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

FIRMAN, Dr Jennifer Ruth, Principal Medical Adviser, Office of Health Protection, Department of Health and Ageing

HART, Ms Virginia, Executive Director, Research Programs, National Health and Medical Research Council

JOLLY, Ms Maria, Assistant Secretary, Health Protection and Surveillance Branch, Department of Health and Ageing

LUM, Dr Gary, Assistant Secretary, Department of Health and Ageing

MORRIS, Dr Clive, Head, Research Group, National Health and Medical Research Council

MORRIS, Ms Megan, First Assistant Secretary, Office of Health Protection, Department of Health and Ageing

SMITH, Dr David William, Chair, Public Health Laboratory Network of Australia

CHAIR: I welcome all participants to this session, the third session of the roundtable discussion on health issues across international borders. Thank you for making the time to come and speak with us and the committee. Welcome.

Like session 2, the committee is seeking information on the Commonwealth policy framework regarding infectious disease issues across international borders in this session. The committee is interested the role each of your departments play in monitoring and controlling infectious disease in Australia and across regional borders. We are also interested in how you coordinate with other Commonwealth departments and agencies and with some state governments and nongovernment agencies. For those participants that were not present in session 2, the committee has decided to structure these sessions as informal roundtable discussions to encourage an interactive discussion. We will hand over to you for some statements; we will then ask some questions and then have an informal discussion. The proceedings will be broadcast live through our House of Representatives website and recorded by Broadcasting and a Hansard will be available in the near future.

If one of our members has to leave, is it agreed by the committee that we will form a subcommittee? There being no objection, that is agreed. I would now like to offer each participant the option of making an introductory statement.

Dr Smith : I am a clinical virologist in Perth and Chair of the Public Health Laboratory Network, which you may not be familiar with. The Public Health Laboratory Network was formed about 15 years ago to bring together major public health laboratories within the country to play a leading role in the laboratory aspects of public health microbiology control of infectious diseases. All of the jurisdictions are represented on that, with senior members from each of the laboratories. Most of us are medical practitioners who have specialised in microbiology in infectious diseases. Most of us also have associations with universities and with hospitals as well.

Ms Morris : The Department of Health and Ageing will not make a statement. We made one last time round and we would add little and take up your time if we gave one this time.

CHAIR: Thank you. Dr Smith, would you like to continue with an opening statement about what you do and where we are heading?

Dr Smith : Yes, thank you. In terms of the roles of our organisation, the members of PHLN are involved in a lot of communicable disease surveillance. We do a lot of diagnostic testing for identification of pathogens and reporting of infectious diseases back to the jurisdiction and the Commonwealth committee. We look at a lot of infections in returned travellers as one of the sources of exotic infections. We have a formal membership, representing New Zealand and the private health laboratories as well, national reference capacities such as the WHO centre for influenza in Melbourne, and also animal health laboratories. So we try to bring together all of those aspects.

We have been involved already in a number of emerging diseases and dealing with those. Of course, there was SARS. There was avian influenza, pandemic influenza, anthrax and the other biosecurity threats. Developing the capacity to detect and deal with those was largely vested in the members of the Public Health Laboratory Network. In the past we have dealt with threats due to viral haemorrhagic fevers. We also have a number of the high containment laboratories—level 3 and 4 laboratories—for dealing with highly dangerous pathogens as well.

A number of existing interactions occur within the regions, and there are quite a few of them. These include ones with Indonesia, PNG, Timor-Leste, Malaysia, Sri Lanka, India, Vietnam, China and Singapore. In most countries in the region various members would have interactions of different types. That is largely to look at how we work with them to improve our capacity to identify infectious agents there, to build their capacity to offer services and to improve the quality of laboratory services. That is based on the premise that, if you are going to deal with existing and emerging threats, you have to be able to identify them first. So the capacity to accurately diagnose infections is fundamental to the ability to control them and prevent them, both in terms of knowing what is happening but also in identifying potential interventions or therapies and, later, vaccine development—all the sort of information you get from knowing more about the organisms. We have gone through that process.

We have a very robust system in Australia that has been able to deal with a number of threats that have come up so far. We now have a greater capacity. I believe you have heard about a number of quite sophisticated technologies that give us a lot more power to identify organisms. When SARS appeared, we knew the infecting organism within a couple of months. A decade or two ago, it would have been months or years before it was characterised. When pandemic flu emerged in 2009, we had tests available for that within two weeks, long before the pathogen ever entered into the country. So this maintenance of communication, maintenance of capacity and flexibility is all crucial to the ability to respond.

We also engage in active and applied research activities, usually with our university colleagues, to look at how we get the system further along. It does not happen without any costs. By that I mean that the capacity to deal with it is a significant physical, professional capacity or infrastructure drain. It is a necessary one and it is being met, but we have gone through the process, particularly post-pandemic, of looking at what went well, what did not go well and what we needed to do a little better. Certainly there are some things to do with establishing communication lines and lines of responsibility, looking at how we transfer information, better rationalisation and utilisation, and ensuring we have sufficient reserves to meet emergency situations.

That is an ongoing process that is happening now, but again it is critical to maintaining our capacity long term. We all have day jobs and we all have to deliver. There is an expectation that a certain level of service will be delivered. If things are added on top of that, we have to make sure that we have the capacity to do that and to continue to deliver all the other services that the public expect as part of their health care and that public health practitioners expect as part of that.

In terms of what we have the capacity to do, we have a lot available to us in Australia. We have a lot of very skilled and expert people. We have a lot of enthusiasm and a lot of interest in this. A lot of people are prepared to reach out to the region for many reasons. What we need to do is make sure that it is adequately resourced and that the bit that operates around it is also a seamless interaction that makes the most efficient use of those resources. We have practical experience now over a number of years of how to deal with this, and we know we are going to have to. We sit in an area which is one of the hot spots for the emergence of new pathogens. There has been a trend of one or two each year, so we expect to have to deal with new threats regularly.

Dr Morris : I will make a brief statement on behalf of the NHMRC. The NHMRC is established under the NHMRC Act and we have four statutory obligations under that act: firstly, to raise the standard of individual and public health; secondly, to advise on developing consistent health standards between the states and territories; thirdly, to fund health medical research and public health research and training; and lastly, to advise on ethical issues relating to health. Also under the act we are charged with developing a three-year strategic plan and, in that strategic plan, identifying the major health issues that are likely to arise during the subsequent three years and how the organisation will deal with those health issues.

