Aim and Scope

This review examines the Australian health sector’s response to pandemic (H1N1) 2009 (the 2009 pandemic) in the context of what was planned for and what occurred during the response. The review identifies what worked well, as well as issues that require further consideration to strengthen the planning, management and operational aspects of pandemic health response arrangements in Australia. The recommendations included in this review accordingly focus on the issues identified. This review does not attempt to resolve these issues; an implementation process will be developed jointly with state and territory health officials through the Australian Health Protection Committee (AHPC).

Methodology

Under the governance of the AHPC, the Office of Health Protection (OHP) within the Australian Government Department of Health and Ageing (DoHA) gathered and collated information and opinions from key stakeholders, including health committees, the clinical sector, Australian Government agencies and statutory bodies, and the private sector. The information was generally collected under the three broad headings of what worked well, what did not work well, and recommendations for improvement. The following broad topics were captured: governance structures, public health measures, border measures, hospital and laboratory capacity, surveillance systems, communications, the vaccination program, and the National Medical Stockpile (NMS). Issues identified through the information collection process inform the specific recommendations contained in this review.

Debriefing sessions were conducted in the form of workshops, teleconferences and external reports. Some agencies, committees, individual jurisdictions and industry organisations have provided outcomes from their own evaluation processes to inform this review. A list of key stakeholders consulted during the review process is included as Appendix A to this review. Formal feedback has been received from broader stakeholders, including critical infrastructure sector groups, indicating the desire for closer industry interaction with all levels of government. These issues are not covered in this review but are being worked through by means of other formal processes.

Emerging Threat

On 24 April 2009, the World Health Organization (WHO) notified the DoHA of outbreaks of an influenza-like illness in the United States and in Mexico, where in particular it appeared that a virus was causing high mortality in relatively young people. On 25 April 2009, on the advice of the Emergency Committee called under the rules of the International Health Regulations 2005, the Director-General of WHO declared this event a ‘public health emergency of international concern’. By the time WHO declared a pandemic on 11 June 2009, a total of 74 countries and territories, including Australia, had reported laboratory-confirmed infections2 of the new ‘pandemic (H1N1) 2009 influenza’ virus. Its sudden appearance and rapid international spread - it spread more in just six weeks than other pandemic viruses in six months3 – demanded an immediate and coordinated international and national health response.

Three major concerns emerged early which required prompt analysis and decision making. Firstly, the age demographic of those affected was typical of pandemics and different from the pattern typically seen in seasonal influenza (that is, the virus was causing severe illness and death in young people). Secondly, the virus was successfully spreading during a time of year outside the normal influenza season in the northern hemisphere. Finally, there were early indications of severe outcomes in Mexico and there were high numbers of admissions to intensive care units (ICUs) in developing countries. While there were some signs indicating that the illness was moderate overall, Australia could not be complacent about the impact of the disease around the world and in Australia. This was a new virus, a new problem, and therefore initially, before we knew the clinical picture, we did not know what this new virus would do.

Australian governments had spent considerable time since 1999 developing and regularly updating a series of connected pandemic action plans – health and whole-of-government; national and jurisdictional – to guide a coordinated response to an influenza pandemic. These plans had also been exercised.

The Australian response to the 2009 pandemic was guided by the Australian Health Management Plan for Pandemic Influenza 2008 (AHMPPI), which provides the health sector with a nationally agreed strategic framework to guide preparedness and response activities for an influenza pandemic. This plan is always activated and Australia had been in the pandemic ALERT phase since 2005 with the emergence of the avian H5N1 influenza infection in humans. The AHMPPI is supported by the National Action Plan for Human Influenza Pandemic (NAP) that has been in place since 2006.

In this context, Australia was in a good position to respond rapidly to the emerging threat, and moved quickly to implement an appropriate health response.

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Australia’s Response

The Australian national response moved to the pandemic DELAY phase on 28 April 2009, which continued for three weeks to 21 May 2009. Consistent with the main objective of delaying entry of the pandemic (H1N1) 2009 influenza virus into Australia, the focus of the DELAY phase in 2009 was the early identification and management of cases and contacts. During this period Australia declared the new virus a quarantinable disease under the Quarantine Act 1908; implemented border measures, such as thermal scanners and Health Declaration Cards (HDC), from 29 April 2009 at Australia’s international airports; commenced intensive case and contact management activities, including providing antiviral medication for both treatment and prevention (prophylaxis); provided personal protective equipment from the NMS to GPs to maintain an important workforce; and began issuing public messages to advise people with influenza-like illness to remain at home and maintain good hygiene practices to help reduce the spread of the disease.

