5.3 Key Issues and Lessons Identified

By the time community-level transmission was established in Australia, public health officials had recognised the limitation of the pandemic phases outlined in the AHMPPI to guide the response through a pandemic of moderate severity. The rapid development of a new phase is evidence of the flexibility of Australia’s public health leaders to respond to a crisis. It also provides an example of the strong commitment from all public health officials to support teamwork across governments and a consistent national response.

5.3.1 Development and implementation of case definitions

An important lesson learned from 2009 is that the development and communication of case definitions can be challenging. A new process for the development of case definitions during a pandemic response needs to be explored. This could enable more robust definitions to be developed that avoid the need for frequent changes, which in 2009 led to confusion among some users. Consideration could be given to methods of collecting case data based on clinical diagnosis. The purpose of case definitions – whether screening, surveillance or clinical – also needs to be clearly described. The intersection between the development of case definitions for public health purposes and for clinical need should be better communicated. The initial extensive testing regime, which was intended to capture all potential cases for extensive laboratory testing in the early stages, created an apparent expectation that ongoing testing to confirm individuals’ infection status was desirable. This was at a time when more targeted testing for public health purposes was limiting the number of suspected cases that needed laboratory tests.

5.3.2 Infection control messages and advice

In a survey of more than 800 people across Australia, 99.4 per cent knew that “hand washing and using a tissue to cover your mouth when coughing are practical ways of reducing the spread of flu”.²² Approximately half of respondents reported they “paid more attention to covering coughs and sneezes” and had increased their own frequency of hand washing. In a vaccination survey, hygiene was the most reported strategy for protecting oneself and family from influenza,²³ with one third of people perceiving hand washing as the most important. This evidence demonstrates that the messages promoted by national, state and territory and local governments about the importance of hygiene made an impact on the community.

Developing multiple-sector tailored infection control advice was a drain on public health resources. It is worth considering whether the accepted infection control precautions used in the health sector can be used to develop generic infection control messages to cover a multitude of settings, emphasising the principles of infection control rather than specific actions and equipment.

There is a view that more consistent infection control advice for healthcare workers and GPs was needed early in the pandemic. Better formal engagement with state and territory infection control committees would be beneficial to establish an authoritative source when determining national advice.



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5.3.3 Antiviral medication

Although the use of antiviral medication was limited in 2009, antiviral medication remains an important protective measure for pandemic management and would need to be more widely used in a more severe pandemic. Antiviral medication was found to be life-saving for those who were more severely affected in hospitals, including ICUs. An area for future work would be to understand 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 Indigenous Australians and other vulnerable groups when no prophylaxis is provided generally for the well population. The planned provision of antiviral prophylaxis for healthcare workers was not implemented in 2009.

The medication is most effective if taken within the first 48 hours of the onset of illness. The current logistical system would have difficulties in ensuring extensive access to antiviral medication within the required time frames. There is a need to ensure timely access to antivirals for cases and contacts in the community, including a review of the policy for prescribing antivirals. The models which were identified in the pre-planning phase were not used in the pandemic response. Further work is needed to develop supporting documentation in this area.

5.3.4 Quarantine

The purpose of voluntary quarantine was not well understood by the community in 2009. Quarantine is inconvenient for individuals and difficult to enforce as a public health measure. The challenge is to communicate, facilitate and encourage the message to ‘stay away from others’ without invoking the concerns associated with the idea of ‘quarantine’. People who did not comply with voluntarily quarantine were identified as mostly being motivated by the financial losses that would be incurred from staying home for the seven-day quarantine period. Educating the community and building social expectations about what individuals can do after they have been exposed to the disease is important.

Policy and operational plans for managing people in quarantine had not been finalised, both at state/territory and national level, when the pandemic emerged. Accommodation for non-residents identified at the border and requested to quarantine themselves was an issue, as many hotels refused to provide accommodation to individuals under quarantine. The roles and responsibilities of all governments for the management of people in quarantine, both at home and in other accommodation, during a pandemic should be clarified. A set of nationally consistent principles could form the basis for jurisdictions to develop operating guidelines, including plans for accommodating potentially infected people in future pandemics and better systems to support people in quarantine. It is the view of some stakeholders that quarantine of contacts should only be undertaken for severe pandemics.