The current strategic plan is for 2010 to 2012 and we are about to start the process of developing the new strategic plan. Of the 10 major health issues in the current plan, four relate to the NHMRC. Those four include global health, where we are looking to be a good international citizen and contribute to supporting Australia's contribution to the global research effort, including in infectious diseases. The second issue is genomic medicine and frontier technologies. As you just heard, the technologies are changing very rapidly and it is important that we fund research that leads to improvements in technologies. The third issue is planning for emerging infectious disease threats, which is self-evident, and the fourth is global health. Global health is of course relevant in that, whether or not you believe in climate change, there are diseases that have been shown to be moving down from the north to the south especially, such as dengue fever.

So how do we achieve this? We do three main things. First, we do evidence synthesis. The NHMRC develops guidelines—for example, the recently developed guidelines for infection control, which are used in hospitals. We do quite a few other clinical practice or public health guidelines. We also approve guidelines developed by other organisations. So we approve the process that other organisations may go through in synthesising evidence and developing advice. A good example of that would be the immunisation handbook developed by the Australian Technical Advisory Group on Immunisation through the Office of Health Protection.

The next thing we do is fund the best research ideas and the best researchers in Australia. We administer the government's investment in health and medical research, which this year is approximately $800 million. We run a variety of research funding schemes. Our largest scheme is a project grants scheme. When we run the project grants scheme annually we invite applications related to the major health issues we have identified, and we do that in our other research schemes, as we do with our people support schemes, funding the best people. We have a number of fellowship schemes ranging from scholarships right through to very senior research fellows. That funding for fellowships covers all elements of health and medical research from basic biomedical research through to public health research.

Also, in response to particular issues, we run targeted calls for research, especially when we want to fund research on things that may emerge in the future, such as emerging disease threats. We maintain the capacity to run urgent calls for research. Over the last 10 years we have done that four times. In 2003 we ran an urgent call for research in response to the SARS epidemic. In 2006 we made an urgent call for research in response to the threat of bird flu—H5N1. And in 2009 we made a very urgent call for research on the swine flu epidemic. When I say 'very urgent', that is against the normal time frame for calling for applications, doing peer review and allocating funding. It is very difficult to do in under four months. We were able to call for applications and have research dollars going out the door within about six weeks. We followed that up with a workshop about six months later. We brought together the researchers we had funded and the policymakers to look at the outcomes of that research.

In 2012—that is this year—we ran an urgent call for research into the hendra virus. This was in response to concerns that the virus, which is currently limited in its ability to infect humans, may cross the species barrier. There was concern—especially when a dog in Queensland became directly infected—that that was a sign that it was leading towards being more infective in humans. We are in the process of finalising the peer review for that urgent call for research. We hope to make announcements of the funded research very shortly.

Lastly, the NHMRC, on behalf of Australian researchers, maintains links internationally with major funding organisations. We work through both government and non-government funders of research. A good example of that is the Bill & Melinda Gates Foundation. We are in discussions with them about potential research collaborations. Just recently we held a joint symposium with the Singaporean health research agency, A*STAR, on tuberculosis and influenza. We will shortly be doing a joint call for research into infectious diseases. We anticipate that that will be opening in June or July this year.

Mr WYATT: What have we done to develop our human capacity to combat potential epidemics and epidemics in the future?

Ms Morris : Can I check what you mean by that question? When you say 'human capacity', are you talking about workforce on the ground?

Mr WYATT: Yes; workforce on the ground and the coordination role within the workforce. I will come back to coordination in a more particular reference.

Ms Morris : All right. That is what I wanted to check.

Dr Smith : I can certainly comment from my perspective. We did an extensive debriefing process after the pandemic in terms of dealing with additional workloads. It is a challenge because what you find, given that we have a certain amount of expertise—particularly high-level, professional expertise—is that gets stretched very thin in those sorts of circumstances. In such a situation you have a much more complex demand process occurring because people are wanting rapid turnarounds and samples are coming in different ways and often in large numbers.

At that time you are also developing and validating new tests at the same time. Their interpretation is often more difficult, and indeed much more critical of course—wanting to know that you were confident that this was the first case of pandemic influenza in your state was an extremely important call to make. So that did drain those resources and we recognised that there was a critical shortage at that level when you had these very high demands. So we have looked at how we can build up that sort of skill base. You do not want people who have nothing to do until an epidemic comes along so you really see how you utilise them within those frameworks.

The other issue is to look at things we can do that take work away from people—so going to more electronic systems so that people are reserved for things that we really need people for. That is now the direction laboratories have been moving in for the last decade or so—for a lot of reasons—so it is about ensuring that you maintain that skill base.

We found another thing. A number of assumptions were made about how you could deal with emergency workforce demands, one of which was that you would lay off some of the work to someone else who could do that while you did the specialised work. It did not work. There were lots of reasons why it did not work. Obviously they were not reasons we particularly anticipated. But it was clear that, where you were dealing with highly specialised work, you were going to have to take that into highly specialised laboratories.

One of our strategies is to now look at how we engage some of the other laboratories such as the large private health laboratories. You could not suddenly go to them and say, 'Can you take this work?' It created all sorts of logistical and funding issues that were not easily soluble. How do you put those processes into place before it happens so that when it happens you can turn them on? That is tied up with a lot of issues of how you build the pre-existing capacity. It has to be there already. You cannot suddenly get people with the skills that you want; they have to be there already. That is a process but it is difficult.

CHAIR: How do you recruit at the point when an emergency such as swine flu comes up? We are talking about having the expertise there. If there is no urgency, you cannot have people doing nothing. At that point you want to have the expertise somewhere out in the field. How do you coordinate bringing them all in?

Dr Smith : It depends a little on whether it is a localised emergency. It happened in a slightly different but related field I am involved in. There was an appearance of an exotic mosquito in Tennant Creek, I think, in the Northern Territory. They asked whether there were people from WA who could come and help with the process. That was fine. We did not have any emergency problems at that moment and people could go and help. In those circumstances we look at drawing in expertise from elsewhere, either in terms of bringing people in or being able to engage other laboratories.

