Download Key Recommendations

Review of the Western
Australian Health Sector
Response to Pandemic
(H1N1) 2009: Key
Recommendations
Public Health and Clinical Services
Division
September 2012
Background
In March and April 2009, a novel strain of
In Australia, national and state pandemic
influenza virus, pandemic influenza A/H1N1
planning was accelerated following the
2009 (abbreviated to pH1N1 in this
emergence of severe acute respiratory
document), emerged in Mexico and the
syndrome (SARS) in 2003 and reemergence
USA1. On 25 April 2009, the World Health
of avian (H5N1) influenza in humans from
Organization (WHO) publicised concern
2004 onwards.4 Although the plans were
about the pandemic potential of this virus
written to address a range of pandemic
and, on 27 April, it declared a “public health
severities, the emphasis was on preparing
emergency of international concern”. The
for a severe pandemic similar in scope to
situation evolved quickly and, on 11 June
the 1918 Spanish influenza pandemic. Key
2009, the WHO declared it to be a
planning initiatives included the
pandemic.2
development of state and national health
The virus caused a wide spectrum of illness
around the world. In most patients, the
H1N1 pandemic 2009 was mild. The illness
was more serious in certain population
groups, such as pregnant women, people
with morbid obesity, Aboriginal people and
sector and whole-of-government (WoG)
pandemic plans, the establishment of the
National Medical Stockpile (NMS) of antiviral
agents and personal protective equipment
(PPE), and enhanced surveillance
arrangements.
those with chronic underlying disease.
The national pandemic plan was the
Despite public health control measures, the
Australian Health Management Plan for
virus spread rapidly due largely to a lack of
Pandemic Influenza 2008 (AHMPPI).
immunity within the population2. The fatality
The AHMPPI outlined six phases of
rate of cases infected with the pandemic
pandemic: ALERT, DELAY, CONTAIN,
virus was not higher than that of seasonal
SUSTAIN, CONTROL and RECOVER.
influenza H1N1 virus, however, it did lead to
The DELAY Phase was activated from 28
a higher rate of critical illness in younger
April to 21 May 2009, the CONTAIN Phase
age groups. Australia had 37,127 confirmed
from 22 May to 21 June 2009, and the
cases of pH1N1 by 6 November 2009, with
PROTECT Phase from 17 June 2009 until
189 confirmed deaths3.
1 December 2010.2 The PROTECT Phase,
not described in the original AHMPPI, was
1
developed during the pandemic when it

Non-health sector Government agencies,
became clear that the SUSTAIN and
including the Department of Education,
CONTROL phases were inappropriate for
WA Police, Fire and Emergency Services
the pH1N1 pandemic. The pandemic plan
Authority, Department of Premier and
for the Western Australian health sector is
Cabinet, various utility providers
the Western Australian Health Management
(Western Power, Water Corporation),
Plan for Pandemic Influenza (WAHMPPI),
Tourism WA, Corrective Services and
which describes a graduated response plan,
Department of Agriculture.
in line with the AHMPPI.
Development of this
document
Stakeholders in the Western Australian
response provided feedback during
Positive legacies
During the H1N1 pandemic, a number of
positive initiatives were developed and will
be incorporated in future plans.
debriefing sessions in 2010, which has been
incorporated into this report. Debriefs were

conducted with the following groups:


Protective Equipment (PPE) starter
packs. WA was the only state to
Area Health Service Executives and the
proactively supply GPs with PPE starter
Hospital Health Coordinators Group
packs whilst access to the National
(HHCG).
Medical Stockpile (NMS) was being
Key health partners, including St John
negotiated. This initiative was welcomed
Ambulance, Royal Flying Doctor Service,
by the GP sector.
Aboriginal Medical Service, community

General Practitioner (GP) Personal

Online PPE ordering. The Disaster
care groups and Residential Aged Care
Preparedness and Management Unit
providers.
(DPMU) developed a PPE online
Public Health Division (PHD).
ordering tool for use by GPs and
hospitals. This allowed for easy and

Communicable Disease Control
auditable ordering of stock 24 hours per
Directorate (CDCD).
day.

