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Standing Committee on Health and Ageing
25/05/2012
Health issues across international borders

GIVNEY, Dr Rodney, Infectious Diseases Physician and Clinical Microbiologist, University of Newcastle

GOTTLIEB, Associate Professor Thomas, President, Australian Society for Antimicrobials

LOKUGE, Dr Kamalini, Medical Epidemiologist, National Centre for Epidemiology and Population Health, Australian National University

McINTYRE, Professor Peter, Director, National Centre for Immunisation Research and Surveillance of Vaccine-Preventable Diseases

SLEIGH, Professor Adrian, Professor of Epidemiology and Population Health, Australian National University

SORRELL, Professor Tania, Director, Sydney Institute for Emerging infectious Diseases and Biosecurity

Committee met at 08:51

CHAIR ( Mr S Georganas ): I declare open this public roundtable discussion on health issues across international borders and I welcome all participants to the roundtable. Thank you for making time to speak with the committee. I also welcome those who have come to observe. The committee is conducting a series of roundtable discussions to explore infectious disease issues in Australia including current screening, surveillance and control practices. In the first session the committee is seeking information on the current research in this area—what the experts have to say regarding how all levels of government are currently monitoring and controlling infectious disease in Australia and across regional borders. By convening a roundtable discussion instead of a public hearing we are encouraging participants to engage in broad and interactive discussion with other participants and committee members. The proceedings will be broadcast live through the House of Representatives website and will be recorded by Broadcasting. A Hansard of today's discussion will be made available on our website.

I advise participants that although the committee does not require you to give evidence under oath, this roundtable discussion is a formal proceeding of the parliament and warrants the same respect as proceedings of the parliament itself. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. Do you have any comments to make on the capacity in which you appear?

Prof. Sleigh : I have been sent by the ANU because of my long experience in infectious disease research in many parts of the world.

Prof. Gottlieb : I am an infectious diseases physician and a microbiologist. I am also a recent president of the Australian Society for Infectious Diseases. My interest is very much an antimicrobial resistance and a range of infectious diseases affecting Australia.

Prof. Sorrell : The Sydney Emerging Infections and Biosecurity Institute is interested in preventing infectious diseases and looking at risks for global emerging infectious diseases and biosecurity. We are trying to do that through an academic presence at the University of Sydney, which looks at basic research but also capacity building, which includes in Australia and our region and then advocacy.

Prof. McIntyre : My background clinically is in paediatrics and infectious diseases and, in research terms, in epidemiology. The National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases was established after a tender almost 15 years ago by the Commonwealth. We do a lot of work for the Department of Health and Ageing in relation to supporting the technical advisory group on immunisation and also work with other committees such as the Communicable Diseases Network and the National Immunisation Committee as well as the TGA as far as adverse events relating to immunisation are concerned. So we have quite a broad brief but we do not do any laboratory work as such in vaccines.

Dr Givney : I am a clinical microbiologist and am currently based in the Hunter region. I was formerly the Director of Communicable Disease Control in South Australia, which meant that I was also a member of the Communicable Diseases Network of Australia. I guess you might say that my research interest is in the application of all the knowledge these other people generate on the understanding that we cannot actually control disease at our borders. It is the nature of human disease that it is very likely to get into the country. As a result of that, we need to have if not a seamless system then at least very tight seams between those who are dealing with problems at the border and those who pick up a disease after it arrives in the country.

My particular research interest is in remembering that a lot of what we do in the way of disease control, particularly for new diseases, SARS and pandemics, is in getting people to alter their behaviour in ways which are extraordinarily difficult. Yet our understanding of whether people are actually going to behave the way we want them to is very short on. We will never have enough policeman to do it so we need the cooperation of the country and we need to know how to do that.

CHAIR: I will offer each and every one of you five minutes for introductory statements, a little about your area and what you are doing. We will then have an informal discussion.

Prof. Sleigh : We know that many things cross borders: people, animals, air, water, floods, foods, goods and bads. Among the bads are infections of people, animals or both and also intrusions of plants. Australia is confronting all those threats. Over the last few decades, we have also confronted new infectious diseases or re-emerging infectious diseases, which are appearing at the rate of 50 to 90 per decade. Recent examples that we have encountered include influenza, avian flu, equine flu, plague, foot-and-mouth disease, bat lyssavirus, Hendra virus, Nipah virus and SARS. The SARS event is still pretty dramatic and well remembered by most of us. At the same time this is going on we also have the emerging problem of drug resistance in hospital. Bacteria, which was mentioned this morning, is a major looming problem. Just three years ago I was involved with an expert committee reporting to the Prime Minister and Cabinet through the PMSEIC process, the Prime Minister's Science, Engineering and Innovation Council. That was in 2009. Unfortunately the day we were scheduled to present to cabinet was the day that Minister Fitzgibbon resigned and the Prime Minister was preoccupied with that problem. But we made a report, which I think would be helpful to your committee, called 'Epidemics in a changing world'. I am happy to table the report.

CHAIR: Is it the wish of the committee that the report entitled 'Epidemics in a changing world' be accepted as evidence? There being no objection, it is so ordered.

Prof. Sleigh : I will summarise the five key recommendations that we made because I think they remain valid today. They were based on a lot of contemplation by the expert committee that went on for several weeks. We thought that it was very important for Australia to maintain its human capacity to combat epidemics, and this involves workforce planning and the training and maintenance of first responders: epidemiologists who are trained to investigate epidemics; pathologists, particularly veterinary pathologists, and microbiologists are key members of the first-responding workforce and we need to maintain an adequate number and distribution and appropriate age and experience mix of that workforce.

We need to maintain the capacity to collect, analyse and interpret relevant information. That is very important. We also need a forward regional engagement with our neighbours, because we are surrounded by countries which may generate new infections or old infections which will be a problem for the whole region and for us. We need to have this forward regional engagement involving all the governments. We realise that this involves multiple parts of our government: Prime Minister and Cabinet, in particular; DFAT; DAFF; DoHA; plus WHO and its animal counterpart called the OIE.

The fourth major recommendation was that we in Australia maintain vaccine production capacity, particularly for influenza and also the niche vaccines. The fifth recommendation was that cross-portfolio mechanisms be created to enable the first four recommendations to operate. I do not know what has happened to that report since it was first made, but I think it is a good start for what we are doing today.

Many issues are realised when dealing with complex infection challenges across borders. We need to remember that with infectious diseases we are dealing with something a little bit different to other areas in the health sector. We are dealing with the intersection of the environments and the lifelines of at least two different organisms. This creates complexity. The situation may be quite unstable and expansive, creating an explosive epidemic such as when we were confronted with SARS and avian influenza, or it may be stable and constrained and be a habitually present problem like tuberculosis in Papua New Guinea. It often has an ecological dimension and often involves predilection for people in poor situations, so that the poor are particularly afflicted. Just in the last 10 years, as I mentioned earlier, we have dealt with SARS, an avian flu pandemic, human flu, equine flu and Hendra within Australia. We have learnt so much from each of those. On our doorstep we have multidrug-resistant TB threatening us from the Western Province of Papua New Guinea, Denge haemorrhagic fever ever expanding throughout the region, malaria, Japanese B encephalitis and many other threats.

Cross-border research, in my experience, is based on collaborative relationships that take years to develop and mature. These relationships are essential for Australian investigators with neighbours like Indonesia, China and Thailand. They are all very strategic countries in strategic locations with respect to us, and also in their capacity to generate new infections. The SARS experience showed Hong Kong needed—and did not have—cross-border links into China. It also showed the need for preplanned internal links within Hong Kong, which were also not in place, between the hospital authority and the health department, and the police and Customs. I was sent by WHO to look into the research dimensions of the SARS epidemic in Hong Kong. I will table my report to WHO, which would not normally be available. It contains unusual information about what actually happened in Hong Kong, in particular with respect to a huge outbreak in a high-rise building and a very worrying outbreak on an airline flight which could not be investigated and which was blocked in every way possible. I do not think the situation with investigating airline flights has improved a lot.