Having a national network has been extremely important in that process, because we have a communication network. We can say, 'Who can do this? We need to be able to do this. Who can do this now?' Or 'Who can tell us how to do this' if we do not already have it,' or 'We're all doing this, let's look at what we found works best.' That happened in the pandemic in the development of tests. Australia was extremely quick in getting tests up and available.

When everybody has the problem at the same time—which is what happened in the pandemic—to be honest, you do not have a level of reserve. People work harder and longer, and you look at what you can or cannot defer. That works well for about three to four weeks. After that you cannot say to people, 'All these other things we normally do, we'll get onto later.' People cannot wait forever for the routine stuff. They will understand for a while. Staff then start burning out because they are working too long. They are getting stressed. We then work with our public health colleagues to say, 'This is the limit of our capacity.' This is the really important communication bit of saying: 'Let's decide what really needs to be done.' Some of it was nice to do, but it was not essential to control the pandemic. That is part of how you look at building up a skilled workforce. You maintain other people who have that skill base with some regular re-training. It is a bit like the Army Reserve. They are there ticking over. They are doing something else most of the time but they can be dragged into this when they are needed.

The truth is that, in the current system where basically everybody is fully employed, it is very hard to cut the slack to develop those systems—to say, 'We're going to do this.' Everybody will say, 'Sorry, I'm fully employed. We don't have extra time.' That is the challenge in how you get those things. Everybody thinks it is a great idea. The question is how you actually get it done. I think it has been flagged in some of the other reviews I have seen in terms of maintaining the capacity through the universities and training, and making sure that these sorts of issues are part of what we expect our undergraduate medical and scientists to get engaged in.

We are building collaborations in the animal health sector as well. It is not just infections that cross over; a number of the technical problems are the same. We are looking at how we share that expertise. We send samples to the animal health labs for some of our testing. They deal with some of the things that we do not. They have a much more sophisticated high-containment set-up. So it is looking at how we achieve efficiencies across the sectors as well.

Ms Morris : I have been thinking about the question. I asked at the beginning for more clarification. In thinking about it, I have a further question and I will just explain why. The workforce to manage a pandemic is really, really diverse. It is not always because of the most obvious things you would think about. The capacity to use that workforce well, for me, is very closely linked to whether you have sensible processes in place or whether you are just lining people up and marching them around to different places and sending everyone quite spare. So I find it hard to de-link the two things.

In terms of the workforce that would actually cope, the workforce you would immediately think of is the medical/nursing workforce. A large part of that is actually in the state public health system. But, that said, most people are probably going to turn up to a GP first, especially in the early stages before you know the severity and there are not a lot of cases. So we are talking GPs and practice nurses. Public health systems in the broad and public health laboratories are part of that. We would also be looking at the private health system and the private hospital sector and how you would best use your bed capacity in a pandemic. They are all the sort of things that we have considered in the past and continue to consider. Then there are the civil society and your economy workforce, because if you have a pandemic the capacity of society and the economy to keep functioning get really tested. So it is a very broad issue and I am wondering if you have a particular area that you are most interested in.

Mr WYATT: I was wondering if we had an Ebola virus outbreak in Perth and a plane that went on to say Melbourne and we had an outbreak there—

Ms Morris : On the north or south side of the river?

Mr WYATT: It does not matter. What is our capacity to harness the human capability, let alone the facilities of hospitals, which in that case would have to be isolated totally?

Dr Lum : Using the example of a viral haemorrhagic fever like the Ebola virus—and I have to concede that David as a medical virologist is more expert in the virology and the clinical side of that—if you have an aeroplane coming in from southern Africa into Perth and then you have the transfer of passengers to other places in Australia there have been plans developed. There was a viral haemorrhagic fever plan developed in the 1970s, reinforced in the 1980s. Certainly there is the situation that in Melbourne we have the Victorian Infectious Diseases Reference Laboratory, which is the designated national high security quarantine laboratory for that component of it. All of the states and territory at the time were meant to be developing a situational capability so that they could have negative pressure rooms available to handle potential patients with a viral haemorrhagic fever infection.

In this day and age, we often get the information well in advance. We are on top of the social media aspects of it as well. We certainly get information about potential outbreaks in other countries. We do a broad surveillance sweep continuously through our processes within Canberra. We work very closely with our colleagues and states and territories around that. So in terms of that broad workforce issue, I think that we will be aware of something emerging very quickly. The fact is that if it was from an area where we would be thinking about viral haemorrhagic fever, we would have the likes of Dr Smith and his clinical colleagues in Perth well aware of that. We would be communicating that pretty quickly around the country. We would be not wanting to create a stir about it but we would be working quietly and quickly to ensure that all of the various reference hospitals in the states and territories were aware of the possibility. In addition, from our perspective in Canberra, we are the national focal point under the World Health Organisation's International Health Regulations. We have a responsibility and obligation to share information and to receive information from our international colleagues, and we would be doing that at the same time. Should there be a need for assistance within the country, we would be calling upon the relevant professional groups and organisations to assist in that matter.

I think that, on that example, while there is that scary Hollywood potential of a major problem, if we were alert to the situation early enough we would be able to contain it, and we do have plans for that contingency. If it was a non-natural incursion—if it was a deliberate incursion—we are also in the development phases of plans for that sort of eventuality as well. We certainly have relationships with other countries to assist us in that regard.

CHAIR: When you say non-natural, are you talking about biosecurity terrorism?

Dr Lum : Yes.

CHAIR: You would still deal with it in the same way?

Dr Lum : Yes.

Dr Firman : In that circumstance CDNA would be integral to that response as well. CDNA is made up of representatives from the heads of public health units in the states and territories and additional experts from a range of areas. When an event like that occurs, CDNA would quickly meet and look at what sort of information is required for a coordinated national response so that all the states and territories, who will actually be doing the work on the ground. As a group they all know exactly what they need to do, and they have an agreed approach. They would develop what they call a case definition so that everyone would know what they are looking for. They would look at what surveillance systems they would need to set up to detect it quickly and readily and they would liaise with PHLN to look at what would be the lab capacity and the lab issues associated with it—they would actually be looking at what that response should be like and who should be doing what on the ground. As Megan suggested, the states and territories have the doctors and nurses in the hospitals, and they are doing the work and seeing individual conditions. But from a health perspective that needs to be coordinated, and that is the role of CDNA.