There were also reports that insufficient and conflicting information was provided to quarantined individuals. The HQSS was slow to be implemented, which resulted in late commencement of calls to individuals in quarantine and did not allow for the timely delivery of ‘home quarantine support packs’ from the National Medical Stockpile intended to support individuals in quarantine. The effectiveness of the HQSS needs further consideration.

5.3.5 School exclusions and closures

The disruptive nature of school closures is paramount. In 2009, school exclusions were far less disruptive than school closures. It is important that the severity of disease that warrants the level of disruption caused by school closures be incorporated in future plans to enable public health authorities to make informed recommendations. School closures in some areas had a substantial impact on the available health workforce, predominantly nurses.

Despite school closures being identified as a potential countermeasure in the AHMPPI, which was rehearsed in simulation exercises and discussed in public health settings, the suggestion to close schools appeared to surprise newcomers to the pandemic response, including other government departments.

There were also tensions with implementing the school exclusion policy, in particular sensitivities with identifying ‘areas of prevalence’ within Australia when jurisdictions were experiencing different stages of disease spread.

A body of evidence is available following the 2009 experience of school closures in Australia and internationally. This needs to be systematically reviewed to provide the evidence base for future policy in the AHMPPI. There is some evidence that school closures can be effective if implemented early, but there are considerable social costs associated with their implementation. Also, the behaviour of children during closure is key to minimising spread of infection within a community. Research shows that compliance beyond non-attendance at school was poor, for example, children continued to meet socially and at sporting fixtures, and ways of improving voluntary compliance should be explored. Any review of school closure policies should also include childcare centres, as it is known that pre–school-aged children are even greater transmitters of influenza virus than school-aged children, because in this age group the virus is shed for longer and hygiene is poor.



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5.3.6 Influenza services

The role of ‘flu clinics’ during pandemics of differing severity needs to be clearly defined. There was limited use of such clinics in 2009, given the moderate nature of the pandemic and the lesser need to reduce transmission. Whether such clinics can attain their objective of separating infectious patients in a severe pandemic is not known.

Flu clinic plans varied across jurisdictions, which caused confusion and was particularly problematic at borders. GPs reported being unclear about when, where and how clinics would operate; how they would be staffed; how to refer patients to them; and the interface of the clinics with general practice. GPs also expressed concerns about whether flu clinics were an appropriate model for triaging patients with pandemic influenza, as they duplicated the work of general practice. However, where GP services were unable to be accessed, including in non-metropolitan areas, hospital EDs were being attended instead. This limited the ability of EDs to maintain their core business. The flu clinic model would thus be useful in assisting EDs to maintain capacity.

In a communicable disease outbreak, indirect patient care may reduce the risk of transmission to GPs and staff, making telephone consultations prudent. The UK recognised that face-to-face assessment of each patient at the peak of a severe pandemic would not be feasible,²⁴ and developed a National Pandemic Flu Service to assess the clinical condition of callers. A process of telephone consultation during a pandemic, including how to remunerate GPs for time spent indirectly triaging and caring for patients, is worth further consideration in the Australian context.



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²² Eastwood, K, Durrheim, DN, Butler, M & Jones, A (2010), ‘Responses to Pandemic (H1N1) 2009, Australia’, Emerging Infectious Diseases, 16(8), 1211–1216.
²³ Miller, K & Tuffin, A (2010), ‘Pandemic (H1N1) 2009 (Swine Flu) Vaccine Campaign Evaluation’, report for the Department of Health and Ageing by GfKBlueMoon.
²⁴ Hine, Dame Deirdre. (July 2010), The 2009 Influenza Pandemic: An independent review of the UK response to the 2009 influenza pandemic, p. 96.