A defining feature of infectious disease research in my experience is the need for long-term partnerships and the need to train and maintain a workforce of first responders. It is always involving borders and multiple jurisdictions. That is all I have to say.

CHAIR: Thank you very much for your submission.

Prof. Gottlieb : I agree with the comments that we made by Professor Sleigh. I will try to focus a little bit more on one area: on bacterial issues. As a general comment, the thing about infectious diseases—and we are here to talk about infectious diseases—it is a hard thing to lump together anyway because these are varied infections. When you look at dengue fever or SARS, it is very different to bacterial infections or bacterial resistance. Some infections are relatively overt as part of an epidemic; some infectious diseases issues are very subtle. I will try to refer to them perhaps anecdotally to illustrate that. I think the important thing is that, unlike some of the disease entities we deal with as a national issue—whether it is mental health or obesity, which are compartmentalised in Australia—infectious diseases or, say, antimicrobial resistance, is an international issue, and we cannot look at it in one country.

CHAIR: They have no borders.

Prof. Gottlieb : They have no borders and bacteria do not respect international borders. That is one of the things that essentially we have to understand. So, when we look at what is happening, we need to have a sense of what is happening internationally but we also need to know what is happening in our country. So surveillance is a very important entity. I believe that until recently we probably have not had sufficient surveillance in areas that I am involved with, which is particularly bacterial resistance.

I belong to a group called AGAR, which is the Australian Group on Antimicrobial Resistance, which has with Commonwealth funding done what we call active surveillance, where we target individual organisms and look longitudinally at what is happening over time. Because it is targeted and because we only do a certain amount of bacteria at a time, we do not have a sense of what is happening across the country in real time. The next solution is to look at passive surveillance where we have some capacity to bring IT technology together to bring in data from all our laboratories, which are collecting data at any one time, to actually get an immediate sense of what is happening. That is one way of doing surveillance.

The other way of doing surveillance is to link unusual things that are developing at any one time and bring it to common notice because one of the problems is we do not have a sentinel system for picking up problems as they occur. In terms of surveillance, we need to think about different forms of surveillance. Here I am talking about bacterial resistance, but of course it applies to other areas such as tuberculosis et cetera.

CHAIR: I have not got any more questions but on this point: are we talking about bringing it all together internationally?

Prof. Gottlieb : Nationally. I think there is a lot of data coming internationally, but, what I was going to come back to is that a lot of the resistance that we are seeing is no longer hospital; it is community. Beyond that, it is not just in Australia but it is in our immediate neighbours, be it Indonesia, Vietnam et cetera. A lot of those countries do not have the capacity to detect some of the issues that are developing. I personally believe that it is our role to help support that or to build the capacity—I am sure Professor Sorrell will enlarge on those areas—because it is to our gain to know what is happening—

CHAIR: Regionally?

Prof. Gottlieb : Absolutely. Can I give a couple of examples which I think illustrate the issue. In terms of bacterial resistance we know that there is a strain that has developed in India and Pakistan called New Delhi metallo-beta-lactamose, also known as NDM. This is an enzyme that is present in certain gut bacteria which makes that bacteria resistant to almost all antibiotics that we have currently available to us. It emerged four or five years ago in parts of India, and due to poor antibiotic use and poor sanitation. Some of those issues are not an issue in Australia—such as sanitation—but nonetheless the spread of these strains has been very rapid. It parallels other spreads, such as SARS, and now these strains have been found all across the world.

It is estimated by one group that there is probably 100 million to 200 million people in India who are silently carrying this strain. Of course, it does not cause disease in the vast majority; it will only cause an infection in those that might develop a urine infection or peritonitis—a small tip of the iceberg. So, unless you go looking for it, you would not know how much resistance there is. We do not believe we have much of this in Australia. It is coming either through tourists or travellers. It may not spread, but the potential for the spread of it is there. Without knowing how big the problem is, without having the capacity to detect it in real time, we may be at risk. That is one example.

Moving to a different topic, to mention another example very briefly. We had three cases in our hospital—Concord Hospital in Sydney—where we detected three elderly Italian women who had not travelled overseas but who all had cholera. That is very unusual. It was a serendipitous detection in the laboratory which probably would have been easily missed, because it is not something we normally look for. The fact that we found three cases helped us think about a common cause. There was a common cause: the three elderly women had all bought fish which was imported from Indonesia, which they were preparing for the family. Because they were making whitebait fritters and they were tasting them before they cooked them, they got a dose of the—

CHAIR: I expect these women were related.

Prof. Gottlieb : They were totally unrelated from three different families, but they bought it from the same fish shop. They tasted the food and they developed cholera, but none of the rest of the family did. All of these women, because they were elderly, were taking proton-pump inhibitors, which a lot of Australians take for their gastric acid and which allows the bacteria to escape protection. The point I am trying to make is: here was a strain that you would not see in Australia and that had been imported through food insecurity. It probably is a food safety issue. We talked about human antimicrobial resistance and bacterial pathogens; some of these can come from overseas as well. If we are focusing on issues from overseas, we also have to look at food products and the potential effect they can have on our local environment.

There is another study from the Netherlands, which recently sampled chickens from local supermarkets, which showed that 80 per cent of them carried highly-resistant bacterial strains that we would not normally detect in Australian chickens, because we do not use antibiotics to that degree. Again, it highlights the issue of food safety and the detection system there. I think some of these things will be discussed later.

The final example I wanted to use is patients come in for prostate biopsies. A lot of elderly men have to have these things performed. These go through the rectum and can carry bacteria across the rectum and cause sepsis. Normally we give patients antibiotic prophylaxis for prevention to stop that happening—the antibiotics will stop the bacteria getting into the bloodstream—but as we get more and more resistance we cannot predict which patients are carrying much more resistant strains. The concern we have is that, while are doing certain procedures which are currently seen as safe and day-to-day in Australia, there might be a time when these things are no longer safe. A lot of these resistances are coming from overseas and a lot of these patients are coming as medical tourists or people from overseas. I think we do need to have a sense of what is happening over time and how it is spreading. I think I should limit my introduction to those points and we can enlarge on them subsequently.

CHAIR: Just before I go on to Professor Tania Sorrell, can I welcome Dr Lokuge. Doctor, if you could briefly introduce yourself and who you represent.

Dr Lokuge : Yes, I am a medical epidemiologist specialising in infectious diseases and I am representing the Australian National University.

Prof Sorrell : I would like to focus in a little bit more on the transborder issues and particularly the regional connections that are important for us to support. When we think about emerging infectious diseases within Australia, we are thinking about what we can do within our own borders—to detect them, to control them et cetera. But we need to recognise that the Asia-Pacific region is quite an important incubator for emerging infectious diseases and for increasing antimicrobial resistance. Perhaps we should be looking to develop collaborative interactions with strategic partners in the region so that we can actually anticipate some of these problems and prevent them reaching our borders.

Earlier, we talked informally about your visit to Papua New Guinea and the issue of potentially drug-resistant TB entering through the Torres Strait, as an example. If we could put in place the systems to manage that problem at the interface, potentially that would mean we would not have that issue to deal with in Australia. We know at the moment, that around 80 per cent of our cases of TB are actually imported. There is very little, what we call, endemic transmission—that is to say, transmission within the community once people actually come to Australia.

I would like to make a couple of general comments about the kinds of areas we might like to focus on and then perhaps give some specific examples.