CHAIR: When we had the flu pandemic a few years ago, as an outsider not involved in health, to me it seemed like we coped pretty well with it. First there was this fear and panic, and then it subsided and it looked like things went into place and people knew what they were doing and it panned out and it was quite good. This system that you have just explained to the committee was in place then?

Dr Firman : Absolutely.

CHAIR: So you took up the—

Dr Firman : The CDNA is a subcommittee of the Australian Health Protection Committee, and they are there to do national responses for health emergencies of any description. In that instance CDNA were providing the advice to AHPC, who could provide that governance across Australia. So CDNA would do just those steps: they would meet daily, sometimes twice a day, and go through all those issues. At the start of any pandemic, when you do not know the actual severity, there is a lot—

CHAIR: Panic is the best thing, I think

Dr Firman : That is when you are frantically gathering information as fast as you can, and, once that information is known and you know what the severity is, you can be clear about what the proportionate response is that you need to that particular threat and then things settle down into a smoother situation.

CHAIR: Do you think we overreact—not you guys but all of us—or is it just the natural phase that you go through when something unknown happens?

Dr Firman : If you do not know the severity, you do not get a second go to say, 'I wish that I'd reacted more vigorously in the first instance,' because it is a bit late then. You actually have to be ready for any level of severity at that point, and you have to be able to assess it quickly. Then, when you know, you can then scale your response appropriately.

CHAIR: Is there anything that we would do differently? I suppose you always learn out of experiences. Is there anything that we will do differently this time if something happens? What could be done better?

Dr Firman : I think that the processes that we went through in terms of CDNA and AHPC are tested, tried and true. They work every time. In terms of the review post the pandemic, we looked back to say what we could do better just like every country in the world did and the WHO did. That issue about severity and having your response flexible was one of the key things to come through. We would set up systems whereby we could really assess that severity more efficiently than we did last time, so that we can get that information as quickly as possible. We have it clear that we have a plan that is quite flexible, that can respond to different levels of severity. In terms of capacity and workforce—your question from before—in some ways, something like Ebola, because it is a severe disease with a high mortality rate, may because of that very fact potentially have less demand on the workforce than something that is milder. If it is milder it will go on for longer, you will need more and more people to sustain the response.

Dr Smith : We have dealt with a few Ebola cases and they are actually not that difficult because it is generally one person and, whilst you will have contacts, the risk of transmission to contacts is minuscule—it is not easy to get. If you go to the contagion sort of thing, or if you deal with influenza or if we got West Nile virus—as happened in the US—where you get large numbers of people exposed to a potentially serious illness then that becomes the real management challenge. We have special negative pressure rooms for querying VHF cases as they are in each jurisdiction—but there is only one of those. You could possibly make it into two. Then there are another 10 or 20 in the hospital that could be adapted. After that you are looking at how you cohort people and it becomes much more challenging to manage. I would say also that, in relation to pandemics, I think there was in the community a perception of mildness—which is true—but in the hospitals it was a very different situation. ICUs were full to overflowing, we were seeing pregnant women die—that just did not happen previously— and fit and young adults were ending up in ICU. It stressed the hospital system quite a lot, but it was not the 1918 scenario, which everybody has fixed in their mind in relation to influenza. But it was a bad pandemic.

CHAIR: But this pandemic is still around—

Dr Smith : The virus is settling into more of the pattern that we see with seasonal influenza viruses, which is usual with pandemics—they adapt to the human population because it is not in the virus's interest to kill its host. They are getting into a more calm and transmissible state, but we are still seeing younger people coming into hospital with severe pneumonia.

Mr WYATT: What is our strategy for regional centres?

Dr Smith : That is a really good issue and a very challenging one, because so much of what we have found with the management of the pandemic was reliant on treating people. You treat them on spec because if you are going to treat you have to treat early. But there are the issues of whether they had it, what to do with them and whether we cohort them with other people who have got it. The only test that worked with the pandemic was a PCR test and that was not available outside the metropolitan centres, other than in the east coast and some large regional centres. It meant that if somebody came into Derby Hospital, we had to fly the samples down to Perth to test them. That is one of the things we have looked at with some of these issues with testing—what we are looking at in building capacity in the region. We have an interest and face the same sort of challenges in our rural and remote areas of getting them access to the test they need to help in these sorts of situations. It also improves their routine capacity to deliver services nearer to where the people are. It was one of our biggest challenges because we basically had to say, 'Well, you're going to have to wait an extra day or two,' because of the distance involved.

Mr IRONS: This is off the edge a bit but do we see any threat through the fly-in fly-out system? I know in Western Australia a lot of the FIFOs live in Bali or live in Singapore and come in. We do not keep regular tab of those people, do we?

Dr Firman : I must admit that there is a population of people who do just that, but then there are the millions of people who are coming in and out of Australia every day, and the millions of Australians who travel overseas for holiday—sometimes for extended periods—and come back. In a concentrated population you might spot a disease potentially a little bit earlier just because it is a confined group but that is always going to be the case and it would be no different, I do not think, compared with all the travellers who normally come in and out.

Dr Smith : You know that the reappearances of dengue in Queensland are due to people who come in. We know that the spread of the pandemic was largely driven by air travel and now most people can travel around the world within the incubation period, so even when they come in they may be feeling perfectly fine because they are still incubating at that stage. There are so many people coming in that way. We do think that it has contributed to some of the spreads within Australia because we see a different pattern for seasonal flu now in WA. It used to always be the metro and then it would go to the regional areas. Now they all seem to ping off at the same time, and that may be because there is so much more traffic of people taking things back and forth between the metro area and the regional centres.

CHAIR: One of the questions that were surprising was when we had the bird flu—what was it called?

Dr Smith : The swine flu?

CHAIR: Not the swine flu. The bird flu.

Dr Smith : The avian influenza.

CHAIR: Avian influenza. The question was how we managed not to be affected by it. We are so close to Asia, and there is the interaction that we have with South-East Asian countries.

