8.3 Key Issues and Lessons Identified

Australia’s NMS met the demands of the 2009 pandemic; however, the moderate nature of the pandemic led to limited demands on the NMS overall. Demands would be expected to be much higher in a severe pandemic.

8.3.1 Distribution arrangements

There was a strong collaborative working relationship between the DoHA and NMS logistics and product suppliers, built over time during the planning stage. Planned arrangements, including transport, for the distribution of NMS supplies from the Australian Government to jurisdictional receiving facilities generally were effective and enabled timely movement of consignments. Holding stock in various Australian Government storage facilities across Australia and pre-positioning them in jurisdictional warehouses was also effective in reducing distribution response time, particularly for the large volumes of PPE items. Tracking stocks for reporting to key stakeholders could be improved. Consideration should be given to predetermining data requirements.

There were some issues with ensuring appropriate storage at all sites. Delivery of PPE to border agencies at airports was challenging due to limited storage capacity, which resulted in frequent requests for small quantities. Delivery of medication requiring cold-chain storage was problematic for facilities in rural and remote locations, which sometimes affected the timeliness of delivery. This issue needs further consideration in planning.

The distribution mechanisms to move items from the jurisdictional receiving facilities to the front line were not well established. New systems were developed in some jurisdictions which provide lessons and models for the future. These include distribution of antiviral medication through community pharmacies and provision of stockpiled PPE through the AGPN, as occurred in Victoria.

Although there was significant awareness and agreement from jurisdictional policymakers on distribution arrangements, this was not always well communicated to the operational and logistics teams in the jurisdictions. The MOUs should be renewed to clarify and reinforce deployment and distribution arrangements.

8.3.2 Access policies

Some states and territories held more substantial stockpiles than others. While a clear principle of use of the NMS was that no jurisdiction would be disadvantaged because of its own stockpiling, there was a lack of clarity with respect to the policy regarding the timing of the transition from jurisdictional stockpiles to the national stockpile. Agreements between national and jurisdictional policymakers on the rationale, contents, allocation and release of stockpiled items were not well communicated. There was some discontent regarding eligibility, within the context that jurisdictions affected first were receiving supplies from the NMS and other jurisdictions were concerned about the ongoing availability of sufficient supplies. An area for further policy consideration is whether it would be desirable to develop a detailed allocation policy prior to another pandemic. This could be based on a per capita share, for example, or on an agreement to allocate as much as required where and when first needed during a pandemic given the inevitability that all jurisdictions would be affected, or on guiding principles clearly defining the goal of using NMS supplies.

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The 2009 pandemic experience has demonstrated that healthcare providers expect PPE resources to be readily available when required. Policy regarding responsibility for providing PPE to GPs was not understood at the start of the pandemic, which caused ill will among some GPs and inconsistencies across the country. This emerged as a significant issue. Whether it is feasible for general practices to procure and store their own PPE for a pandemic needs to be reconsidered. Such private purchase and storage seems to have been limited. If GPs are not able to provide their own PPE, the efficient use of government resources comes into consideration. The place of assessment of influenza patients (for example, at GP practices or at ‘flu clinics’) is crucial to consideration of the magnitude and delivery of the stockpile items, and affects who requires PPE and who is responsible for the provision of that PPE (whether the practitioner, the jurisdiction or the NMS). This issue needs substantial clarification and communication before another pandemic. For example, in a general practice, one P2 mask may be needed to protect a staff member assessing a single patient before the mask needs to be discarded, while in a flu clinic, one P2 mask may be used to protect a staff member assessing multiple patients. However, a counterpoint to this is that even if flu clinics are established, patients may continue to visit GPs, since within Australia’s normal health system individuals have a choice about whom to consult if they are unwell, so attendance at general practices may be unavoidable.

Another area for further policy consideration relates to the timing of termination of access to the NMS.

8.3.3 NMS contents

While the PanFlu VacPacks were considered useful, there were a number of issues that needed to be addressed during the response. The size of the packs developed for mass vaccination clinics was problematic for both storage and transport, and did not meet the needs of GPs. While a one-off transportation to rural Queensland and Tasmania via air freight was required to meet vaccination commencement deadlines, it was not possible to transport the packs containing alcohol hand rub by regional airlines to regional and remote areas. However, as items for PanFlu VacPacks are stored in bulk, creation of packs without alcohol rub was feasible and some PanFlu VacPacks were quickly modified to enable air transport to remote areas.

There were concerns raised about the quality of some of the items in the PanFlu VacPacks. The products included in the packs were not the same brand normally ordered by GPs, which added to the perceived inferiority of the products provided. In particular, concerns were raised that the sharps containers did not meet Australian standards, that the needles were of poor quality, that the large gauge of the needle provided for drawing up vaccine from the multi-dose vials (MDVs) repeatedly piercing the bung could compromise the integrity of the bung. Other concerns included the presence of latex in the syringe plungers. There was no pre-planned strategy to rapidly supply alternative types of items while awaiting appropriate testing of materials. There is a need to engage with healthcare professionals to inform future specifications of certain stockpile items.

Some concerns have been raised regarding access to paediatric formulations of antiviral medication. Most supplies of oseltamivir paediatric suspension were deployed quickly due to the relatively high incidence of pandemic (H1N1) 2009 infection in children. To maintain paediatric formulations, paediatric oseltamivir capsules were purchased by the Australian Government; however, these were not available until towards the end of the pandemic peak. While some were deployed, most were held in reserve. Consideration of the types and amounts of paediatric antiviral formulations held in the NMS should be given further consideration. Also, containers of oseltamivir bulk powder were supplied to some jurisdictions to be made into solution by local hospital pharmacies (negating the need for cold-chain transportation). Due to regulatory requirements, the solution could not be distributed widely from the hospital pharmacies, which meant that rural pharmacies were required to fulfil this obligation. The Australian Government engaged a licensed pharmaceutical manufacturer to produce oseltamivir solution on a large scale so that bulk supplies could be delivered to state and territory health authorities. Implementation of this arrangement was delayed due to contractual and legal issues.

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Although P2 masks are an important piece of equipment for the protection of healthcare workers from respiratory infections, they require training to ensure correct use and fit. Their utility in a national stockpile should be reconsidered.

There is a need to review the need for pre-packaged equipment, in particular those for use by border staff, given that the prepared (pre-planned) packs were either not deployed or not available early enough during the response. A review would include consideration of the reasons that packs were not requested, whether pre-deployment would raise awareness, and the storage issues and potential costs involved. Also, the delivery of home quarantine support packs through the Home Quarantine Support System to individuals was not always timely and therefore their effectiveness as a resource was limited.