When we are looking at trying to contain emerging infectious diseases there are really three separate areas that we have to address. One is obviously basic research to understand the nature of the organism and the nature of its interaction with humans. I think it is interesting to note that all of the emerging infectious disease events of the last 40 years, around 60 per cent of them, have related to animal-human contact. We need to have basic research around how that transmission occurs, how organisms jump from species to species et cetera.

Once we understand the nature of that, or how an organism causes a disease, the next series of things we need are the tools to actually do something about it. The sorts of tools I am talking about here relate to surveillance issues that Tom was talking about, to the rapid detection and identification of the movement of some of these infections. Of course flu would be one of the examples of one of the most rapidly transmissible ones. But there are other examples closer to home that we need to be able to track the movement of. An example of a more slowly moving issue is rabies in Indonesia, which is moving slowly towards the Torres Strait. It is partly related to the movement of humans and dogs between different islands. We need to keep a handle on that. We need to collaborate with partners and build their capacity to do research in Indonesia to actually contain the problem in Indonesia.

I have already mentioned the example of TB. The other tools that we need are—not only the surveillance mechanisms as a network in Australia, but as a regional issue—to have in place the interrelated networks that are needed. By that I mean that we need to understand the genetics of the organism to see if it is one particular organism that is spreading into a particular place, as might be the case with flu or dengue. We need to actually integrate that with information systems that allow us to then do something about the problem—in other words, try and prevent its spread. And we need to integrate it with the social aspects with the spread of infection, the behavioural issues that actually promulgate those infections—something Dr Givney talked about. Once we understand where they are occurring and what we need to do to do something to control and prevent them. Finally, if we have got the tools—the rapid communication systems, if you like, that lead to public health action—we then need to have the health systems in place to implement outcomes. In Australia we have lots of isolated systems that in and of themselves can work, but they are not coordinated; they are not integrated together. If we look at countries like PNG, we actually have broken down health systems; we might be able to get a drug for TB, for example, to a particular health centre but it might be so long getting there that the drug is no longer active, or it might be onsold in a corrupt sort of way so that the person needing it does not take it. As an example, in PNG the Australian government, through AusAID, has put quite a lot of money into providing TB treatment. The outcome of that was that when they looked at the health centres to which these drugs were being sent some were actually no longer in existence. There was money allocated and material being sent to health centres that were not having functional outcomes. That has now been resolved and a mechanism put in place to prevent that happening, but large amounts of money can be wasted if there is not a functional health system. You might hear from Peter on vaccine chains: there has to be a cold chain established so the vaccine remains effective. There are many complicated interrelated things that we need to address, and I applaud this particular committee for looking at it, because it is an enormously complicated area.

Prof. McIntyre : A lot of the things that have already been said are relevant to the area of vaccines. I think Australia can look in two ways at its achievements in the area of vaccine-preventable diseases. There are world-leading systems and achievements that Australia has made but there is also the potential for contributions, both regionally and internationally.

The areas where Australia is a world leader include the fact that we are the only place, still, that has a national immunisation register that includes all children. This gives us tremendous capacity to track what we are doing. We have also developed over the last 20 years or so a national program, which means that, once a vaccine is on the national program, the delivery of the vaccine right to the point of administration and so on is all covered, and is not at cost to parents or others who might be receiving the vaccine, including the elderly—it is not just children anymore. That means that Australia achieves a very high uptake of vaccines very quickly and that our regional neighbours—and, more broadly, internationally—often look to Australia for early evidence of what is happening with vaccines that are introduced. Recent examples of that include the pneumococcal vaccine and the HPV vaccine.

There are some really significant achievements that Australia has been able to demonstrate over the last 20 years, and they have been realised in some of the disease outcomes as well. We were the first in the western Pacific to eliminate polio. More recently we have eliminated home-grown measles in Australia. Why do we keep seeing measles? It is all coming from somewhere else; we do not have our own home-grown variety of measles any more, and so measles in Australia has become a travel-acquired disease. This is an important achievement that we need to struggle hard to maintain, because the flipside of our achievements in high coverage have been that there are people who have not seen measles or some of these other diseases and are saying: 'Why do we need this? We are concerned about, for the most part, unwarranted adverse event concerns.'

Of course, we have had a recent example of an adverse event which was genuine and which has prompted a very strong response from the Australian government: the flu vaccine episode relating to young children in Western Australia. That comes back to the point that Professor Sleigh made earlier about the potential advantages of retaining a capacity to produce vaccines in Australia for our own use. But as things currently stand the only vaccines in that category are the influenza vaccine and the Q fever vaccine. Otherwise, all the other vaccines that we use are manufactured by manufacturers based outside Australia. On the downside, the other area we are in a world leader in is whooping cough. We have more whooping cough than anyone else has anywhere. Part of that is because we are better at finding it, but part of that may be because of changes in the way that we give whooping cough vaccine, which have resulted in more rapid loss of protection, particularly in children. So that is an area that we are very actively looking at at the moment. I suppose something like whooping cough is different in different countries around the world and is not really a direct threat for importation along the lines of rabies or dengue or some of these other things that we are talking about, but nevertheless it is a very important issue internationally. It is something where I in particular have been involved with WHO committees on that and pneumococcal disease, where Australia has an important contribution to make.

If I were to look on the other side of where the unrealised potential is and how Australia can contribute more from the great successes that I think it has achieved in this area, one is that—Tania really opened up this fact—we do have a lot of capacity in Australia and we could be contributing more to our regional neighbours in the context that the next thing on the agenda for the Western Pacific region is the potential to eliminate measles. Australia has done that. If we want to retain that, we need to really be actively involved with the other countries and particularly Papua New Guinea, which comes to mind as an area where the immunisation system has really fallen into a hard place and where measles is totally out of control, amongst other things. Papua New Guinea is obviously right on our doorstep and we have not up until now had the standing or spare capacity to offer that kind of input to our regional neighbours, yet we have a lot of expertise in the country which could potentially do that.

The other area where there is potential is improving coordination. I think the thing which would really strike you if you were a Martian coming down and looking at the Australian system now is that we have all these fabulous initiatives and groups—some of whom are represented at the table today—which are doing great work, but we do not have one coordinating group that we can look to as happens in the US, Canada or the UK. You know where to go. You know where to find out what is happening. It is not that it is all done in one place, but there is one place you can go to find out what is happening. In Australia, there is not that coordination and the potential of all the rich data that we have to actually inform us, but also inform our neighbours, is not being realised at this point in time. So there is a challenge about how to do that, but there is tremendous potential if we can harness that.

Dr Givney : If I could just perhaps summarise to some extent and also just expand on Professor McIntyre's last point, I think first of all that all of our speakers today have talked about a whole series of individual infections, but all of them would agree that there is a body of knowledge that deals with all infections. So it is foolish to set up individual programs for each separate infection. It is much better if we can be organised in a fashion where we have an organisation to deal with all of them. The sort of skills that you need, if you like, are the generic skills. We need epidemiologists, we need microbiologists, we need virologists and we need infectious diseases physicians. We need the capacity to implement it, so we actually need social scientists as well. So we need to stop wasting our efforts in setting up separate individual programs.

The other things that I think the other speakers have talked about are the maintenance of the workforce and the capacity to run surveillance systems—not only to run our current ones but to introduce new and innovative ones. What Professor Gottlieb is talking about—actually downloading data directly from laboratory databases—is not a straightforward exercise, but certainly there is a wealth of data there which we could actually get our hands on, which would be of huge value to us in our efforts to control antibiotic resistance. Of course, we have to implement interventions, but you have heard about a whole series of interventions. You heard about antibiotic stewardship from Professor Gottlieb. You heard about the need for new vaccines and the capacity to make our own new vaccines. We think we are a small country, but New Zealand developed its own meningococcal vaccine for its own meningococcal outbreaks. So we have to think larger than we did traditionally.