WHO moved to pandemic phase 5 (human-to-human spread of the virus into at least two countries in one WHO region) on 29 April 2009. The first case to arrive in Australia was identified on 8 May 2009. Australia moved to the pandemic CONTAIN phase on 22 May 2009 when it was clear there were clusters of cases indicating community transmission occurring within Australia. The rationale for the CONTAIN phase is to reduce the spread in the community, limit the number of cases and support the health system while waiting for a pandemic vaccine to be available. Individuals most vulnerable to poor outcomes were identified early as including pregnant women, those with underlying medical conditions, and Aboriginal and Torres Strait Islander peoples. Individuals with rapidly deteriorating influenza with respiratory distress were specifically targeted nationally for early antiviral treatment and for careful follow-up by primary-care physicians and hospitals.

On 3 June 2009, Victoria moved to a MODIFIED SUSTAIN phase as 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, outlined in the AHMPPI, was viewed as disproportionate to the moderate severity of the disease.

WHO declared a pandemic (pandemic phase 6) on 11 June 2009. By this time WHO described pandemic (H1N1) 2009 as being mild in most but severe in some and moderate overall. Australia developed and implemented a new pandemic phase known as the PROTECT phase on 17 June 2009, in recognition of the fact that while the pandemic influenza virus was mild in most people, with most of those infected making a rapid and full recovery, a greater focus was needed on treating and caring for those people more vulnerable to severe outcomes. The PROTECT phase included the rollout of the largest vaccination program in Australia, the national Pandemic (H1N1) Vaccination Program, on 30 September 2009 (see Figure 1).

In addition to the need for a new annex to define the PROTECT phase, an appendix to this specific to Aboriginal and Torres Strait Islander people was needed to meet the challenges of the 2009 pandemic. This appendix was developed in conjunction with the Indigenous health sector. It clearly outlined issues specific to Indigenous Australians who had underlying medical conditions or who lived in remote communities.

Epidemiology

Following the April 2009 emergence of a novel strain of influenza overseas, Australia’s first case of confirmed pandemic (H1N1) 2009 was identified in May 2009. By the end of 2009, there had been more than 37,000 laboratory-confirmed cases, including almost 5000 hospitalisations and nearly 200 deaths.

At national level, the main wave of the pandemic lasted about 18 weeks, from mid-May to late September, peaking at the end of July 2009. There was substantial variation in the incidence rates and peak times of the epidemic among jurisdictions.

Although laboratory testing of people presenting with influenza-like illness to primary care varied throughout the phases of the pandemic, it is clear that the pandemic affected a much younger age group than usually seen in seasonal influenza patterns. The age distribution of pandemic notifications tended to occur in people aged less than 55 years, with substantially higher rates observed in people aged less than 30 years, compared to older age groups, whereas seasonal influenza notifications tend to occur mostly in the very young and elderly.

The median age of notifications increased as the severity of the disease increased, from 21 years for all laboratory-confirmed cases to 31 years for hospitalised cases, 44 years for ICU cases and 53 years for deaths.

The pandemic had a substantial impact on hospitals and ICUs, particularly during July 2009, when there was a peak in pandemic-associated hospitalisations of more than 600 people in one week.

Hospitalisations represented 13 per cent of all laboratory-confirmed cases, equating to a crude rate of 22.8 per 100,000 population. The highest rate of hospitalisations was in children aged less than 5 years, with the median age of cases being 31 years. Indigenous Australians represented
20 per cent of all hospitalisations where Indigenous status was recorded, which was in 81 per cent of cases. Pregnant and postpartum women were also severely affected, with 287 hospitalised.

Fourteen per cent of hospitalised cases required admission to ICUs, with almost 75 per cent of these admissions belonging to vulnerable groups, including pregnant women, Indigenous Australians and/or people having an underlying co-morbidity, including cancer, diabetes mellitus and/or morbid obesity. Treatment with extra-corporeal membrane oxygenation (ECMO), a highly specialised treatment, is estimated to have been required in more than 8 per cent of patients admitted to ICU, with a quarter of these aged 35 to 39 years.

