Some experiences and lessons we have learned

1. Some experiences and lessons we have learned may be of some assistance

2. Case development without planned interventions Case development with planned interventions Vaccine availability

3. Table 3: Current international confirmed cases and associated deaths, by region, reported by official health ministries* (1100 AEDT on 12 October 2009) Confirmed Region and Country Cases Deaths Americas 135 645 3 196 USA 43 956 593 Mexico 36 593 248 Chile 12 252 134 Europe 55 085 162 Germany 19 893 2 UK 13 471 82 Portugal 2 983 2 Middle East 13 802 111 Saudi Arabia 4 119 28 Israel 2 880 24 Kuwait 2 459 7 Africa 13 574 80 South Africa 11 545 59 Egypt 927 2

4. Cases Deaths Asia 114 318 722 China (including Hong Kong + Macao) 47 240 24 Thailand 26 270 165 India 10 375 328 Oceania 41 819 227 Australia 36 889 185 New Zealand 3 163 18 New Caledonia 500 9 Total 374 243 4498

5. Total Australian cases • In excess of 40000 ++ • Limited serology conducted for majority of cases • 185 fatalities • ECMO emerged as an important ICU treatment modality for pandemic (H1N1) 2009 influenza, and will be an important consideration for future pandemic planning.

6. Table 1: New hospitalisations reported in the past week and cumulative number of hospitalised confirmed cases of pandemic (H1N1) 2009 in Australia (1100 AEDT on 12 October 2009). Past Week Cumulative Hospitalised ICU Hospitalised ICU ACT 1 0 61 1 NSW 3 0* 1269 245 NT 5 0 302 45 Qld 7 0 1202 162 SA 7 2 531 76 Tas 1 0 108 9 Vic 0 0 513 118 WA 0 0 844 79 Total 24 2 4830 735

7. Pandemic phases Australia is an island state relatively non porous borders Good opportunity to impose border measures to slow progress The Australian pandemic phases are designed to describe the situation in Australia and to guide Australia's response. Thus, the Australian and the WHO phase may not always be the same. Having an Australian system means that actions can be taken in Australia before a change of phase is declared by the WHO. The description of each phase is shown in the following table.

8. SUSTAIN Note: the current phase has been highlighted

9. Aims of Australian plan • Early accurate communication of information • Minimise transmission to allow time for vaccine development • Recognize cant prevent • Early surveillance emphasis • Whole of Govt response required to reduce impact

10. Some lessons we have learned • Whole of Govt response is key • Australian Govt Crisis Committee incl • PM&Cabinet chair • Health • D Foreign Affairs Trade • Quarantine • Police • Customs • Attorney Generals • Defence a small player

11. Some lessons we have learned • Australian Health Protection Committee • Important to provide expert advice to Govt • Dept of Health chair • All jurisdictions represented • States & territories, Emergency management, Defence, Chief Health Officer, Quarantine & Immigration reps • Not always agreement on the way ahead • Open communications vital • Aware of whole of Govt needs

12. Some lessons we have learned • State vs Federal Jurisdictions • Communication formally and frequently • Teleconferences daily / twice daily • Messages need to target • individuals and households • Health professionals • Legislation National Health Security Act 2007 formalised decision making and coordinated response arrangements and allowed information exchange

13. Some lessons • Policies and plans need to be flexible • Planning based on assumptions incl incubation period, attack rate, transmission modes, virus survival, et al and some of above will prove to be incorrect • Social distancing will be a difficult issue, with political implications • Use oldest national stocks first

14. Some lessons • Transmission will vary in different parts of the country • The various jurisdictions may have differing priority requirements, all of which will need to be addressed • In Australia required modification of the Influenza plan • Required close cooperation between the State and Federal bodies

15. Some lessons Plan revised in order to assure a measured, reasonable and proportionate health response to the risk that the virus poses to the Australian community. It is consistent with the message from the WHO when it lifted its Pandemic Alert to 6, that countries will need to adjust their responses to accommodate the knowledge we now have that this disease is moderate in most cases.

16. Identification and early treatment of those with moderate or severe disease especially in people with respiratory difficulty. • A focus on early treatment of people who may be vulnerable to severe outcomes. These people include pregnant women and those with respiratory disease (asthma, COAD), heart disease, diabetes, renal disease, morbid obesity, and immunosuppression. Some lessons

17. Some lessons • Control of outbreaks required in institutional settings, such as special schools. • Widespread school closures or school exclusion for students who have travelled to areas of high prevalence are no longer appropriate and will not be continued on a national basis. • Voluntary home isolation for those with mild disease with supportive treatment only, such as over the counter medication.

18. Some lessons • Antivirals from the national or state medical stockpiles will be provided to those people with moderate or severe disease or whose underlying conditions, after appropriate clinical assessment, could make them vulnerable to severe infection. It is not appropriate to provide antivirals to their otherwise healthy household contacts, nor will those contacts be placed into quarantine.

19. Some lessons • Ongoing monitoring of the virus for the emergence of antiviral resistance, genomic drift or reassortment that could herald a change to greater virulence. • Additional border measures such as thermal screening and Health Declaration Cards will cease.

20. Some lessons • Testing would focus on to identification of H1N1 Influenza 09 in people with moderate or severe illness, people more vulnerable to severe illness, those in institutional settings and Indigenous Australians. • Increased identification and monitoring of H1N1 hospital admissions, ICU admissions and levels of morbidity and monitoring of clinical outcomes throughout the influenza season.

21. Some lessons pathology testing of all potential cases will not be required or desirable. This is because most cases are mild and do not require treatment and confirmation is no longer required to inform clinical decisions about quarantine or use of antivirals.

22. Australian lessons we have learned • Vaccine now widely available • Slow uptake • Decision made to incorporate H1N1 strain into 2010 fluvax • Community made aware public health advice is available • Simple messages in relation to hand washing and coughing are important

23. ECMO emerged as an important ICU treatment modality for pandemic (H1N1) 2009 influenza, and will be an important consideration for future pandemic planning.

24. ECMO The anticipated demand for ExtraCorporeal Membrane Oxygenation in the wake of pandemic influenza A(H1N1) threatens to overwhelm the facilities currently equipped with the technology

25. Thank you for the opportunity to share our experiences