My particular interest is in making sure our community is able to accept and take on the behaviours that we would like them to carry out. We have a lot of experience in doing that over the long term with things like HIV, hepatitis C, clean needle programs and safe sex. But we are unlikely to be certain about our capacity to do that in a hurry. Thinking about that, you begin to see—just as Peter McIntyre is saying—that we need to start talking about coordinating better, using our resources more efficiently, and that is particularly with regard to our regional involvement. I think we have had two nice examples. Adrian has said very wisely that you need long-term relationships, and I think Professor Sorrell has indicated very clearly what happens if you do not have that long-term relationship, that what you think you are doing falls apart.

My sense of the programs that we have in the region is that they are one-off, individual programs for individual organisms rather than having the ability to oversee the whole of the problems, to pick what is important and to work with these communities. Remember it is a two-way answer, a two-way street. H5N1 influenza has fallen out of the news but it is still endemic in Indonesia. It still kills people regularly. We would be in terrible straits if that disease became readily transmissible between people. That would be our next pandemic, and in fact it is the one that we are expecting. So there are benefits to us in actually knowing what is going on in other people's countries very close by. The downside to it is that if we are not involved then we will run into problems again like we had with Indonesia. The Indonesians simply said that they would no longer provide their isolates for work for developing vaccines because the vaccines were to be developed for the First World and they would not get any. While that problem has been solved, that is a stupid hole to have got into in the first place.

I think we need a much better organised capacity. But I would take it further than Professor McIntyre. I would say not only do we need coordination but we actually need leadership—and I think you implied that too. We need an organisation that people will look to for what should be done with regard to the whole of infectious diseases.

CHAIR: Thank you. Dr Lokuge?

Dr Lokuge : I will follow directly on from what Dr Givney said. I was involved with the Indonesian ministries of agriculture and health. I led their initial teams when avian influenza first appeared. We visited farms affected and I found that that was the most effective way to establish ongoing collaborative relationships, to be part of technical teams that work directly with health staff dealing with the problem on the ground. I think that sort of partnership is insulated from changes at a high level, from policy change, from relationships at the higher level between governments. I would encourage the committee to push for that, for real, technical, on-the-ground partnerships.

One example was, as I said, the early phases of avian influenza, and the way to achieve that is to invest in technical capacity building in Australia that is directly linked to similar capacity in our regional neighbours. Another example I can give is the issue of tuberculosis and drug resistant tuberculosis in the Torres Strait region. We organised a panel yesterday at the ANU with community members from the southern Fly region. These are people that live five kilometres from Australian shores who come to clinics in Saibai Island and go back to their village, which is 15 minutes by banana boat. One of the panel members we brought across was Councillor Kebei Salee Koeget, who is the local level ward member for that part of the southern Fly region of Papua New Guinea. He expressed the opinion that that was the first time he had had the opportunity to represent his community's views on this issue in a forum where it could be heard by people making policy.

I think there have been Senate inquiries into these similar issues. I would encourage the Senate committees to go and speak directly to these communities. It is the only way we will understand what will work on the ground in those regions and, as some of my fellow panel members have said—I think to quote the DFAT committee—Australia has a history of aid which is short term, ineffective and does not produce long-term outcomes. In my experience of delivering this type of assistance very much at the grass roots level, the best way to avoid that is to engage communities and health workers who are involved directly in uptake and delivery of service.

CHAIR: Thank you very much. I thank all of you for your statements. What I will do now is open up for questions.

Prof. Sorrell : Sorry, Mr Chairman, I omitted to table one page formally which was a piece—

CHAIR: Is that one we already have?

Prof. Sorrell : Yes, you have. It was a piece we were asked to write for the GO8 meeting.

CHAIR: Can I have someone move that we accept the submission? So moved, Mr Coulton. Thank you.

What I will do now is ask the committee to ask some questions—not even questions, just a very informal discussion. I have a few questions, but just before I do ask my questions this committee visited PNG a few years ago and we actually visited those villages that are closest to Saibai and we met with the local representatives. We met with the members of parliament for the Fly region, which was—you mentioned a name, could you just mention that name again?

Dr Lokuge : Councillor Koeget.

CHAIR: Yes. We met with many councillors, many members of parliament, especially the governor for the Fly region as well, and there was an extensive report that the previous committee put in—Mark was part of it and Steve was part of it as well. We saw a lot of these issues. We were actually in Saibai Island, where we witnessed banana boats coming over to the health clinic there with all sorts of issues. It was interesting; someone mentioned rabies earlier, and they were telling us that occasionally they will have their dogs on the banana boat and sometimes they are left behind, so it can cause a lot of problems.

Mr IRONS: One of the PNG people that came across died—or collapsed in the clinic on Saibai Island—

CHAIR: While we were there, yes.

Mr IRONS: and died the next day of TB and HIV. He had been trying to get into the clinic for four months.

CHAIR: But it was very interesting and we did see a lot of the AusAID programs that were taking place. One of the problems was the remoteness of some of the villages. I cannot remember the exact names of the villages, but they were the ones closest to Saibai; when we went, one of the arguments about putting a health clinic there is that you can put a health clinic there but it would be inundated by people coming in. It would be the only health clinic in that entire western region—there was nothing apart from the Daru Hospital. The problems are very extensive. What we saw, it was not as easy as just going in and putting in a health clinic—there was maintenance. There was, for example, no electricity to have a fridge to keep the drugs in. There was a whole range of issues that we saw. So very complex issues, but I think at the same time, as we have said earlier, diseases do not have borders—illnesses do not have borders. We come up with borders as human beings, and it is important that we do. Sorry, you were going to add to—

Dr Lokuge : Just that I have delivered health programs on front-line areas of Afghanistan so I believe it is possible.

CHAIR: It is, yes, it is.

Dr Lokuge : I have done it in many areas. I think what is needed is real engagement with those who are directly involved in taking up those services and delivering them, rather than just limiting our involvement to external assistance that is not monitored and is not accountable. I think your committee has a better understanding of the context than many people developing policy.

Mr IRONS: I think you are right because it was while we were on Saibai that they spoke about how the Australian government—and I am not saying which one it was—had committed funding to the western province for a clinic and a hospital, and the money never got through because there was no accountability.

CHAIR: No accountability.

Mr IRONS: And no supervision, yes.

Dr Lokuge : I think in your report, the chair of the Torres Shire Council said that they build a clinic and 12 months later the screen door does not close because it is salt affected. No-one has funded maintenance.

CHAIR: Yes. The classic example was when we were in the Solomons. There was an AusAID beautiful clinic that was built, brand new, and we were one of the first visitors to see it. They were treating malaria and a whole range of things, and there were no fly screens anywhere. We actually raised that and then within a few days they told us that they put some in, but no-one had thought about it. Because they use local traders, it is just something that—

Prof. Sorrell : You make a very important point about the unhelpfulness of just dropping a clinic in one place. We really need to build the capacity of the health system in the particular country that we are referring to. But also, in the context of the delivery of health, what is very noticeable in developing countries is their inability to make the diagnosis. The laboratories are fairly rudimentary. We have just come back from Indonesia and it is certainly true that their influenza capacity has been increased as a special initiative, funded from outside, but their ability to detect multi-drug-resistant TB is minimal, and some of the other diseases that occur in eastern Indonesia. They are asking for our help to build laboratory capacity. I think the two need to go hand-in-hand.

