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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