Dr Lum : That is because that particular virus was not easily transmitted between humans. Those humans that were infected were in very close, almost intimate contact with the birds.

CHAIR: So it was not from human-to-human; it was from the birds.

Dr Lum : That is right. There are cases and instances where there are flocks in Australia that get influenza. We have very good relationships with DAFF, and we work constantly so that, if they are aware of a case of an avian influenza outbreak in a bird flock in Australia, we work together with them to monitor the situation.

CHAIR: So it would not be unlikely if those birds had some sort of disease, but you would have to be in very close proximity, and these are violent birds, so—

Dr Lum : For that particular virus—influenza virus A(H5N1)—yes, at the moment. That has been the controversy at the moment with the two research centres that have been reporting increased transmissibility in ferrets from Holland and from the United States. Those reports were demonstrating some increase in transmissibility. What those reports also demonstrated was that, while there was an increase in transmissibility, there was not an increase in lethality. The ferrets that were infected did not necessarily die, or they were not getting severe infection.

Dr Smith : It is an example of how you need to integrate in with human and animal health, because the H5 strain, as Gary said, remains an animal pathogen that humans get occasionally. The concern was that it would mutate in the way that the 2009 strain did. The migratory birds still did bring it round, but there are not many migratory bird pathways from South-East Asia down to Australia. They largely go in other directions—down into Africa, where it spread, and across Europe, where it spread. The spread across Indonesia was probably largely due to movement of chickens for commercial purposes, and our domestic flocks are not managed in that way. But, as Gary said, we do get occasional introductions of bird flu, but not the bird flu. There are a number of different strains that can infect birds. It is something where we keep our interactions going with our animal health colleagues. We had some influenza in workers at a piggery in Perth. We thought a few alarm bells went off—pigs and humans—but it turned out that it was a human flu and they gave it to the pigs.

Dr Firman : Australia, compared to other countries that have avian influenza, has much better biosecurity about commercial flocks and stops mixing of wild and domesticated birds, and that reduces risk as well. We usually do not live in the same house as our chickens, and that close contact is often what is required for bird flu.

Dr Smith : Interestingly, we did see that situation with the entry of Japanese encephalitis into the Torres Strait Islands in 1997. I think they had the first cases there. That was an example of a situation where they had the right circumstances for it. They had pigs near human habitation, and the pigs are the ones that get infected and infect the mosquitoes, which then bite the humans. They have a vaccination program, and the pigs are now moved a distance away from the human habitation, which greatly decreases the risk of any infected mosquito biting people. It is one of the issues with Australia. We have a number of ecosystems that are potentially susceptible to introduction of some of these exotic viruses. We are very wary that these things can happen. It is looking at where you think they are going to happen, whether you can actually stop it, or, if you cannot stop it, how you are going to know it as early as possible so that you can prevent and eliminate it. The dengue introductions into Queensland have been successfully eliminated each time. If you catch it early, there are things you can do.

CHAIR: I think it was Ken who raised Ebola, and the scenario was that we know in advance the areas where these diseases are. How do we monitor them? Obviously we have a world body that monitors illnesses around the world—

Dr Lum : There are a number of methods. We get them electronically, through email. There are a number of organisations set up around the world that, either sponsored or unsponsored, that provide information freely.

CHAIR: It is pretty accurate?

Dr Lum : It is reasonably accurate, but there is also this thing called rumour surveillance, which is also really important. You will find that there are epidemiologists working in other countries. They will pick up on something. They will report it up the line. That will be shared between experts—

CHAIR: Investigated.

Dr Lum : Investigated. Country-to-country sharing will occur and then it becomes global information.

CHAIR: Is that done on a formal or informal basis?

Dr Lum : Some of it is formal; some of it is informal.

CHAIR: So we have got some formal bodies and some informal bodies.

Dr Lum : Yes. That is right.

Mr IRONS: How often? What is the frequency of notification?

Dr Lum : Regularly.

Mr IRONS: Weekly?

Dr Lum : There is one approach called ProMED-mail, which is an email distribution system of experts around the world that just freely inject information via email. You could get an update a few times a day on a particular subject. There are other programs that do a little bit more investigation before they release information and then there are other ways in terms of formal country-to-country communication. If we, under the international health regulations, make a request for information from another country, that would be one of those formal ways.

CHAIR: Would you be able to walk us through a scenario? If an email turns up from somewhere in South-East Asia—Cambodia, let us say—and there has been an outbreak of some form of pandemic and we are unaware of what it is, what do we do from that point?

Dr Lum : From a national perspective—and state and territory colleagues will be aware of these things often as well and they will be communicating with each other and with us and we will be communicating with them—we have a process in place—

CHAIR: It would be good to walk us through the process.

Dr Lum : Yes, sure. Within the Office of Health Protection we do what we call RATs and MITs. A RAT is a Rapid Assessment Team and a MET is a Monitoring and Investigation Team. Within the division that Ms Morris heads, we have in place a process where, if, for example, in Ms Jolly's branch there is an epidemiologist who gets this information in an email and says, 'This is very interesting,' he or she would take it to Ms Jolly or to me, as branch heads, and within an hour we will have a process in place where we will investigate this matter, and then we will take it to Ms Morris for further action.

CHAIR: How would you investigate this email that has come from someone in Cambodia?

Dr Lum : Within my branch, we have a process of constant monitoring of information on the internet. We would be looking through any of the feeds that we have. We would also be quickly calling colleagues in states and territories to find out if they had heard anything. We might also, if we do have a contact in Cambodia, using this example, go directly to them by telephone and ask for more information. If after an hour we feel we have a situation that we think needs to progress, then we would take it to Ms Morris and ask her specifically whether we need to do anything more.

What I wanted to do before, in the context of what Dr Firman was saying about CDNA, was to give a bit of context about how the Australian Health Protection Committee works. It is a principal committee that works under AHMAC, the Australian Health Ministers Advisory Council. It is basically made up of chief health officers from the states and territories, so very high decision makers in each state and territory. It is chaired by the Chief Medical Officer of Australia, Professor Baggoley, who holds deputy secretary level within the department. It also has members who are subject matter experts in disaster health. For example, this year we have met a couple of times by emergency teleconference. We can switch on a teleconference with an hour's notice to talk about a particular situation. If we deemed that this situation in Cambodia was of such important ort we would go directly to the Chief Medical Officer through Ms Morris and he would say to me, 'Gary, I need you to organise a meeting.' We would organise a teleconference within the hour. We would have all the chief health officers online. We would discuss it and from that we would have a plan in place on how to approach this.

