups can be identified and offered vaccination prospectively. It will not be necessary to try to contain early infection to prevent widespread disease, as the illness is generally mild, and efforts can be focused on those at risk and the necessary infrastructure changes can be undertaken now, to maximize quality health care. The provision of intensive care services and an interface with health-care workers independent of general practices can be established. The opportunity to observe events in the northern hemisphere and studiously examine and re-evaluate our own initiatives, along with the presence of moderate levels of protection in the community and the availability of vaccine, should place us in an immensely strong position to minimize the impact of this illness in the winter of 2010. It should also cause us to revise our assumptions about this virus and to revisit the more ominous prospect of a virulent virus such as influenza A/H5N1, which could still be around the corner and for which our recent experience might simply have been a rather short and mostly benign dress rehearsal.
It is important to note that geographically targeted non-pharmacological measures such as early case isolation, household quarantine, school/workplace closure and restrictions on travel are useful measures in controlling an influenza pandemic only at its early phase.42 As pointed out by both authors, these measures and their goals can only be achieved effectively through international collaboration, faster and more efficient coordination across the various national and interstate health planning bodies, with more surge capacity in clinical service, laboratory testing and more support for the general practitioners.24
Clinicians and researchers in Australia and New Zealand are to be commended for their great efforts and achievement in this pandemic in disseminating their clinical knowledge especially intensive care experience including the use of extracorporeal membrane oxygenation, infection control guidelines, treatment recommendations and the rapid development of a pandemic vaccine.12,21,24,39,43–46 These have facilitated clinical management of pandemic (H1N1) 2009 infection in Australia and other countries especially with the possible second wave of cases, which may occur in the Northern Hemisphere over the next few months.
- 4World Health Organization. What is phase 6? [Accessed 20 Sep 2009.] Available from URL: http://www.who.int/csr/disease/swineflu/frequently_asked_questions/levels_pandemic_alert/en/index.html
- 5World Health Organization. Pandemic (H1N1) 2009—update 68. [Accessed 5 Oct 2009.] Available from URL: http://www.who.int/csr/don/2009-10-02/en/index.html
- 142009. CDC H1N1 (Swine Flu) response, actions and goals. [Accessed 10 Sep 2009.] Available from URL: http://www2a.cdc.gov/podcasts/player.asp?f=11288#transcript.
- 15Department of Health and Ageing. Australian health management plan for pandemic influenza. [Accessed 15 October 2009.] Available from URL: http://www.flupandemic.gov.au/Internet/Panflu/publishing.nsf
- 16Department of Health and Ageing. 2008. Aim, goals and objectives of pandemic planning. [Accessed 10 Sep 2009.] Available from URL: http://www.health.gov.au/internet/panflu/publishing.nsf/Content/ahmppi~ahmppi-introduction~ahmppi-introduction
- 17Centers for Disease Control and Prevention. Outbreak of swine-origin influenza A (H1N1) virus infection—Mexico, March–April 2009. MMWR Morb. Mortal. Wkly Rep. 2009; 58: 467–70.
- 18Centers for Disease Control and Prevention. Swine influenza A (H1N1) infection in two children—Southern California, March–April 2009. MMWR Morb. Mortal. Wkly Rep. 2009; 58: 400–2.
- 19Department of Health and Ageing. 2009. First case of human swine influenza detected in Australia. [Accessed 12 Sep 2009.] Available from URL: http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/news-012
- 20Department of Health and Ageing. 2009. New pandemic phase protect. [Accessed 13 Sep 2009.] Available from URL: http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/news-170609
- 252009. Anger over breach in swine flu quarantine. [Accessed 10 Sep 2009.] Available from URL: http://www.theage.com.au/national/anger-over-breach-in-swine-flu-quarantine-20090526-bm4i.html, .
- 262009. Swine flu response described as over-reaction. [Accessed 12 Sep 2009.] Available from URL: http://www.abc.net.au/am/content/2009/s2597343.htm.
- 272009. Swine flu: a beat-up or a real fear? [Accessed 12 Sep 2009.] Available from URL: http://www.smh.com.au/national/swine-flu-a-beatup-or-a-real-fear-20090501-apq6.html.
- 32A pandemic that's not bird flu? Pigs might fly. Med. J. Aust. 2009..
- 34Department of Health and Ageing. Australian Government swine flu website. [Accessed 8 Dec 2009.] Available from URL: http://www.healthemergency.gov.au
- 38Pandemic planning lacks GP input. New South Wales Doctor. August 2009. [Accessed 8 Dec 2009.] Available from URL: http://www.nswama.com.au.
- 39Impact of pandemic (H1N1) 2009 influenza on critical care capacity in Victoria. Med. J. Aust. 2009; 191: 1–5., , et al.
- 45ASID (HICSIG) position statement: infection control guidelines for patients with influenza-like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities. Med. J. Aust. 2009; 191: 1–5., , et al.