Intensive care units (ICU).

WA Country Health Service (WACHS).

ICU dashboard. An online real time
tracking system was developed for ICUs
2
to track the activity of pH1N1 patients
and document their clinical status.

Warehouse. The DPMU warehouse was
critical in the logistics support of the
pandemic response. The warehouse was
used as a staging point for the NMS PPE
prior to its distribution to health agencies
across the state and was used as the site
for packing and distributing the GP PPE
starter packs.

Utilisation of the Emergency
Department Information System
(EDIS) for surveillance. The ‘InfluenzaLike-Illness (ILI) Data Extract’ was
created by modifying the existing EDIS
extracts. This enabled near real-time
data to be collected on patients
presenting to ED with influenza-like
symptoms.

Communications between health and
education sectors. The communication
process between a single point of contact
at the Department of Health and
government and non-government
schools enabled the different education
systems to align their messages and
actions. Key messages developed for
schools were useful in guiding actions.
3
Key recommendations
1. Governance
2. Policies, plans and guidelines
The State Human Epidemic Coordinator
2.1 General
(SHEC) was expected to meet various state
A large number of policies and guidelines
and Commonwealth requirements during the
were produced during the pandemic and
pandemic but was unable to fully exercise
some lacked integration across health, or
the authority vested in him by WESTPLAN
were conflicting.
Human Epidemic due to the internal line
management structure within WA Health.
This was exacerbated by the SHEC not
being a member of the Australian Health
Protection Committee (AHPC), which was
the main Australian decision-making body
for health.
Recommendation 1a
The development of Commonwealth policies
and guidelines relating to the pandemic
were often delayed and some conflicted with
local guidelines and capabilities. Agencies
found it difficult to keep up with the
information from the Commonwealth, as it
changed frequently.
The emphasis in the AHMPPI was on
Reassign the role of SHEC to the Executive
preparing for, and responding to, a severe
Director of the Public Health and Clinical
pandemic and assumed an emerging
Services Division (PHCSD) to ensure the
pandemic would move sequentially through
role has appropriate authority.
a number of phases across the country.
Recommendation 1b
Review WESTPLAN Human Epidemic by
September 2013, including the clarification
of roles and responsibilities of key positions
within WA Health.
The phases lacked the flexibility to
accommodate outbreaks across different
jurisdictions at different times.
There were delays in the release of some
plans, such as the Western Australian
Health Management Plan for Pandemic
Recommendation 1c
Influenza (WAHMPPI).
Reconvene the State Human Epidemic
Recommendation 2.1a
Emergency Management Committee to
provide oversight to the implementation of
the recommendations.
Maintain a central repository of existing
pandemic policies, plans and guidelines
developed by the Commonwealth
4
Department of Health and Ageing, the WA
Health developed the Surveillance and
Department of Health, and WA health
Management Plan for H1N1 09 Influenza
services.
(Human Swine Influenza) in Aboriginal
Recommendation 2.1b
Communities in Western Australia in the
early stages of the pandemic.
Advocate at the national level for a rigorous
evaluation of the effectiveness of public
Recommendation 2.2a
health strategies implemented during the
Review and revise WAHMPPI, following
pandemic for incorporation into the revised
revision of the AHMPPI by the
Australian Health Management Plan for
Commonwealth.
Pandemic Influenza 2008 (AHMPPI).
Recommendation 2.2b
Review the Surveillance and Management
2.2 WA Health plans and policies
Plan for H1N1 09 Influenza (Human Swine
Regional areas, in particular, found the large
Influenza) in Aboriginal Communities in
volume of information difficult to process
Western Australia, as an annex in the
and disseminate, and general practitioners
WAHMPPI, with a view to reconfiguring this
(GPs) felt overburdened with information.
into a remote area pandemic response plan.
Communication between Communicable
Recommendation 2.2c
Disease Control Directorate (CDCD), the
Disaster Preparedness and Management
Unit (DPMU) and service providers was
Incorporate a Communications Plan into
WESTPLAN Human Epidemic.