It might just be that we monitor and investigate. It may be that we need to do something more. It would depend what was happening within the region under the Western Pacific or South-East Asia regional offices of the WHO or more broadly. So that sort of paints a picture of how we might respond.

CHAIR: It is a bit of a hypothetical.

Dr Lum : But more often than not we are just monitoring things. Somebody might come to me and say, 'Gary, is this worth doing anything with?' and I would say, 'No.' Sometimes, though, we go a bit further.

Ms Morris : I would add that there are a lot of informal phone calls and emails just to test what is really happening. Just to add to the context of AHPPC—I know that you know this but we were just talking about the process—a real example is that both CDNA and AHPC are subcommittees.

Dr Lum : PHLN.

Ms Morris : Sorry, PHLN and CDNA are subcommittees of the Australian Health Protection Principal Committee. So that would meet within an hour. The members of the other two committees would probably be aware and would be on an alert to meet. There would be an exchange of information between sub-committees and up to the principal committee.

CHAIR: Going back to this hypothetical, if it has come to your attention that it is pretty serious, at that point do we isolate any aircraft? Do you isolate the people coming from Cambodia to Australia to cut it off? At what point does that take place?

Dr Lum : If there are Australians on board there is nothing that we can do to stop Australians returning to Australia. I think the better example would be to look at what happened in 2009, on 24 April. We know that there were reports of a severe influenza occurring in Mexico. We also know that there were reports of influenza moving into the United States and through into Canada. We were getting direct information from Mexico and we had a very close colleague who was working in Canada providing us with information at the time.

CHAIR: We had some colleagues that were there?

Dr Lum : That is right. So within a few days of the World Health Organisation declaring that this was an event of international significance—it had not declared it quite as a pandemic—we were monitoring it and we were kicking in place the decisions that we needed to make to inform our minister and the Governor-General on whether to make this infection a quarantinable disease. Once we had made it a quarantinable disease then certain actions under the Quarantine Act of 1908 had to come into play. The minister would be a decision-maker on whether or not we would do things in terms of overall quarantining—

CHAIR: He would be taking advice from you guys?

Dr Lum : That is right. At the time it was 'she'. She would be taking advice from us. The notion of isolating an aeroplane was exercised in 2006 in a very large three-day exercise, called Exercise Cumpston, where we specifically looked at avian influenza incursion into Australia. We looked at the intricacies involved in quarantining an aircraft. That proved to be extraordinarily difficult. In 2009, while we did not have an aircraft, we had cruise ships coming in and out of Australia, and we learnt a lot from that process of cruise ships and what was happening in Sydney at the time. There were a couple of cruise ships that came in with infections. There was a process in place where the passengers that were coming off those cruise ships had to be asked—they were not necessarily placed into quarantine per se—to stay in Sydney and were provided with telephone numbers to get advice every day. We already had in place, as part of our preparation planning, a program called the Home Quarantine Support System. So if they were Australians who were going home we were asking for their contact details, and if they were sick we had a system in place using our colleagues in Centrelink and Medicare Australia to make telephone calls to their houses every day asking how they were. At the same time we were sending out a quarantine home pack of some small items—alcohol hand rub, masks and things like that—so that they were aware that they should just stay at home. So we had done a lot of planning around that at the time.

What we have learnt, though, from that particular event is that doing those things did not necessarily work. It was too difficult to arrange all of that to cover the country, particularly if the infection was more severe. We are now in a process of planning. We are embarking on a process of implementing the lessons that we have identified from a review of 2009 and we are going into a process where we will be reviewing the plan for pandemic influenza in Australia.

Mr David Smith : The process has worked that way for a number of real events, and potential events, from our point of view. An example of what happens at AHPC level is that, once we are aware that there is a potential risk, we will seek information from our colleagues about what they think it might be and what the possibilities are. Then we will start looking at whether we would be able to detect it and how we are going to do it We would establish a test and determine who we are going to test and what turnaround times are necessary. We would then work with our public health colleagues in terms of setting up those systems. If it was something serious in Cambodia, what are we going to do when somebody returns from Cambodia unwell, how are we going to know whether they have this or not? Hopefully, they knew what it was. There actually are quite sophisticated processes now for dealing with situations where you do not know what it is, much quicker than we used to be able to.

Dr Lum : Ms Morris has suggested that I should also mention something about our relationship in terms of incursions with our colleagues in other Australian government agencies—for example, the Australia Customs and Border Protection Service and DAFF, through the Australian Quarantine and Inspection Service. Those border agencies are really important for the work that we do at the border, particularly at airports and seaports. We work very closely with them so that they ask relevant questions of any passenger who volunteers information that they are unwell. In 2009 we put in place a process of health declaration cards so that, when any aeroplane was descending into Australia or any ship was coming into Australia, the master of that particular vessel would have to ask all of the passengers, through a public address system, whether any of them were declaring themselves unwell. The health declaration card needed to be distributed and handed to all of the passengers that needed to complete them. That is distinct from the incoming passenger card, which is a routine process that the Department of Immigration and Citizenship manage for themselves at the moment.

There were also the issues at the border where AQIS, as well as state and territory staff, were looking after things such as the thermal scanners. We all recognise that, from a scientific perspective, they were not very useful. From a public confidence perspective, we got a lot of letters from well qualified health professionals telling us that we were wasting money. However, at the same time we were also getting letters from Australians who were saying 'This is fantastic, you should buy more,' or 'Why do don't we have one at every gate and in shopping centres?' You can see that, from a public confidence perspective, they really had a role to play.

Mr WYATT: Given the turnover of staff over a period of time within health systems and jurisdictions, what biosecurity information collections do we have and how are they analysed?

