1.3 Key Issues and Lessons Identified

1.3.1 Pandemic plans and phases

The existence of an exercised pandemic plan meant that Australia was in a good position to implement actions rapidly to respond to the emerging threat of pandemic 2009. The AHPC used the AHMPPI to guide the implementation of actions that were adapted as the scientific and international understanding of the disease evolved. Development of the new PROTECT phase showed that Australia has a flexible public health response system. Relationships already established between all levels of government that allowed for an ongoing cooperative effort were important when it became necessary to modify the AHMPPI to reflect the response actions needed for the 2009 pandemic.

The fundamental purpose of the Australian pandemic phases and the actions that they drive needs further consideration. The phases were intended both to define a consistent national operational response and to be a useful communication tool. However, jurisdictions were affected differently at different times and the application of consistent public health actions was difficult and not always appropriate. While the AHMPPI indicates potential implementation of different control interventions in different parts of the country at the same time, it does not clearly articulate the aim or the process. While there was a strong and legitimate desire to maintain common phasing nationally, the purpose of uniformity was not clear, and communicating different actions through phase-change announcements was problematic. Jurisdictions sought the flexibility to implement tailored public health actions at a local level, such as school exclusion policies.

The key issue, then, is how to manage the inevitable geographical differences. Areas for further consideration include whether phases and the resulting public health interventions can or should differ between jurisdictions; whether travel restrictions between jurisdictions should be considered; and the implications for community transmission in other jurisdictions if one jurisdiction relaxes containment measures. For example, the 2009 State of Origin rugby league match was held in Victoria and attended by a significant number of supporters from New South Wales and Queensland. The match was held during the peak of Victoria’s pandemic activity and, while cancellation of the match would have had minimal impact on Victorian case numbers, this mass gathering of interstate visitors presented a significant opportunity to enable seeding or to enhance the spread of the pandemic virus in other Australian areas not yet or minimally affected. Had the virus been more severe or infectious, the cancellation of mass gathering events such as this could have been a critical opportunity to impede the spread of the pandemic across the country.

Other countries, such as the United States and Canada, have proposed developing a ‘severity index’ to assist in scaling a pandemic response and to enable responses to be tailored to the pandemic’s severity and disease pattern. Defining severity is a complex process and the full spectrum of a disease may not be apparent until the virus is more widespread; it may also change over time.

Alternative phases had not been envisaged in the planning for a severe pandemic. Victoria’s proposal of a MODIFIED SUSTAIN phase was new ground. The development of new phases in 2009 highlighted that rapid decision making and coordination of public messaging are vital. The experience of a sudden move to a new phase, unsupported by developed communications, led to confusion as it gave the appearance that Australia was stepping up its pandemic response (at least one country modified its travel advisory to include specific reference to Victoria and consideration of screening and quarantine of arrivals from Victoria), and using the term ‘SUSTAIN’ for this situation implied that other containment strategies were no longer required or effective. Lessons learned with respect to the MODIFIED SUSTAIN phase were applied to the new PROTECT phase. The move to PROTECT was accompanied by a new PROTECT Annex to the AHMPPI describing the phase and an agreed set of public messages, which resulted in a smooth and welcomed process.

The process of changing pandemic phases in 2009 did not follow the procedure detailed in the AHMPPI. Rather, the Prime Minister was advised of the proposed phase changes, which were announced by the Australian Government Minister for Health and Ageing as the primary impact was on the health sector. The process of changing phases needs reconsideration and streamlining, including clarification of the roles of the CMO, the expert advisory groups and the AHPC in phase determination.



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1.3.2 Decision making

There was strong commitment from all public health officials to support teamwork across governments through the leadership of the AHPC. The AHPC was supported by a number of multi-stakeholder advisory mechanisms that provided valuable expert and operational advice on different aspects of the response.

To ensure that the AHPC’s strategic function was not subsumed by a focus on operational matters, detailed consideration of some issues was undertaken ‘offline’ to develop recommended policy positions that were then considered by the AHPC for decision. Nevertheless, more strategic discussions at critical points could have occurred to allow for cross-committee information sharing. To support decision making and effective communications, consideration should be given to developing a decision support document that identifies the public health actions available during a pandemic, including policy objectives, consequences (risk and benefits) and powers to act, to guide the AHPC’s consideration of options in the context of new information available, rather than rediscussing policy during the response.

The current pandemic committee structure encourages the separation of the scientific and operational streams of expert advice. This separation is important in order to work through the variety of complex issues. Some stakeholders have questioned the need for expert advisory groups reporting directly to the CMO, considering that there was a disconnection between these groups and jurisdictional representational groups, and a need for more transparent and timely information sharing. The CMO’s convening of meetings of CHOs and relevant key experts at critical decision-making points in order to rectify this apparent disconnection was a successful approach. There is a need to formalise this process.