CHAIR: I have one last question. Who was it that spoke about the prostate biopsies? It was very interesting. I have heard some reports that the majority of people that become ill after the prostate biopsy are people that have travelled to Third World countries in the previous six or 12 months, and in fact some of the advice is that, if you are going to have a prostate biopsy, you should not do it for at least six months after you have come from certain places around the world.

Prof. Gottlieb : The prostate biopsy highlights a particular issue. If you take E. coli, which is your typical bacterium in the bowel—

CHAIR: You could have it and not even know.

Prof. Gottlieb : In Australia we would expect the vast majority of people to have relatively drug sensitive strains. For example, there is a particular antibiotic group called third generation cephalosporin. We currently in Australia have about three per cent resistance in E. coli, less so in the community. So, if you are coming from an Australian community and having a biopsy, the likelihood that you have a resistant strain, and the likelihood that the prophylactic antibiotic you are given at the time will not work, is very, very low. If you go to India now, the current surveys show that 85 per cent of people are carrying third generation cephalosporin resistant E. coli.

I tried to highlight the point about the chickens. The only reason I was saying that is that those strains have been shown that they will mix between animals and humans. So, at the end of the day, we are what we eat. There is good evidence now that if resistant strains are becoming present in veterinary strains that we eat, clearly it will come to us as well. In China, the rates are a little bit lower, but still about 60 to 70 per cent of E. coli resistant.

With a lot of the people we have seen who have developed bacteremia—that is, blood poisoning—immediately after prostate biopsy, when you actually look at them, they have often come back from being overseas, because they have probably picked up these resistant strains. There was research done in Canberra where they looked at Australian healthcare workers who agreed to have a rectal swab before they went overseas to check what their sensitive strains were, and then they monitored them after they came back from travel from overseas. Before they went away about five to seven per cent had resistant strains; when they came back about 40 per cent had highly resistant strains, and the majority had come back from either East Asia or the Indian subcontinent. That also showed that over about six months those strains disappeared, so they are not sustained, because, at the end of the day, what you eat will determine your gut flora. I think it is just an ambit claim that you should not have it after you have travelled, but there might be some truth to it depending on where you have been. There is increasing resistance overseas. So that is answering that aspect.

I would like to support what Tania has said about lab capacity as well, and it is in Australia and overseas. We are doing a lot of sophisticated tests that detect infections very rapidly and we can pick up TB in people immediately from the direct specimen. In the old days, you would require often six weeks of culture to pick up the strains. In parts of Indonesia or Papua New Guinea, they do not even have culture available to them, so the disparity in laboratory availability is incredible. I think we need to build up our own local laboratory capacity and for the laboratories to link with each other. We have very good, sophisticated technology now, but we also need to provide some of these things for overseas.

Prof. McIntyre : I think there is one unifying theme in some of those comments it would be fragmentation. Australia has very strong capacity in lots of areas but there tends to be fragmentation both at the national level and in our capacity to respond regionally and more broadly, because we lack the sort of coordination that would achieve that. It is a challenge in a federation, as we know. Everyone would be keen to have one leading centre—as long as it was their leading centre; they would be fine about that—and it is always the challenge as to how to achieve that and come up with a mechanism that will capitalise on all the expertise and get the most effective use of that.

Mr COULTON: When I came in this morning I thought we would be discussing more of the issues that might come from the northern borders but I realise now that, as a general population, we are probably at far greater risk from some of the other things that you have mentioned. Is the fact that in Australia we have been relatively successful as a society with handling disease? The feeling now is that if you are born in Australia you are entitled to a long life. People do not quite understand, like they used to, the dangers that they face. When you suddenly have something like the AIDS epidemic or SARS, when people know people who have died of these things, all of a sudden you will see behavioural change. But when there is not a pandemic or something dramatic like that, how do you make people aware? We look at the problem of whooping cough at the moment. A lot of younger mums have lived their lives not really knowing anyone who has died of an infectious disease or anything like that. Is that a problem in how we try to protect ourselves? I have a heap of questions but that is one I thought I might start with.

Dr Givney : That might be an occasion for me to respond. One of the approaches is to run what the Americans call 'community forums' or, as in Australia, what is run under the name of 'citizen juries'. It is a way of informing people and at the same time getting their response to the sort of interventions that you might plan. It is a forum. I think it is fair to say our backgrounds are all in what you might call quantitative research. I have had to branch out, as a result of having taken on jobs that I did not know how to do, into qualitative research as well, and this is that sort of process. So it is the same idea as focus groups but it starts with educating people, actually getting a few experts in to inform them of what is going on, and then seeing how they respond. You can take that approach.

You can do surveys, of course, to find out what people think and how they feel. These are very unreliable because it will all depend on, as you exactly said, when the issue arises that they will suddenly get interested. There are ways around that. It is something that we worry about frequently although you would think, in that case, our immunisation programs would drop off. I think, Peter, we still have extraordinarily high immunisation rates.

CHAIR: Have they dropped at all?

Prof. McIntyre : No, not at the macro level. I think what we are hearing about is the sons, the daughters, the nephews, the nieces that we talk to, those people who are concerned. We cannot be complacent about the high immunisation rates that we have and there is certainly still room for improvement there. Australia does not have groups of religious objectors that you get in say, North America or parts of Europe. We have lifestyle objectors. We have groupings of people where there are relatively high rates of opposition to immunisation in localised areas. If we got something like measles into one of those areas then, as we saw a little of on the Sunshine Coast in Queensland a few years ago, we could see a big problem.

The other thing, going on from what Rod just said, is that the environment is changing. There was a recent incident, I do not know if you were aware of this, with the Australian Vaccination Network, which sounds very learned but actually is a group of anti-immunisation lobbyists based in northern New South Wales. They were trumpeting the fact in the media that they had got American Airlines to agree to broadcast on all their flights in the US an interview with Meryl Dorey, their chief spokesperson, which was really bagging immunisation and talking about a whole lot of stuff which was actually complete garbage and which was totally recycled and refitted. Just as we were preparing together with our chief health officer Professor Bagley to get a learned response out to say why all these things were wrong, Twitter was at work. Twitter was bagging it out and within 24 hours there was a tweet from American Airlines saying, 'It is gone.' So Twitter did a much more effective job than any learned rebuttal that we could have come up with for the claims that were made.

CHAIR: The idea is to get those messages out through any means we can.

Mr IRONS: Professor McIntyre, you were talking about immunisation, so you might be the person to ask this question of. For people who immigrate to Australia, do we have a process for immunisation? Do we check their records? You said Australia has a great immunisation record-keeping database for children, but what about people who immigrate to Australia?

Prof. McIntyre : There has been a lot of work done in this area of migrants and refugees but again it is fragmented. It happens in different ways in different places and it tends to have defaulted to a state and territory responsibility. So it is something that has been talked a lot about and that people are aware of—and there may well be comment from the departmental representatives about this later today—but I think it would be fair to say there is still fragmentation in that area.

Mr WYATT: Professor Sleigh, I have had a quick look at your article on Hong Kong and you make reference to flights. If I put this scenario to you: a businessman leaves Sydney, goes to Hong Kong, spends four days there, then travels to New York, and then across to London; in the meantime he is starting to show symptoms of a highly contagious disease. He leaves London and comes back to Australia because he is not feeling well. What is the disease modelling and its likely flow-through in terms of a city like Sydney, if he is not aware that he has this infection until he fronts five days later to his GP?

Prof. Sleigh : If he has a disease which is transmitted by air borne mechanisms, there is a very good chance that he is going to transmit it onboard the flight to people who are within one to two metres distant from him or further. In the case of the flight I referred to, the distribution of the secondarily infected people in the plane was over a much larger area than had previously been anticipated. So, if it is an air borne infection, he is likely to infect people as he goes, on all the flights that he travels on.