Dr Lum : Can I ask how you define 'biosecurity'? Because there are a variety of definitions of biosecurity that—

Mr WYATT: I know there is a range but the issue is that, in every jurisdiction, we see a turnover of people—even in the CDNA, there has been a turnover of people in the last decade—so your corporate knowledge is not always there. So how do you then manage your biosecurity information collections to ensure that they are adequate to deal with pandemics within Australia? As an example, some of those people who were heavily involved in the Cumptson activity that took place have now moved on so those remaining will not know about the richness of those discussions that you had as to what the preventative measures where and what those areas were that just were unreal and were not workable.

Ms Morris : I preface whatever intelligent contribution others are going to make by saying that a lot of that comes down to how well you document things and what processes you have. If you are entirely dependent on the knowledge of the individuals then you are always exposed in anything that you do.

Mr WYATT: So how do you do your processes then, based on what you were just saying?

Ms Morris : I will let Doctor Firman speak.

Dr Firman : There are a lot of processes you are discussing there. Certainly there is turnover of public officers and public health physicians from states and territories and from the Commonwealth. Often that turnover is not out of public health but to another public health unit in another state or internationally and then they return. The knowledge does not evaporate overnight. The people move around, yes, but often it stays within that system for a start. We do have surveillance systems nationally which remain, no matter who is there. We have the Nationally Notifiable Disease System, and that depends on the state and territory public health legislation, which lists notifiable diseases that are reported by individual clinicians or by laboratories when they detect them. That comes centrally to the state and then is shared with the Commonwealth and the Nationally Notifiable Disease System . That will run no matter who is present.

CHAIR: There is a system in place.

Dr Firman : There is a system in place and the data is analysed. We have a number of other systems for doing what we call enhanced surveillance, depending on a disease of interest. For instance, for influenza, we have some enhanced systems. Those systems look at different snapshots of surveillance at different points along a key pathway, if you like. We would look at a system that tracks peoples' symptoms of the flu at the start of the flu season. They report their symptoms on a web based system. That is individuals saying 'I am sick', and we certainly get early signs. We get a system whereby general practices will actually record every patient who comes in with an influenza-like illness and then would send regular samples from those people so we get a good warning at the start of the flu season because we start to see people who are symptomatic and confirm that with diagnosis.

In emergency departments, there are surveillance systems that again monitor people coming in. You can change that to focus on a particular disease or syndrome so that during the flu season or if you are in a pandemic you focus it on influenza symptoms. We have hospital systems, which are sentinel systems, to look at all the patients who are admitted to hospital and collect lots of data on them for a particular disease. Then intensive care units have a national systems whereby they can actually focus on a particular syndrome or disease. So they collected comprehensive data on influenza cases during the pandemic. You can see that there are a lot of different systems that sit there. They do not depend on people.

They can examine a range of diseases. They look for TB in the chest clinics. They collect enhanced data so we know where TB patients are coming from and what sorts of demographics are around that so we can see what sort of effect it will have if we take some different public health measures. That information is recorded: it is recorded in annual reports and it is recorded and reported on in Communicable Disease Intelligence, which comes out regularly. That is a web based journal which reports this sort of information as well. We have obviously policy papers that are informed by this. I can say that when I came to the department I had not had a long history in public health, but I was able to work out what was going on quite easily from all the documentation and the information that is available. I think that we can say that we have a comprehensive surveillance system that is tracked well that does not depend on individuals.

Mr WYATT: There is no data collection, then. Is that what you are implying?

Dr Firman : No, that is all data. It is all brought in centrally.

Ms Morris : And surveillance data.

Dr Firman : And that is reported regularly, too. It is reported on the web and each fortnight, the Communicable Disease Network Australia meet and they discuss the data. They look at all the data nationally that is reported for a fortnight and they look at what states have reported. They notify of interesting cases or particular cases from these states. That is discussed further and that is all reported back. Once that data is agreed as valid and correct, that is then posted on a website for public consumption.

Dr Lum : As well as the data collection and sharing, the other process—in terms of assisting workforce and assisting in knowledge-sharing and knowledge-progression—is the use of exercises. While we do spend a lot of time thinking about outbreaks and pandemics of disease and infectious diseases, in a lot of the areas in state and territory health departments and in the Australian government health department we have now taken an all-hazards approach to managing emergencies. For example, it may be what we have done in terms of extreme natural hazards like bush fires and floods, or pandemic, or it may be through other mechanisms—what we did helping Australians in terms of responses and information-sharing for Fukushima. We do a lot of exercises in that all-hazards context, which allows us to continually train various people in the health agencies. Through exercising we can also continue to progress that information so that it is not just sitting somewhere and not being shared.

Ms Morris : I would add that those exercises are sometimes within the health system, and sometimes whole-of-Commonwealth-government or whole-of-Commonwealth-government-state, but there is a rolling program of exercises across the country within states and at the Commonwealth level.

Dr Smith : I also sit on the some of the CDMA subcommittees, one of which is the arbovirus committee. That is drawing up response plans for various mosquito-borne viruses that are either here or are a threat and looking at how we would manage those in the event that they entered. I think that is very important. One of the big challenges—particularly with things like flu pandemics, which might only happen every 50 years or so—is that you are not going to have the same people there. I hope I am not there for the next one! You will not have the same people there, so how do you keep that experience base there?

It was interesting this time to look back—and there was very little documented about the 1957 and 1968 pandemics in terms of the practical things that we actually faced. I think there is a much better process now through the debriefing to look at how you document that experience. The other important thing in that is to look back on what was the same, but also to have the flexibility to understand that it may not be exactly the same—to learn from the things that are going to be the same but not expect everything to be exactly the same. And that relies on people who have the right mental framework, the right experience base and the right expertise and flexibility to be able to adapt those responses to what is really happening at that time, or when there is something different. We talked about the disease in young people. That was a surprise to people. How are you going to think on your feet in that circumstance?

CHAIR: Sorry to divert you away, but a lot of the discussion around the young people was that they had not gone through the influenzas of the past and therefore did not have any resistance. Was that just a discussion, or—

Dr Smith : No, that was quite true. The influenza A strain was most similar to the one that emerged in the 1920s and 1930—the first one that circulated after the 1918 pandemic and became seasonal. So the older you were, the more likely you were to have some memory. And it happened to be the same major type as that one was.