The number of committees supporting the AHPC and the CMO meant that accountability for decisions made was sometimes unclear. There is a need to clarify, consolidate and communicate the roles and responsibilities of advisory and decision-making committees.

Existing well-functioning expert advisory committees should be used in future in preference to separate pandemic advisory structures. It would be valuable to formally include ATAGI in the AHMPPI, as the quality and timeliness of advice developed through the ATAGI H1N1 Working Group established in 2009 was widely acknowledged as authoritative and proved to be vital to the success of the pandemic vaccination program.

The planned PCN did not convene as described in the AHMPPI due to resource limitations, and the need for this group should be reconsidered. Rather, in order to make the best use of limited resources, it was recognised that experts could only devote time to subject matter directly related to their expertise, therefore meeting on an as-needed basis under the individual advisory group’s governance structure.

Some proponents consider that Australia’s response to the 2009 pandemic may have been improved by having an independent body, similar to the US Centers for Disease Control and Prevention (CDC) model, to improve the process for the development of robust, independent and nationally consistent advice for national decision makers. The pandemic experience indicates that it is now timely to review the priorities and gaps identified since pandemic preparedness activities commenced, in order to identify efficiencies across policy areas, for example, similar to a One Health⁶approach.

The vital role of the clinical sector in obtaining early warning of the severity seen within Australia’s hospitals, particularly in intensive care units (ICUs), was not documented in the AHMPPI. Early recognition of this clinical link was established with the formation of a clinical intensivist experts group. In addition, the GPRT was an important initiative to enable the government and representatives of front-line clinicians to work together in a highly effective manner to improve communication and to ensure that policies were realistic, effective and efficient. Both networks served the public health response well during the pandemic. There is a need to formalise these processes as 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 the AHPC and public health objectives. Optimal communication between national, state and territory governments, peak bodies and primary healthcare professionals needs to be further addressed. This could include formalising networks and considering ways of enhancing the intersection and integration of all governments and local networks of peak bodies.

It is important to ensure broader stakeholder engagement during planning and the early stages of a response on key aspects of the AHMPPI, to allow for discussion of risks and benefits of all actions that can be taken during 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 enable better management of media commentary on key public health objectives during the pandemic.

A move from consideration of ‘health’ issues to ‘whole-of-government’ issues for decision making was not widely tested. A process to enable early recognition of the point at which broader whole-of-government considerations are necessary needs further development. This would ensure that the AHPC is able to provide timely and robust public health advice to the NPEC to inform public health intervention with wider social and economic implications.

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School closures and exclusions was one area that resulted in tension between the public health recommendation of early school closures to control the spread of infection and the political and social realities of implementation. This highlighted the difficulties that will be encountered by all governments in a more severe pandemic to contain spread by implementing and continuing more extensive and potentially disruptive measures. The NPEC needed more time to absorb and appreciate any potential benefits of school interventions and to weigh these against broader issues, including the costs of school closures. An important lesson learned is that a stretched health sector will be limited in its capacity to provide resources to support the NPEC, particularly in a more severe pandemic. The NPEC requested more input from the health sector, but the health sector was fully engaged with health issues and recommendations were based on the best information available at the time, which will always be limited during unfolding outbreaks of an emerging disease. Further research is needed to weigh the evidence on effectiveness and timing of implementation, taking into account the clinical severity and the period before a vaccine will become available.

1.3.3 Science and research

While it is recognised that the NHMRC urgent research grants were tendered and awarded rapidly, there were limited linkages with appropriate decision-making and expert bodies (for example, the AHPC and the CDNA) with respect to the research required to fill critical information gaps to support decision making. The sharing of results was also not timely enough to inform the public health response. For example, the critical early data on the epidemiology of the disease that were outlined in the AHMPPI were not available, and no funding was provided through the NHMRC to support seroprevalence studies which were widely recognised as necessary to inform public health actions. These were ultimately separately funded by the Australian Government and most jurisdictions. Jurisdictions reported a lack of engagement with research outcomes and, while CHOs participated in a forum on study results, these were not available to other committees until publication.

Consideration should be given to developing a set of key research questions in advance of a future pandemic and a process to enable commissioning of research with tight time frames, including contract provisions to allow governments to have access to results before they are published by the researchers.



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⁶ The One Health approach ensures that experts in animal, human and environmental health work together to ensure a holistic, mulit-sectoral approach to the prevention, early detection and management of zoonotic diseases in humans and animals.