hindered by databases of key contacts
(including the GPs and Residential Aged
Care Facilities databases) not being up-to-
2.3 Whole-of-Government (WOG)
plans and policies
date or accessible. Communication between
Prior to the pandemic in 2009, WA Health
hospital executives and Departmental staff
and WoG planning was often disconnected.
was only partially effective, due to
This was mainly due to competing priorities
competing priorities.
and the varying level of importance placed
on pandemic planning by differing agencies.
As pandemic planning for Aboriginal
communities was incomplete at the time of
commencement of the pandemic, WA
5
Recommendation 2.3a
Recommendation 2.4a
Improve cross organisational relationships
Review the ICU surge plan incorporating
between WA Health, other government
site-specific requirements (paediatrics
agencies (particularly the Department of
versus adults) including an audit of ICU
Education) and the private sector to finalise
equipment, such as the number and type of
planning in the areas of public information
ventilators (fixed and transport) and number
and response.
and position of ECMO machines.
Recommendation 2.4b
2.4 Clinical services
Develop a mass vaccination framework for
There were increases to the clinical
WA.
workload and overall demand on health
services during the pandemic.
The number of critically ill patients infected
with pH1N1 placed a disproportionate
burden on intensive care units (ICUs).
There was an increased demand for
extracorporeal membrane oxygenation
(ECMO)
machines. ICU policies and
practices were not consistent between
hospitals.
3. Information systems
There was a high demand for data of
various types during the pandemic and
some existing data systems were not robust
enough to meet demand. In some instances,
routine data collection was not available
electronically, necessitating manual data
collection - particularly in ICUs. Unlike EDs,
most ICUs did not have real-time software
Mass vaccination clinics were established
applications to track patient activity. During
at several sites across metropolitan Perth
the pH1N1 response, an ICU dashboard
in the early stages of the pH1N1 vaccination
was created, allowing ICU staff to track and
campaign. These clinics were an adjunct to
monitor pH1N1-related cases and the
the main delivery method of the campaign,
Department of Health to extract real-time
which was via general practices. Although
ICU data.
the logistics burden of conducting these
mass vaccination clinics was considerable,
the uptake of vaccination by the public was
Some hospital data collection systems were
not high.
not adequately linked, for example, EDIS
was not effectively interfaced with ‘TOPAS’
6
for surveillance purposes. It should be noted
that the ED surveillance figures were not an
accurate reflection of how busy EDs were in
that the total number of patients presenting
to ED was not an indicator of the workload
of isolating and quarantining individuals.
Recommendation 3b
WA Health to implement the web-based
emergency operations centre (WebEOC)
crisis information management system,
including modules able to support the public
health emergency response.
Requests for the same type of data from
different stakeholders created inefficiencies.
For example, data was requested from ICUs
by both the Australian and New Zealand
Intensive Care Society and WA Health.
The demand on infection prevention and
control teams to provide data reduced their
ability to conduct normal business.
4. Logistics
Access to PPE was limited by the lack of
adequate warehousing facilities and just in
time supply levels within WA Health. In
particular, regional areas had minimal PPE
stock available and experienced delays in
restocking. Delays in the release of PPE
items from the National Medical Stockpile
(NMS), in turn, delayed WA Health’s access
Some GPs found it difficult to provide
antiviral and PPE data reports within the
required time-frame and weekly reporting
requirement of antiviral stock by regional
pharmacists was demanding.
Obtaining data from private hospitals was
difficult, as they are not routinely linked to
the public sector’s surveillance systems.
Recommendation 3a
to PPE. There was a general lack of
consultation with logistics experts and
announcements about the distribution of
PPE were often premature.
Limited access to intravenous formulations
of anti-influenza agents delayed its use for
critically ill patients.
