After declaring a public health emergency of international concern under the International Health Regulations 2005 (IHR), the World Health Organization (WHO) advised against imposing restrictions on regular travel or closure of borders, recommending instead that people who were unwell should consider delaying international travel and that people who developed symptoms following international travel should seek medical attention according to guidance from national authorities. Many countries, including Australia, implemented a range of activities at different times to screen incoming and/or departing15 travellers in an attempt to delay the spread of pandemic influenza.
From 27 April 2009, with commencement of the DELAY phase, Australia began rapidly implementing a program of complementary border health measures at Australia’s major international airports (see Table 4.1 and Appendix C). The border measures continued into the CONTAIN phase and were scaled back on 22 June 2009 at commencement of the PROTECT phase.
On 30 April 2009, the Minister for Health and Ageing authorised implementation of emergency quarantine measures under subsection 12A(1) of the Quarantine Act 1908, which authorised airports and airlines to be directed to implement enhanced border measures to minimise the public health risk from potentially infected incoming international travellers. This power was not invoked, as the airports and airlines voluntarily complied with government activities.
On 8 May 2009, the first confirmed pandemic (H1N1) 2009 influenza case was detected at a Queensland airport in a passenger returning from the United States.
Table 4.1 Commencement and termination dates of border health measures for 2009 pandemic
| Date | Border health measure |
|---|---|
| 27 April 2009 | In-flight announcements on all incoming aircraft originating from countries in North, Central and South America |
| 27–29 April 2009 | Automatic pratique withdrawn from all incoming aircraft originating from countries in North, Central and South America |
| 28 April 2009 – ongoing | ‘Human swine influenza with pandemic potential’ proclaimed a quarantinable disease |
| 29 April – 22 June 2009 | Automatic pratique withdrawn from all incoming aircraft Health declaration cards (HDCs) deployed Thermal scanners at all international airports Health assessment by nurses at all international airports |
| 29 April – 12 October 2009 | In-flight announcements on all incoming flights |
| 29 April 2009 – ongoing | Public communications at airports |
| 30 April 2009 | Emergency quarantine measures enabled under subsection 12A(1) of the Quarantine Act 1908 |
| 6 May – 22 June 2009 | Mandatory presentation of HDC to the Australian Customs and Border Protection Service primary line |
| Early June – 22 June 2009 | Information for the public distributed in business card format |
| 7 August 2009 – ongoing | Cruise ship protocol implemented |
A decision was made at the start of the border measures response that border nurses would take nose and throat swabs from symptomatic passengers and supply antiviral medication on-site, which was an additional requirement that was not included in pre-pandemic training and necessitated the use of nurses with higher levels of clinical skills.
Thermal scanners16 were rapidly deployed as a result of good planning and training undertaken prior to the pandemic.
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4.2.1 Identifying unwell travellers at Australia’s international airports
On average, more than 28,50017 passengers arrive daily at Australia’s eight major international airports (see further detail in Appendix C). From 28 April 2009 to 1 June 2009, nationally a total of 15,457 travellers were identified as unwell. This represents approximately 13 per cent of all international air arrivals for this period.Unwell travellers were identified through information provided on Health Declaration Cards (HDCs) (84 per cent), airline notification (13 per cent), ‘other means’ (2.5 per cent) and thermal scanners (0.5 per cent) (see Table 4.2). Note that these figures refer to all unwell people identified at the border, not only those with pandemic (H1N1) 2009 influenza. Of these, a very small number (154 or 0.1 per cent) were managed as if they had a case of pandemic (H1N1) 2009 influenza and were either advised to stay in home quarantine or hospitalised. For example, in Queensland, of the 780 incoming passengers identified as unwell through border measures who were then screened by public health border nurses, 52 people met the case definition, were tested and were referred to public health units for follow-up. Of these, only four (or 1 per cent of those identified as unwell) tested positive for pandemic (H1N1) 2009 influenza.
Contact tracing occurred for some passengers on early flights; however, this could not be sustained. Millions of international air travellers entered Australia during the pandemic, and with the relative mildness of the disease many, even symptomatic, infected travellers could not have been identified.
4.2.2 Management of international travellers arriving by cruise ship
The arrival of international travellers by sea had not been addressed in the Fluborderplan. Cruise ships had been assessed as a low risk to Australia due to the relatively small number of (largely Australian) travellers during the Australian influenza season, the existing pre-embarkation passenger screening used by cruise ships to minimise onboard health issues, the onboard medical personnel and facilities and disinfection protocols, and the pre-arrival requirements for all ships entering Australia. However, the 2009 pandemic experience has shown that, when an international influenza outbreak is occurring, cruise ships pose a risk that needs to be managed. If infection and spread has occurred onboard, there is potential for the introduction of many cases of disease into Australia at one time if disinfection and other controls have not proved effective.On 23 and 25 May 2009, respectively, two cruise ships arrived in Sydney carrying travellers exhibiting symptoms of influenza-like illness (ILI). The first ship, Dawn Princess, was cleared of pandemic (H1N1) 2009 but on its subsequent voyage (departing Sydney on 25 May 2009) had five passengers with ILI symptoms. The ship was refused entry to New Caledonia and returned to Sydney. The second ship, Pacific Dawn, had 172 passengers with ILI symptoms identified through HDCs. These passengers were released to home isolation and provided with antivirals to reduce secondary transmission to close contacts and for treatment. The Home Quarantine Support System (HQSS) provided telephone advice to these passengers. Of these passengers, 77 were subsequently confirmed as having pandemic (H1N1) 2009. On the ship’s next voyage, departing Sydney 26 May 2009, seven crew members had ILI symptoms. They were treated with antiviral medication and placed in isolation. Three were confirmed as having pandemic (H1N1) 2009. New South Wales Health provided a doctor and 25 public health nurses to travel to Brisbane to join the ship and screen all passengers, none of whom tested positive to the virus.
To manage unforeseen issues with international arrivals by cruise vessel, a National Protocol for Pandemic (H1N1) 2009 on Cruise Ships was rapidly developed in consultation with cruise ship operators, state and territory Chief Human Quarantine Officers and Commonwealth border agencies. The protocol’s aim was to ensure clarity of intent, responsibility and action in responding to the presence of pandemic (H1N1) 2009 on cruise ships. The protocol drew on the normal practice of cruise ship operators, who have a strong commercial incentive to minimise infectious disease outbreaks onboard, and clarified the responsibilities of border agencies and states and territories in responding to pandemic influenza on cruise ships.
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Table 4.2 Identification of unwell passengers by method of detection, 28 April 2009 to 1 June 2009
| Method of identifying ill passengers | Number of passengers | Percentage |
|---|---|---|
| Health Declaration Card | 12,958 | 84 |
| Airline notification | 2,011 | 13 |
| Other | 408 | 2 |
| Thermal scanner | 80 | 0 |
| Total | 15,457 | 100 |
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15 Exit screening of travellers is a required capacity under IHR 2005; but was not employed in Australia’s pandemic response.
16 Of the 56 countries that provided information to the WHO on what border measures were used, 88 per cent used thermal scanners WHO, (2010), ‘Public health measures taken at international borders during early stages of pandemic influenza A (H1N1) 2009: preliminary results’, Weekly Epidemiological Record 85(21): 186–195.
17 An average of 28,685 arrived daily for the period 1 May 2009 to 1 June 2009.
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