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During 2009 there were 191 pandemic (H1N1) 2009–related deaths reported, giving a crude population mortality rate of 0.9 per 100,000 population. Of these deaths, 13 per cent were recorded as being Indigenous Australians, and overall almost two-thirds were recorded as being people from vulnerable populations or with underlying co-morbidities. The median age of all people who died with proven pandemic infection in 2009 was 53 years, which is considerably lower compared with 83 years in previous influenza seasons.

Timeline of Events
17 April 2009
  • A small number of human cases of a novel influenza virus (swine influenza A/H1N1) are reported by the US government in mid–late April 2009.
  • At the same time, the Mexican government reports three incidents of influenza-like illness (ILI) throughout the country.
24 April 2009
  • The World Health Organization (WHO) announces an outbreak of novel H1N1 human influenza virus in Mexico and the US.
25 April 2009
  • WHO declares a “public health emergency of international concern” under the International Health Regulations 2005.
  • The Australian Government Department of Health and Ageing (DoHA) activates its National Incident Room.
  • The Australian Health Protection Committee (AHPC) first meets.
27 April 2009
  • WHO moves to pandemic phase 4 – sustained human-to-human transmission of a pandemic potential virus.
  • In-flight announcements commence on all aircraft coming to Australia from countries in North, Central and South America.
28 April 2009
  • Australia moves from the standing pandemic phase ALERT to pandemic phase DELAY – novel virus has emerged overseas but not arrived in Australia.
  • The National Pandemic Emergency Committee (NPEC) first meets.
  • ‘Human swine influenza of pandemic potential’ is declared a quarantinable disease in Australia under the Quarantine Act 1908.
29 April 2009
  • WHO moves to pandemic phase 5 – sustained community transmission in two or more countries in one WHO region.
  • Staged implementation of border measures commences in Australia at international airports as planned under phase DELAY, including in-flight announcements on all incoming aircraft, thermal scanners, border nurses.
30 April 2009
  • The Australian Government Minister for Health and Ageing declares the implementation of emergency quarantine measures under subsection 12A(1) of the Quarantine Act 1908.
6 May 2009
  • Presentation of an Australian Health Declaration Card (HDC) at Customs becomes mandatory.
8 May 2009
  • Australia’s first pandemic (H1N1) 2009 influenza case is reported in Queensland. The case is identified at the border through HDC.
Mid–late May 2009
  • Discussions are held with vaccine manufacturers regarding availability and production time frames.
22 May 2009
  • Australia moves from DELAY to CONTAIN phase.
26 May 2009
  • The Home Quarantine Support System is activated and remains in operation until 2 June 2009.
27 May 2009
  • A national television, radio and print communication campaign commences to inform Australians of the government’s actions to reduce the spread of ‘swine flu’, including implementing measures at Australia’s borders, raising awareness of the symptoms of influenza and educating people about the measures they can take to reduce the spread of influenza.
28 May 2009
  • The Australian Government announces that it will place an order for vaccine from CSL Limited for “about 10 million people”.
  • The Chief Medical Officer approves the first release of antivirals from the National Medical Stockpile.
29 May 2009
  • The National Health and Medical Research Council (NHMRC), principal funder of public health and medical research in Australia, calls for public health and medical research proposals.
1 June 2009
  • Pandemic (H1N1) 2009 influenza now in all states and territories of Australia.
3 June 2009
  • Victoria moves to MODIFIED SUSTAIN.
5 June 2009
  • Discussions commence on vaccine allocation and priority groups.
11 June 2009
  • WHO moves to pandemic phase 6 – start of new pandemic, sustained community transmission in two or more WHO regions.
17 June 2009
  • Australia moves to pandemic phase PROTECT – recognition that pandemic virus is mild in most cases but severe in some and moderate overall.
19 June 2009
  • First Australian death from pandemic influenza.
22 June 2009
  • Border measures are wound back following the move to the PROTECT phase.
8 July 2009