CHAIR: Everyone on that flight?

Prof. Sleigh : No. The people who are nearest to him. But our knowledge of the risk and the mechanisms for controlling that is quite limited; the airflow in aircraft is quite complex. It is circular. It goes through HEPA filters. The HEPA filters have to be maintained, changed periodically. The aircraft have records of that but those records were not available to us in Hong Kong. We could not investigate the plane. We could not impound the plane. And there was no mechanism to investigate. There were many inflight incidents with SARS over that three-month period. I think about 64 flights involved people travelling who were subsequently found to be infected. Very few flights involved transmission, but some did, and that was the worst.

Ms O'NEILL: I was not on the committee when they did their travel so this is a brand new groundbreaking experience for me hearing this. Having said that I am on the Central Coast and not near a border, I realise I am very close to Sydney airport which is probably about as high risk as you can get. What concerns me is that we have agencies that the general public would feel were quite significant and effective peak bodies such as the Communicable Disease Network Australia, the Public Health Laboratory Network, the NHMRC and DoHA, especially through the health protection and surveillance branches. All of those things provide me with a sense, coming to this as a citizen, of a high-level integrated, carefully managed national response. Everything you have said to me today makes me feel that is not the case.

I am interested to hear where you see the failure points for the things you have articulated this morning. Where are these peak bodies not providing the overarching leadership that you spoke of, the overarching access to information and the overarching improvement in a coordinated development of a body of knowledge and a body of practice? That is my first short question. The second one is to Dr Givney about the social scientists. Really, that seems to be an area that seems to be completely sitting outside of this medical model.

CHAIR: Good luck.

Prof. Sleigh : Speaking from ANU's perspective, for 20 years we ran a program called the Master of Applied Epidemiology to train epidemiologists to respond to epidemic investigations. Just as we were handing in that report to PMSEC on epidemics in a changing world, DoHA was withdrawing its funds for that program and they have not been replaced.

Ms O'NEILL: What year was that?

Prof. Sleigh : That was in 2009 or 2010. The university is financing a continuation of the program itself. It has stitched together funds from various ways. The program has not actually stopped but the critical funds were from DoHA and they did stop. The funds were withdrawn for that program, which was the national program for training epidemiologists. We trained 160 over 20 years and many of them are in very strategic positions throughout Australia and internationally, in the WHO, and so on. The program was evaluated and found to be very good yet it was defunded. That was the central program for training epidemiologists.

Prof. Gottlieb : I would take the view that I would not want to be too pessimistic in the sense that we have got very good agencies. CDNA or PHLN are very good. I think all of us are echoing that we need an overarching organisation that brings these together. We have a very good knowledge base among our physicians. Our infectious diseases society has a bulletin board. If someone has an issue, they will bring it to the attention of everyone so people hear it quickly. But we do not have a formalised structure for disseminating information, for linking what states and territories are doing. So one of the issues I think we all hear from our members is that New South Wales, Victoria and elsewhere have slightly different approaches to things that could be much more common. Our approach is that we need better integration, taking advantage of these new resources we have in information technology to bring things together.

We wrote a short editorial about infectious diseases in Australia and it came down to the point of calling for a coordinated system. The point I would like to make is that we do not need to create a new structure that needs something to be built; we already have very good agencies. We just need to link these things together very effectively.

There is a new committee I am sitting on called the antimicrobial resistance subcommittee, AMRSC, which has just started and which the Chief Medical Officer has organised. That is going to look at a lot of the antimicrobial resistance issues. Again, there is optimism that when things are highlighted there is a positive reaction to it. But it takes time to develop responses.

Prof. Sleigh : The SARS response was the first internet response globally to a global threat. We have gained a very big advantage since then. We have gained a lot of knowledge.

Prof. Sorrell : I think CDNA and PHLN are really excellent but they just need to be ramped up a bit so they can better assume that leadership and coordination responsibility. That, perhaps, would be one model. But I would also make the point that there are platforms available that could potentially be built on. For example, I am not sure whether you are aware of ABIN, the Australian Biosecurity Intelligence Network, which is a group that was funded out of outstanding biosecurity funds to develop a database and electronic platform which is sufficiently large whereby individual groups can submit their data to it. It can be made available in a secure manner for either doing research or rapid transmission of information, as Tom was talking about, in relation to new things that are emerging. So it has been set up as a series of projects, initially, many of them in the veterinary sphere. But we have just become involved with one in the human sphere, linking laboratories in influenza in Australia—of which there are a few major ones—and TB laboratories, as a model to see whether this can be fed into by the laboratories and be data that is quickly accessible and that can be then actioned in public health terms. So it is not perhaps as gloomy as you have been picking up, but it certainly needs more effort and perhaps resource to bring it together.

Prof. McIntyre : We do tend to beat ourselves up a bit in Australia. Clearly, we are doing very well at one level, but I guess we all see how much better we could do with better coordination. But that also needs some resourcing. Particularly at the regional level we see that we could be doing better and that we could be more coordinated, with more continuity rather than, as I think has been pointed out by the representatives from ANU, project based, individual topic based responses, rather than more unified and coordinated responses.

You will probably hear from the departmental representatives this afternoon that there is a current exercise underway to develop a new national communicable diseases strategy. The last one was 1995, so I guess it is good to have that reviewed. I am sure there will be a lot of worthwhile insights and overview that will come out of that exercise of developing a new strategy, but I think as is recognised by everyone around this table, that we are doing that in an environment where resources are quite constrained and tight at the moment. So it is a difficult time to be doing it. But think it is great to know that that is happening, and I am sure you will hear more about it from the department this afternoon.

Dr Givney : If I could just deal with the first question again. It might be a good idea if you actually understood the structure of both the PHLN and the CDNA. CDNA is a jurisdictional committee, which is chaired by one of the state or territory Communicable Disease Control Branch heads. It has a secretariat provided by the Commonwealth. Each of these Communicable Disease Control Branch heads is in effect a junior public servant in a health department in a state. If you want to get a decision made nationally, you cannot get it done by CDNA. Similarly, PHLN is a group of laboratories, all of them state based and—correct me if I am wrong—predominantly state financed. So even the people who run them do not know where the money comes from. So, as you can imagine, it has to be a decision by consensus. We were very lucky in the flu pandemic: some of the intensivists' accounts of that were: 'One more week at that level of intensity and we would have had young people in desperate straits, in respiratory failure out on ordinary wards being ventilated by medical students.' If the peak of the pandemic had continued—

CHAIR: Why did the peak drop? Because we acted very quickly or—

Prof. McIntyre : I would not like to be that brave.

Dr Givney : I do not think we could really attribute any of our actions—

CHAIR: It was just luck.

Dr Givney : No, it is not entirely like that. The most optimistic measure of our pandemic response, I think people would say, was that we spread it out, and that is a very important thing. If you can spread out the number of very sick cases, it means that you have the facilities to deal with them, and that was really the object of the plan. There is no possibility that you will ever stop a pandemic.

CHAIR: So that includes spreading it out—assisted?

Dr Givney : Yes.

Mr WYATT: I am sorry to interrupt, Chair. This afternoon when we talk with the Commonwealth, get them to outline the AHMAC, Australian Health Ministers Advisory Council, processes, because the point that you make is a very valid one. There is a time lapse. If we had a highly contagious disease and we were waiting for people to make decisions, it would have a significant implication for the health of Australians.

Dr Givney : And the people who are trying to make the decisions—I have the highest respect for our chief medical officers, but we have not had a chief medical officer in my career who has actually worked in infectious diseases or epidemiology or public health.

Mr WYATT: I think New South Wales was the last one.

Dr Givney : It is an extremely important role, but these are not necessarily the people who can make that decision.

