1.2.1 Decision making

On 24 April 2009, WHO notified the NIR (as the NFP) of an outbreak of a novel influenza virus strain in Mexico and the United States. The NIR was activated to respond to the emerging incident and informed other Australian Government agencies, and the state and territory public health agencies, of the need to consider activating their pandemic plans.

The AHPC first met on 25 April 2009. It then commenced frequent teleconferences that continued to January 2010, and convened face to face twice during June and July 2009. The supporting expert advisory committees also met often as required during this period.

In 2009, the role of and level of representation on NPEC differed from what was planned in the NAP. The NPEC met to coordinate activities with respect to the phase changes to MODIFIED SUSTAIN and to PROTECT, in particular to discuss the implications of public health recommendations with a view to ensuring nationally consistent communication regarding phase changes and implementation of the national Pandemic (H1N1) Vaccination Program. Given the nature of the unfolding pandemic and its relatively low impact at societal level, a group of senior officials convened regularly during the early stages of the response. This group was identified as NPEC Officials. It first met on 28 April 2009 and, while it was primarily an information-sharing forum rather than a formal whole-of-government decision-making body, it developed principles to guide the implementation of school exclusion recommendations.

Health ministers held teleconferences to work through key issues at the time, with a particular focus on the national Pandemic (H1N1) Vaccination Program. Advice was provided by health departments when requested.

A range of expert groups met throughout the response, providing valuable scientific and expert advice to inform decision making. While SPAG and the EAG convened as planned, their roles and responsibilities differed during the pandemic.

The CMO convened and chaired meetings of the jurisdictional CHOs and relevant key experts at critical decision-making points, for example, to address the scientific evidence and its impact on the operational aspects of the Pandemic (H1N1) 2009 Vaccination Program.

The pre-existing and well-established Australian Technical Advisory Group on Immunisation (ATAGI) had not been included in pandemic planning, as it had been planned that pandemic vaccine experts would provide advice through the pandemic advisory committee structures. However, ATAGI’s vital role in providing evidence-based advice to the CMO and the AHPC regarding the pandemic vaccination program and related issues as they arose was widely acknowledged as important (see section 1.3).

In addition, the following two groups were established during the response to advise on clinical aspects of the response.
  • The General Practice Roundtable (GPRT), chaired by the CMO, provided a two-way communication forum between the Australian Government and peak bodies representing Australian general practitioners (GPs) and primary care providers, to assist with disseminating Australian Government information, resources, advice and support to general practice, and to communicate issues and provide feedback to the Australian Government from GPs. The peak bodies represented were the Australian General Practice Network (AGPN), the Royal Australian College of General Practitioners (RACGP), the Australian College of Rural and Remote Medicine (ACRRM), the Rural Doctors’ Association of Australia (RDAA), the Australian Medical Association (AMA) and the Australian Practice Nurses’ Association (APNA).
  • A clinical intensivist experts group was established in parallel with the GPRT, and met in June 2009 to develop a clinical resource to provide guidance to clinicians on the clinical management of patients with presumptive or confirmed infection with pandemic (H1N1) 2009 influenza. Its membership comprised representatives from appropriate specialist groups including the Thoracic Society of Australia and New Zealand, Emergency Medicine and Intensive Care and jurisdictional chief health officers, and it was chaired by the CMO.
See Figure 2 for the governance and decision-making structures used during the pandemic (H1N1) 2009 response.

Figure 2: Governance and decision-making structures during the pandemic (H1H1) 2009 response
Figure 2: Governance and decision-making structures during the pandemic (H1H1) 2009 response
Description of Figure 2: Governance and decision-making structures during the pandemic (H1H1) 2009 response

This is a flowchart of the advisory and decision-making committee structure used during the pandemic response.

The flowchart is divided into two halves. The top half is the whole-of-government committee structure and the bottom half is the health sector advisory and decision-making committee structure. The top half contains the Council of Australian Governments (C.O.A.G.), the Australian Government Crisis Committee (A.G.C.C.) and the National Pandemic Emergency Committee (N.P.E.C.).

C.O.A.G. is the whole-of-government overarching decision maker, under which sit the A.G.C.C. and N.P.E.C. Each of these committees report directly to C.O.A.G.

The bottom half of the chart starts with the Australian Health Protection Committee (A.H.P.C.). The A.H.P.C. is the overarching health sector decision-making committee and was the conduit between the health sector and the whole of government during the pandemic (H1N1) 2009 response. The A.H.P.C. reported to C.O.A.G. through the National Pandemic Emergency Committee (N.P.E.C.).

The A.H.P.C. was supported by three operational advisory committees: the Communicable Diseases Network of Australia (C.D.N.A.), the Public Health Laboratory Network (P.H.L.N.) and the A.H.P.C. National Immunisation Pandemic Vaccine Working Group (A.H.P.C.N.I.C.).