  • Funding is provided to 41 Australian medical research projects. Research commissioned includes understanding why some people get more severe influenza; strategies for containment in rural, remote and Indigenous communities; improving detection of the virus; and the best strategies for antiviral use.
22 July 2009
  • First dose is administered in CSL Limited’s Australian adult clinical trial.
3 August 2009
  • First dose is administered in CSL Limited’s Australian children clinical trial.
7 August 2009
  • Cruise ship protocol developed.
31 August 2009
  • Pre-positioning of vaccine into states and territories commences.
3 September 2009
  • First-dose adult clinical trial report delivered by CSL Limited.
10 September 2009
  • Clarification is obtained that only one dose of vaccine will be required for people over 10 years of age.
18 September 2009
  • The Therapeutic Goods Administration (TGA) approves registration of the vaccine for use in people 10 years and older.
  • The Australian Government Minister for Health and Ageing announces that the national Pandemic (H1N1) Vaccination Program will commence on 30 September 2009.
  • The Prime Minister and the Minister for Health and Ageing announce that Australia will commit up to 10 per cent of its vaccine to WHO for use in developing countries in our region.
  • The Australian Technical Advisory Group on Immunisation (ATAGI) endorses guidelines for the administration of the vaccine from multi-dose vials, developed in consultation with the Royal Australian College of General Practitioners (RACGP).
24 September 2009
  • Delivery of the vaccine and associated materials to immunisation providers commences in all Australian states and territories.
  • ATAGI issues a statement on the use of multi-dose vials in vaccination programs globally and in Australia.
30 September 2009
  • The Pandemic (H1N1) Vaccination Program commences.
  • A second-round public communication campaign commences through radio, television and newspapers to advertise the free vaccination program for people 10 years and over.
8 October 2009
  • ATAGI issues a statement of advice regarding influenza, influenza vaccines and Guillain-Barré Syndrome.
9 October 2009
  • ATAGI issues a statement of guidance on the use of latex-containing one millilitre syringes from pandemic vaccination packs.
October 2009
  • National serosurveillance study commences to provide a more accurate assessment of the overall infection rate of pandemic (H1N1) 2009 influenza in the community, including people who may have had the infection without showing symptoms, as well as the impact of the vaccination program.
19 October 2009
  • Australian children clinical trial report delivered by CSL Limited.
19 November 2009
  • ATAGI releases a statement on the use of seasonal vaccine as second dose in children.
3 December 2009
  • TGA approves registration of vaccine for use in children aged six months to under ten years.
4 December 2009
  • Vaccination program for children aged six months to under ten years commences.
  • A third-round public communication campaign commences through national print media promoting the pandemic vaccine for children and encouraging parents to immunise their children.
9 December 2009
  • CSL Limited commences distribution of Panvax® Junior pre-filled syringes to immunisation providers for use in children aged six months to under three years.
22 December 2009
  • ATAGI issues a statement on the recommended clinical protocol for administration of pandemic (H1N1) 2009 influenza vaccine from multi-dose vials for children aged six months to under three years, and for all people over three years of age.
30 January 2010
  • Production of all 21 million doses of the vaccine completed and available for use.
March 2010
  • A fourth-round public communication campaign, ‘Facts about swine flu’, commences through national radio and print media to promote the vaccination program. The campaign demonstrates that this is no ordinary flu and that it affects young, healthy people.
10 August 2010
  • WHO announces that the world is no longer in phase 6 of influenza alert and is now moving into a post-pandemic period.
26 August 2010
  • The shelf life of Panvax® Junior in pre-filled syringes is reduced from 12 months to six months, due to a decline in potency.
1 December 2010
  • Australia moves to pandemic ALERT phase.
31 December 2010
  • Australia’s national Pandemic (H1N1) Vaccination Program is concluded.