Prof. McIntyre : The other instructive area to look at for insights into how this might evolve is the Canadian experience. Probably, if you wanted to look to one country that is most comparable to Australia internationally, apart from being a lot colder, you would look at Canada in terms of a not dissimilar population size, a federal structure et cetera et cetera. Canada were really pushed towards putting more resources into the response capacity as a result of their SARS experience, which we fortunately were spared. That was really the driver for them to say, 'We have to do something.' I think looking at the Canadian experience in more detail and what they did in establishing this public health agency for Canada—which did not mean that everything else got trashed; it just meant that there were additional resources brought to bear and the coordination capacity at the laboratory level and at the epidemiologic investigation level was strengthened.

Dr Lokuge : Can I just add to that. CDNA largely has an advisory capacity. There is no equivalent in Australia, for example, to the Centers for Disease Control and Prevention in the US or the Health Protection Agency in the UK which has technical capacity but is a statutory body. They can make decisions based on technical advice that are implemented cross-jurisdictionally, whereas for CDNA it is more the willingness of the members to take and to give advice.

Ms O'NEILL: Could I just ask, if you were able to make a recommendation to this group, if you could perhaps create a model that you think would address some of the issues that you have raised this morning—perhaps not today but have a think about where you see the critical failure points and what might need to happen—because it seems to me that you are very well placed to provide us with some sort of a structural guide to where the holes are and where you think things might need to be advanced. And I was just interested to hear the response to the social science question.

CHAIR: And then we will go to Mr Coulton straight afterwards.

Dr Givney : There is just one last point on that. The reason why things like the MAE course, which supplies basically the majority of the epidemiologists who work in the state health departments in the communicable disease control branches, can be cut is because there is no understanding of—

Ms O'NEILL: Just how critical it is.

Dr Givney : how critical it is—that is your point. It is actually germane to the activity of all of the communicable disease control branches across the country. They will each have at least a health promotion section. It is the hardest section for them to maintain. It is constantly being taken. In mine in South Australia, the position was actually poached by Communications—they decided that health promotion is not as you have described it but that health promotion was about advertising, so they took our person and turned it into a ministerial media position. So we had to recreate it using immunisation money. Professionally we understand it and we have had a long working relationship with health promotion, but it is not something that they think of. They think of this as doctors in laboratories, I guess, because again, as I said, we are very junior bureaucrats.

CHAIR: I think you want to respond to that.

Dr Lokuge : Yes. The program that Adrian and Rodney mentioned, the Master of Applied Epidemiology program, was running until December last year. For example, during the early stages of the H1N1 outbreak, it was my staff and my students who were largely forming the surveillance and epi capacity in the National Incident Room for the Department of Health and Ageing.

Ms O'NEILL: Now you have no students.

Dr Lokuge : Well, now we have ANU funded students. I am no longer with that program. But it is an essential capacity which is recognised at every level within communicable health units, but because it needs to be funded federally—there it is.

Prof. Sleigh : The elephant in the room is centres for disease control. We do not have—and I like the Chinese model, where there is a national CDC, there is a provincial CDC, there is a county CDC and there is a district CDC. They get smaller and smaller, like Russian dolls.

CHAIR: You are saying we could have a national body, a state body and regional—

Prof. Sleigh : And all structured in a similar fashion as the centres for disease control, getting smaller and smaller and with less and less capacity as you go peripherally out, but all connected in numerous ways, by numerous pathways. That is a very good model.

Prof. McIntyre : Of course, the smallest Chinese province is about the size of Australia, so in a way—

Prof. Sleigh : That is true!

Prof. McIntyre : A few years ago I was part of a group under the NCRIS, the National Collaborative Research Infrastructure Strategy, looking into a biosecurity network, an information network, which I think Tania mentioned.

Prof. Sorrell : Yes.

Prof. McIntyre : The program she mentioned was on the agenda four years ago. It took four years to start. So you might look into the NCRIS agenda for about four years ago on the biosecurity network. I think something like $30 million was allocated. Whether it got spent I do not know.

CHAIR: I am conscious of the time. I know there are many questions still to be asked. Steve had something to ask very quickly, and he has got permission from Mr Coulton to ask it, because Mr Coulton has been waiting for a long time!

Mr IRONS: Professor McIntyre, in your previous answer you just drew a comparison between Australia and Canada, the similarities, but you then also said that we had a different SARS experience. Is there a reason for that, or is it just natural history?

Prof. McIntyre : I think we were to some extent lucky, and Canada was unlucky. But I guess it is an example of where that on-the-ground personal experience that I think Mr Coulton was referring to before is obviously a powerful driver.

The other thing I just want to add, which is a kind of more low level point, is that there is public health training that happens other than through the MAE. The MAE was the only national based one, but there are quite large training programs in New South Wales and Victoria, which are large enough states to support that. But there is not anything able to be supported in smaller states. And I think that Australia has never really had an intention to train professionals to operate regionally, to operate outside Australia, whereas that is something which other countries—the US, Canada, the Netherlands, the UK—do invest in as something which they see as a contribution to areas outside their borders, partly through self-interest but partly through, I guess, responsibility.

Prof. Sorrell : Very quickly, after the SARS question: the flight to Canada was the one that was the problem, and we learned by their experience. So we actually had the diagnostics and the available things in place before it potentially became a problem for us.

Prof. Sleigh : We had a German tourist who was found to have been infected with SARS who turned up in Sydney but did not transmit.

Prof. Sorrell : He actually travelled up the coast to Brisbane.

Prof. Sleigh : One of the features with SARS was that a smaller number of people transmitted most of the infection and most people did not transmit. Superspreading events were a feature of the SARS epidemic.

Mr COULTON: This is a very basic question. Is raised body temperature always an indication of infectious disease? We saw during the SARS times the heat scanners at airports. Is that something that is worthwhile, and should we be doing that on a regular basis?

The other one is that I was quite intrigued about antibiotics in food, as in chickens. Everyone still thinks that Australian chickens are full of antibiotics, but it is my understanding that they have not been for quite some years. But is there an issue that we should be looking at through food standards with regard to lowering immunity through bringing food in with antibiotic immunity attached to it?

Prof. Sorrell : I will take the fever one; I will let Tom do the food one. It is true that if someone newly develops a fever it is most likely to be due to infection, but there are other causes of fever, which might be due to disease or a drug reaction. The issue with the scanners in airports is that they are not reliable—they offer more reassurance to the public than they actually do information to the medical profession. I do not know whether you want to comment further.

Prof. McIntyre : They look good.

Prof. Gottlieb : The issue of food is difficult because it depends where it is being used. There is a lot more antibiotic use overseas. Highlighting the issue again, Australia has got a lot of experience and can export a lot of its knowledge and education elsewhere because the problem that I was trying to highlight was that this is all external to Australia but it will affect Australia. If we want to influence antibiotic resistance, we have got to get out there and inform and educate. That is part of our brief. We do use less antibiotics but it is not well monitored and there is a lot of off label use in larger animals that we do not have much of a handle on because there is no collected data. That is not to say there is a problem, but we just do not know how much there is. But it is certainly an issue overseas. When you look at history, you always look at the bad ideas in history. At the same time that antibiotics were developed for human use, idea of using antibiotics for growth promotion arose, where it is actually not even being used to treat infection. It is just to enable animals to be raised faster. That is not occurring in Australia. It has been banned in the EU, but it is happening all over the place in the rest of the world. That certainly affects drug resistant bacteria. Going back to the point, I do not personally have enough knowledge of food monitoring to comment, and I would not like to profess that, but there is something that should be discussed out there regarding the idea of food safety.

CHAIR: With new—

Prof. Gottlieb : And how we monitor this should be raised.