In addition to the operational advisory groups that reported to the A.H.P.C., the Chief Medical Officer (C.M.O.) also provided expert clinical and technical advice to the A.H.P.C. The C.M.O. was supported in this role by the Expert Advisory Group on Pandemic Influenza (E.A.G.), the Scientific Pandemic Advisory Group (S.P.A.G.) and the Australian Technical Advisory Group on Immunisation (A.T.A.G.I.). Two clinical groups, a clinical intensivist experts group and a General Practitioner Roundtable (G.P.R.T.), were also established to provide advice to the C.M.O.

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1.2.2 Pandemic phases

One of the biggest challenges to decision making and coordination was the variation in the timing of outbreaks across the country. In the early stages almost all of the activity was in Victoria, as shown in Figure 3. The epidemic curve also indicates that the number of notifications in Victoria had fallen at the same time as they were starting to increase in other states and territories. This reflects the fact that the amount of testing was reduced when Victoria moved to the MODIFIED SUSTAIN phase, with a focus on testing vulnerable individuals rather than more widespread testing. It also indicates the variable rate of notifications between jurisdictions over time.

While Australia moved nationally to the DELAY and CONTAIN phases, the overwhelming number of cases in Victoria had strained the capacity of the public health responses outlined in the CONTAIN phase, and the SUSTAIN phase response was disproportionate to the moderate severity of the disease being experienced in Victoria. As a result, on 2 June 2009 Victoria proposed to the AHPC that the state move from the CONTAIN phase to a modified version of the SUSTAIN phase named MODIFIED SUSTAIN.

Figure 3: Crude rates of laboratory-confirmed cases of pandemic (H1N1) 2009 influenza, by jurisdiction, to 2 October 2009
Figure 3: Crude rates of laboratory-confirmed cases of pandemic (H1N1) 2009 influenza, by jurisdiction, to 2 October 2009
Description of Figure 3: Crude rates of laboratory-confirmed cases of pandemic (H1N1) 2009 influenza, by jurisdiction, to 2 October 2009

This graph reflects the information provided in the first paragraph of section 1.2.2 Pandemic phases. It shows the number of laboratory-confirmed notifications for pandemic (H1N1) 2009 as a crude rate per 100,000 population. These rates are shown for each jurisdiction in Australia per week between 17 May 2009 and 27 September 2009. The main features of the graph are the two large peaks of crude notification rates in approximately the week beginning 28 June for the Northern Territory and in approximately the week beginning 2 August for South Australia. Queensland, Tasmania and the Australian Capital Territory have smaller peaks around the weeks beginning 12 and 19 July, and Western Australia has two smaller peaks around the weeks beginning 12 and 19 July and the week beginning 2 August. New South Wales and Victoria have the lowest crude notification rates, with Victoria peaking in approximately the weeks beginning 24 and 31 May and New South Wales in approximately the week beginning 19 July.

1.2.2.1 MODIFIED SUSTAIN

The members of AHPC agreed that Victoria was facing a different situation from other states and recommended to NPEC on 2 June 2009 that Victoria move to a MODIFIED SUSTAIN phase. NPEC requested more information from the CMO and the AHPC regarding this proposal; however, Victoria implemented the phase change due to the burden on its public health capacity. This resulted in media announcements of the change in phase occurring before public information was able to be disseminated to explain what the phase change meant in relation to the disease and the associated response actions. The implications of this are discussed in section 1.3.2.

1.2.2.2 PROTECT

On 17 June 2009 Australia moved to the new pandemic phase of PROTECT, which was developed and implemented in recognition that the pandemic (H1N1) 2009 virus was mild in most, severe in some and moderate overall. The focus of this phase was on treating and caring for those most vulnerable to severe outcomes. The announcement of the new phase was supported by a new publicly available PROTECT Annex to the AHMPPI that described the meaning of the phase and the associated response actions.

1.2.3 Science and research

During the response, the Australian Government worked with scientists, clinicians and epidemiologists to model and analyse a number of complex questions regarding severity, hospitalisation rates, use of antiviral medication and personal protective equipment (PPE), vaccine distribution and various social distancing measures.

On 29 May 2009 the National Health and Medical Research Council (NHMRC), principal funder of public health and medical research in Australia, called for research proposal expressions of interest. A robust international peer review of applications for medical research grants can typically take many months to identify those critical projects that would contribute to areas including pandemic virus virology and clinical and public health issues. In this case the peer review process was completed in little more than a week as a result of the involvement of highly experienced researchers in Australia and other countries including Singapore, New Zealand and the United States. Funding announcements were made on 8 July 2009, approximately two months after the onset of the pandemic in Australia. More than $7 million was provided to 41 Australian medical research projects. The research commissioned included understanding why some people get more severe influenza; strategies for containment in rural, remote and Indigenous communities; improving the detection of the pandemic (H1N1) 2009 virus; and the best strategies for antiviral use.

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