Recommendation 4a
Review the current and future requirements
for medications and personal protective
Identify surveillance systems established
equipment in the State Medical Stockpile.
during the pandemic that should be retained
and/or enhanced, such as the EDIS
Influenza-Like-Illness data extract and the
ICU dashboard.
7
Recommendation 4b
Develop a logistics plan as a subplan of
WAHMPPI for the rapid distribution of
pharmaceuticals and PPE, including to
remote areas.
Recommendation 5b
Infection control guidelines should
recommend appropriate fit testing regimens
and recommend appropriate mask selection
based on the requirements of the majority of
staff (i.e. face sizes and shapes, beards
5. Personnel
etc).
Due to the novel nature of the pandemic
virus and lack of reliable data, decision
makers did not accurately predict the impact
of the virus early in the pandemic, including
how it would affect staffing levels.
6. Laboratories
Laboratories had difficulties in coping with
the considerable surge in service demand
during the pandemic. These difficulties were
Some of the policies developed during the
exacerbated by uncertainty in the national
pandemic regarding management of staff
testing policies and differing laboratory
with influenza-like illness were unclear, such
requirements with changes in the pandemic
as guidance around staying away from the
phases.
workplace.
The turn-around time for laboratory results
High staff turn-over impacted business
was often lengthy. In some instances, the
continuity and made it difficult to maintain
logistics of specimen transfer was difficult,
appropriate training in PPE. There was
particularly from regional areas, and this had
difficulty in the provision of pre-incident and
a large impact on the specimen turn-around
intra-incident training in PPE.
time.
Recommendation 5a
Large volumes of samples from a number of
WA Health Industrial Relations (IR) to work
closely with other government departments
to review and address the broad IR issues
identified in the pandemic.
sources made it difficult for laboratories to
prioritise samples. The increased workload
fell on a small number of senior staff, which
quickly became unsustainable. The system
for informing results was inadequate, for
example; conveying results to patients who
had been tested for influenza in ED and
8
discharged before the results became
available.
Recommendation 6a
PathWest to develop a laboratory surge
management plan for large-scale infectious
disease emergencies.
9
References
1. Peiris YSM, Poona LLM, Guan Y. Emergence of a novel swine-origin influenza A virus
(S-OIV) H1N1 virus in humans. J Clin Virol. 2009; 45: 169–173.
2. Appuhamy R, Beard F, Phung H, Selvey C, Birrell F, Culleton T. The changing phases of
pandemic (H1N1) in Queensland: an overview of public health actions and epidemiology.
Med J Aust. 2010; 192(2): 94–97.
3. Kotsimbos T, Waterer G, Jenkins C, Kelly P, Cheng A, Hancox R, Holmes M, Wood-Baker
R, Bowler S, Irving L, Thompson P. Influenza A/H1N1_09: Australia and New Zealand’s
winter of discontent. Am J Respir Crit Care Med. 2010; 181: 300–306.
4. Weeramanthri TS, Robertson AG, Dowse GK, Effler PV, Leclercq MG, Burtenshaw JD,
Oldham SJ, Smith DW, Gatti KJ, Gladstones HM. Response to pandemic (H1N1) 2009
influenza in Australia - lessons from a State health department perspective. Aust Health Rev.
2010; 34(4):477–86.
10
List of abbreviations
AHMPPI
Australian Health Management Plan for Pandemic Influenza
AHPC
Australian Health Protection Committee
CDCD
Communicable Disease Control Directorate (of the WA Department of Health)
DPMU
Disaster Preparedness and Management Unit (of the WA Department of Health)
ED
Emergency department
GP
General Practitioner
HHCG
Hospital Health Coordinators Group
ICS
Incident Command System
ICU
Intensive care unit
IR
Industrial relations
NMS
National Medical Stockpile
pH1N1
Pandemic influenza virus A/H1N1 2009
PHCSD
Public Health and Clinical Services Division (of the WA Department of Health)
PPE
Personal protective equipment
SHEC
State Human Epidemic Coordinator
SHEF
State Health Executive Forum
WA
Western Australia
WACHS
WA Country Health Service
WAHMPPI
Western Australian Health Management Plan for Pandemic Influenza
WebEOC
Web Based Emergency Management Operations Centre system
WHO
World Health Organization
11
This document can be made
available in alternative formats on
request for a person with a disability.
© Department of Health 2012