Prof. Sleigh : There were statistics kept at Hong Kong when they did the thermal imaging. Something like 36 million people were checked, 1,000 people were detained, 100 people were investigated and maybe one case of SARS was found.

CHAIR: So they are not very effective?

Prof. Sleigh : It was very reassuring to arrive at Hong Kong and pass through that machine and it was quite visually stunning.

CHAIR: You try and look at your own image when you go through. I remember seeing mine and it was red, and I thought something was wrong with me but I felt fine. Does it pick up the body temperature? You are getting off a plane, you have luggage, you have been walking and you are obviously hot. Does it actually detect—

Ms O'NEILL: It does not seem to pick up disease, whatever it is.

Mr WYATT: How well do we screen Australian passengers returning after they go into areas of high risk? For example, if we take SARS, how well did we screen people returning from South-East Asian countries where SARS was reported? When people come back into Australia we normally tick off that little green and white or brown card they give us and that is it. Also, how prepared is Australia for bioterrorism?

Dr Givney : That is essentially the screening that you get. I do not think that it is unreasonable. The important thing about those cards is that we get people's contact addresses. The interest arises when one of them gets ill. The final limitation of those heat screens is that people with flu are infectious before they have a temperature and before they feel sick at all. Border protection for infectious diseases does not work. We have actually known that since the 1890s. You have to be able to find cases when they appear in your community and then you have to be able to trace back their contacts. So the cards will work in that way. I am out of it now but when I was working in it five years ago we were still using a paper-based system. We literally had to ask immigration to get the cards.

CHAIR: They were not put onto a database?

Dr Givney : Not at that time. For example, when we were chasing up meningococcal cases on aeroplanes, it would take us three or four days to get the cards.

Mr WYATT: How prepared is Australia for bioterrorism?

Dr Givney : I am open to persuasion here. Bioterrorism to my mind is just another outbreak. We should drill with it that way. If we have got a good, well organised capacity—and that, again, is why we all keep emphasising that we need to have that rapid capacity to make decisions—I think we are set up, but technologically, you will have to comment.

Prof. Sorrell : Technologically it is well set up. There is a high-level security laboratory in every state, which is able to make the diagnosis. It is in connection with a worldwide network, including with the CDC, so that if new tests for identification are developed, they are made available very quickly.

Ms O'NEILL: I have just been thinking about the movie Contagion that has been showing and the mismatch in terms of timing. How wonderful that could have been in terms of awareness-raising for us to maybe get a local television community to do a reality TV show—you know, Contagion comes to your suburb!—and what it would look like.

CHAIR: There have been some done. I have seen American programs where they have done a simulated sort of contagion thing.

Ms O'NEILL: I was really thinking about that in response to the comment about forums in local areas: people who come to meetings to discuss an idea. It is one way, but there would be that sense of actually have an emersion experience: what would happen now; what would this look like? I wonder if it is something we should think about. Has it happened anywhere?

Dr Givney : SBS actually produced a pseudo documentary about five years ago, which was used for exactly that purpose in the citizen juries that I have been in. Its leading light was one of your MAE graduates who is now working for the WHO.

Prof. Sorrell : Always at the time of an epidemic there is a sort of tension between having people aware of the problem and behaving appropriately versus frightening them out of their minds. If you overemphasise the potential problems and the danger does not happen, then there is a loss of trust or faith in the system and that is inevitably the tension.

A lot of us like to think that the media plays a role in this. I am not sure that, in fact, the media is as much to blame as we like to think. I think it is a natural human kind of reaction. It is an issue that when you are in the middle of a big pandemic, at the beginning when you are trying to make predictions, if you err on the side of caution and it really does not come to the state that you predict then the public tend to compensate the other way. That is a major problem. I agree that the education, the forums, are important but in fact every epidemic is a bit different. SARS was quite different from flu. The advantage of SARS that enabled us to contain it is that you were not infectious until you had symptoms. So you could quarantine people who were symptomatic whereas with flu, as has been pointed out, you are most infectious before you get the symptoms. So, different pathogens behave differently.

Mr COULTON: Dr Lokuge, at a similar roundtable to this we raised the issue with someone—I cannot remember his title off the top of my head but he may have been the High Commissioner from Papua New Guinea. It was in Canberra, in this room, and I asked the question about direct Australian intervention in health clinics in the Western Province rather than—

CHAIR: Rather than going through the central system.

Mr COULTON: And he was very strongly opposed to that because he felt that it was going to undermine the confidence of the citizens of that country in the ability of their own government to look after them and so that was not likely to happen. I am just wondering, in your experience, is there that sort of political resistance and are there ways around it to get that clinical assistance in where it is really needed in a timely, professional manner?

Dr Lokuge : At the panel yesterday, we bought both the head of the national TB program from Papua New Guinea and the director of TB control from Queensland. They both said what they would like is professional exchange. Under the Health Issues Committee the Australian and PNG ministers signed an agreement for facilitated health visits between health staff. In practice, however, it does not work. I think it still takes Queensland Health eight weeks to approve travel and instead of taking the 15-minute banana boat you have to go to Daru. It is the big, dangerous trip down the river. You have these things happening at the high level so that is why I say if you get the people who are involved day-to-day in delivering the services to come up with the solution—

Mr COULTON: It is not legal to hop on a tinnie and go across that little bit of water?

Dr Lokuge : Even in the protected zone. People can come across but it is not legal to come across for health visits, so you can come to trade fish and then go to the clinic on the —

CHAIR: We saw that.

Mr COULTON: There is no way of?

CHAIR: No

Dr Lokuge : There is a way.

Mr COULTON: Say to run an outreach clinic from the Sabai clinic. It is my understanding that since we have been there that has been upgraded. But it is not possible to run an outreach clinic from Sabai over in those villages?

Dr Lokuge : They are doing handover clinics to hand over current PNG practices. I think the processes are there but it is just not happening in practice. Again, I think committees such as yourself can push that.

CHAIR: The issue is that you can run an outreach clinic but you would have to go from Sabai, Port Moresby, Daru—

Dr Lokuge : Get your visa.

CHAIR: Get your visa, get the whole lot.

Mr COULTON: It would be like going to Murrumbateman via Sydney.

Mr WYATT: Can I complement you on that report, Professor Sleigh. It is a great report to continue taking forward. What is the prevalence of community-acquired MRSA now? Is it increasing substantially or incrementally?

Prof . Sorrell : In Australia?

Mr WYATT: In Australia.

Prof. Gottlieb : It is certainly rising. We monitor it with our AGAR rates. The problem is that our surveillance is patchy and there are certain communities where it is going up much higher but a lot of our surveillance are metropolitan hospitals yet we know that the rise in community MRSA seems to be occurring more in rural populations or disadvantaged populations on the outskirts of cities—Dubbo or that sort of example. So we do not have a handle on how much there is. Anecdotally there is a lot more than our figures show but it is certainly going up. Do I need to elaborate what community MRSA means?

Mr WYATT: If you have any information on that I would not mind looking at it.

Prof. Gottlieb : I can direct you to the Australian Group for Antimicrobial Resistance, AGAR, website which does second-yearly surveillance from the community looking at staphylococcal resistance rates. You can see the graphs going up. On that exponential curve, we are still on the horizontal part of that so you never know how much you are really rising. To reiterate, because our surveillance is active and focused on laboratories that volunteer which are metropolitan, it does not quite pick up the rate changes.

Prof Sleigh : Just on the bioterrorism question, we do have white-powder incidents quite commonly and frequently in Canberra involving Parliament House or various embassies.

CHAIR: Even in electorate offices. I will now conclude this session. Thank you all for your participation.

Pr oceedings suspended from 10:29 to 10:45