The epidemic emerges overseas
The influenza pandemic first emerged in April 2009, with a report of large numbers of young adults with serious respiratory illness in Mexico, and almost simultaneous identification of a new swine-origin influenza virus circulating in both Mexico and the USA.1 Initial reports of deaths were above 100, and the World Health Organisation (WHO) first announced a 'public health emergency of international concern', and later declared a full blown pandemic on 11 June 2009 after the disease had spread globally.2,3
If one could have chosen a country in which to survive a pandemic, Australia surely would have been it. As an island continent with defined borders, a developed world health system (including specialist public health and laboratory capacity), current and exercised pandemic plans, existing stockpiles of antiviral medications and protective equipment, and local capacity to mass produce a vaccine quickly, Australia should have performed well. So how did it all turn out?
Was the level of planning adequate?
Pandemic planning had been stimulated by events in the Asia- Pacific region, including the emergence of SARS (in 2003) and avian (H5N1) influenza (2004 onwards), and arrangements had been tested in large-scale pandemic exercises in 2006 (Exercise Cumpston) and 2008 (Exercise Sustain). National planning documents included an Australian Health Management Plan for Pandemic Influenza4 (AHMPPI, published in 2005 and updated in 2006 and 2008), and a whole-of-government National Action Plan for Human Influenza Pandemic5 (NAP, published in 2006 and updated in 2009), which included detailed pandemic governance arrangements.
Several national committees were key to governance: the Australian Health Ministers' Conference; the Australian Health Protection Committee (AHPC), which includes Chief Health Officers from all States, Territories and the Commonwealth; and the National Pandemic Emergency Committee (NPEC), which includes representatives from first ministers' departments (Prime Minister, Premiers and Chief Ministers).
How well was the initial response coordinated in Australia?
Both the AHMPPI and the NAP were the result of extensive and collaborative national effort from all levels of government and multiple other stakeholders over several years. The AHMPPI described several discrete response phases (Table 1), with a list of key questions and decision points in the various phases. Whilst lessons were learnt from Exercise Cumpston, it was recognised that the governance and communication (public and interjurisdictional) mechanisms laid down for a complex emergency, within a complex Federal system, could only be fully tested in an actual pandemic.
The DELAY phase was declared almost immediately in Australia (28 April 2009). In the subsequent weeks, between emergence of the disease in North America and the first case in Australia, the Commonwealth Government exercised its clear responsibilities for quarantine and border measures and prepared for expected use of the National Medicines Stockpile. It also ordered potentially enough vaccine from the pharmaceutical company CSL to vaccinate every Australian, anticipating that this would be ready within 3-6 months. Border control measures were instituted at international airports, including positive pratique of incoming aircraft, health declaration cards for passengers and crew, and health screening by thermal scanners and border nurses. The implementation of such measures was dependent on State health department capacity and workforce, as State employees act as agents for the Commonwealth for human quarantine, with the State providing the nurses to work at the airports, and the Commonwealth undertaking to reimburse this cost.
There was a flurry of policy work over the first few weeks, entailing almost daily teleconferences, which utilised the national committee structure, including key expert groups such as the Communicable Diseases Network Australia (CDNA) and the Public Health Laboratory Network, both subcommittees of AHPC. …