Figure 1: H1N1 Epicurve Timeline and Key Decision Points in 2009
April 2009May 2009June 2009July 2009August 2009September 2009October 2009November 2009December 2009
24 April
WHO announced an outbreak of novel H1N1 human influenza virus in Mexico and the USA

25 April
WHO declared public health emergency of international concern

28 April
Australia declares pandemic (H1N1) 2009 a quarantineable disease under the Quarantine Act 1908

29 April
Border measures implementation commenced
8 May
Australia’s First H1N1 case reported

Mid May
Discussion with vaccine manufacturers commenced

28 May
Announcement that Australia would place an order for pandemic vaccine with CSL Limited
1 June
Reporting by ANZICS of all influenza A ICU admissions commenced

19 June
First death in Australia attributed to H1N1
6 July
Peak of ICU admissions in Victoria

22 July
Clinical trial of CSL vaccine for adults commenced in Australia

27 July
Peak of ICU admissions in New South Wales
3 August
Clinical trial of CSL vaccine for children commenced in Australia

10 August
Peak of ICU admissions in Queensland

31 August
ANZICS data for three months shows a 10-fold increase compared with 2008 data
3 September
First dose adult clinical trial report delivered by CSL Limited

10 September
Confirmation that only one dose of vaccine would be required for Australians 10 years of age and older

18 September
TGA approved the vaccine for registration for use in children 10 years and older and adults

30 September
Pandemic (H1N1) Vaccination Program commenced for Australians 10 years and older
National serosurveillance study commencedLate November
Preliminary results of clinical trial for children delivered by CSL Limited
3 December
TGA approved the registration of the vaccine for use in children aged 6 months to under 10 years

4 December
Vaccination of children in Australia of children aged 3 months to under 10 years commenced

Figure 1: H1N1 Epicurve Timeline and Key Decision Points in 2009

Description of Figure 1: H1N1 Epicurve Timeline and Key Decision Points in 2009

This graph represents the trend in the number of laboratory-confirmed notifications of pandemic (H1N1) influenza 2009 in Australia between April and December 2009. On the horizontal axis is the date by month (from April to December 2009) and on the vertical axis is the trend of the average number of notifications per day (from 0 to 900). The graph also shows the corresponding World Health Organization (W.H.O.) pandemic phases and the Australian pandemic phases.

There are a total of 16 information points on the graph. These mark the dates of significant events, announcements and key decision points. These points are listed below as they appear from left to right on the graph. Changes in the trend-line are also listed in order.
Point 1: 27 April 2009, the W.H.O. pandemic phase changed from 3 to 4.
Point 2: 28 April 2009, the Australian pandemic phase changed from ‘Alert’ to ‘Delay’.
Point 3: 29 April 2009, the W.H.O. pandemic phase changed from 4 to 5.
Point 4: 8 May 2009, the first case of pandemic (H1N1) influenza 2009 in Australia.
The graph trend-line starts to increase from the baseline in mid May 2009.
Point 5: 22 May, 2009, Australia changed from pandemic phase ‘Delay’ to ‘Contain’.
There is a small peak of just under 150 notifications in late May 2009.
Point 6: 3 June 2009, Victoria announced that it will move to phase ‘Modified sustain’ due to the number of cases identified in that jurisdiction.
The graph declines from the peak in late May to approximately 50 notifications in mid-June, then begins to increase steadily.
Point 7: 11 June 2009, W.H.O. declared the H1N1 virus a pandemic and therefore changed the pandemic phase from 5 to 6.
Point 8, 17 June 2009, Australia moved from phase ‘Contain’ to ‘Protect’.
Point 9: 19 June 2009, Australia reported its first death from the pandemic virus.
A sharp rise in the trend-line begins in late June 2009.
Point 10: 6 July 2009, Victoria saw its peak in the number of I.C.U. admissions.
Point 11: 22 July 2009, the clinical trial of CSL H1N1 vaccine for adults commenced in Australia.
The graph peaks at approximately 900 notifications in mid–late July 2009 and then declines as sharply as it rose.
Point 12: 27 July 2009, New South Wales saw its peak in the number of I.C.U. admissions.
Point 13: 3 August 2009, the clinical trial of CSL H1N1 vaccine for children commenced in Australia.
Point 14: 10 August 2009, Queensland announced its peak I.C.U. admissions.
Point 15: 30 September 2009, Australia’s national Pandemic (H1N1) Influenza 2009 Vaccine Program commenced for Australians aged 10 years and older.
The graph continues to decline and flattens out in October 2009.
Point 16: 4 December 2009, the vaccination program commenced for children from 6 months to under 10 years.

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2. World Health Organization (2010), ‘What is the pandemic (H1N1) 2009 virus?’, available from www.who.int/csr/disease/swineflu/frequently_asked_questions/about_disease/en.
3. World Health Organization (2011), ‘Pandemic (H1N1) 2009’, available from www.who.int/csr/disease/swineflu/en.


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