CHAIR: So the older you were—

Dr Smith : The people over 60, over 65 or over 70 still had immune memory from way back then. The difference was the severity of the disease in the young people who did get it. That was the difference. They were not just getting a mild influenza that they got over, which is what you would expect in a season, though occasionally you see severe disease. We were seeing lots of them coming in and ending up on ventilators and on special blood oxygenation systems, which was exceptional. It just reminded us that you can look at how many—we have got three pandemics that we talk about, and for any infectious diseases you never rely on three examples to be confident that it is going to do exactly the same the next time. Different virus, different populations, different way of dealing with it; it adapts to its host differently. So you do have to be flexible. It was very interesting. I looked back on some old newspaper reports from 1918—in the Western Mail, for the Western Australians here—and they flagged some of the same issues—

CHAIR: That we are doing.

Dr Smith : that we flagged as coming out of this pandemic. I think it is important that we have it sufficiently documented so that we can learn from our historical lessons.

CHAIR: From the discussions today, my views are that we would be pretty well placed to deal with any other pandemics. Is that the view? It is a very broad question, but how do you think we are placed to deal with future pandemics? It depends on the pandemic as well, doesn't it?

Ms Morris : It does, very much.

Dr Firman : On that issue we have an all-hazards approach to health emergencies, disasters and communicable disease threats, meaning that we want to have a system that can cope with any kind of hazard that comes along. It might be a pandemic; it might be a food-borne disease; it could be any threat. We need to have a system that is robust and can quickly adapt, so we try and develop a strong, functional system looking at the functions of surveillance, lab capacity, epidemiological responses and public health policy in responses and research. We look at all those things. If we have a strong system there, it does not matter what comes along; we will be able to adapt our approach. Every time you try to guess what the next threat will be or when it will arrive—pandemics being a case in point, perhaps sometime in the next 30 years—you do not get it right. So you have to be ready for whatever comes and be flexible and adaptable to be able to manage those things.

Ms Morris : I would say that we stressed at our last hearing before you, and we have mentioned again today, that our capacity to deal with any of this depends on how good a relationship we have with the states and territories and also with other Commonwealth agencies. My sense is that post bird flu—which turned out not to be a major threat to us, but we went through an awful lot of planning—and then post swine flu, which was a real pandemic, that relationship has got stronger. I think we have a better sense of how and when we need to work together. You can theoretically trust a partner, but until you have actually had to do something under pressure you do not know whether you can rely on each other. I think we have a much better sense of how we should all work together. There were lessons learnt from that and we are feeding them into future planning. So it depends on the severity and it depends what it is, but I think we are probably even better placed than we were a few years ago.

Dr Smith : We are sort of the at coalface in all of this. Overall, the Australian response was extremely good; I think it was exceptional. It would be foolish to think that there were not things that next time we think we should do better, and there are things that we think we should have done differently, but you would be silly if you do not learn from your experiences. What we did find—and it has just been mentioned—is that the pandemic planning as it stood that had gone in up to that stage did not quite fit for what happened and we needed to be more flexible. Having done a lot of that groundwork was great. It means that we were saying, 'This isn't right in this area,' but at least we had something to work from.

CHAIR: You had already test-driven it to know whether that was the case.

Dr Smith : It showed the value of beginning that process, and we need to continue that process to get it even better, to give us a better basis to incorporate the problems and to keep the momentum going when we do not have a pandemic anymore. It benefits not only influenza but also our responses to bushfires and other infectious disease threats such as multi-resistant organisms, West Nile virus if it enters, Japanese encephalitis virus or some horrible new thing that emerges. We had issues many years ago with plague reappearing in India, and that can come into Australia. So all of those are things that, from our point of view, we need to ensure we have the capacity to exercise properly so that we can deal with them and to keep up our expertise in dealing with emerging pathogens. We need to then identify the problems and sort through those.

Mr WYATT: What was your reaction to Catalyst the other night when you had a pretty eminent New South Welshman, who now works with the UK as well, come out and say that Australia is ill prepared for a pandemic?

Dr Smith : I did not actually see the Catalyst, I must admit, as I was away at the time. From my point of view 'ill prepared' is not the right word.

Mr WYATT: I did not agree with what he was saying, but it did go to air on the ABC.

Dr Smith : The pandemic plans were reviewed nationally. There was a large article in the Lancet, and Australia actually had a very advanced pandemic plan and continued to have a very advanced pandemic plan. It was not perfect, absolutely no doubt about that, but it was a good basis. In the review we have identified that there were deficiencies in the plan in practice, and that is what this post-review process is addressing at the moment. We have an incredibly sophisticated and robust system here in Australia and I think we have both the people and the facilities that are really good at dealing with these sorts of problems; that is, people will put in the effort and they will deal with things that emerge. We went through a pandemic and people did manage. We would like to do it better next time.

Ms Morris : When you were referring to the comments made by—was it Dr Tony Adams? Was that the person?

Mr WYATT: It may have been Tony, yes.

Ms Morris : My understanding is that what you were saying is, I think, how it was reported but that what he actually said was for a very severe pandemic. I think there is a limit to what any country can do to prepare for a very severe pandemic. It gets back to your very first question about workforce and the sort of answers we gave. The other thing is that Dr Adams was CMO a few CMOs ago, pre the development of our first Australian Health Management Pandemic Plan for Influenza—lovingly known as the AHMPPI—and pre our experience with bird flu and swine flu and his comments were probably relevant to where we, as a nation, were in our planning for a pandemic when he was CMO. Quite a lot has happened since then—some of it forced upon us, I admit—but I think we are a lot better prepared now.

Mr WYATT: The degree of self-sufficiency for vaccines and vaccinations that we require: how are we placed for that?

Dr Firman : In terms of self-sufficiency, are you talking about vaccines manufactured in Australia?

Mr WYATT: Yes.

Dr Firman : Very little pharmaceuticals are manufactured in Australia. I think we have influenza and Q fever ones manufactured in Australia. As you can imagine, pharmaceutical manufacturing is a worldwide business; it is not individual countries making vaccines usually and indeed that is the case for Australia. Australia is a very small market. I am trying to imagine a multinational who would think that Australia is a good place to set up their manufacturing plant for that purpose and I cannot think of one at the moment. As that would occur, we are part of that worldwide market.

Mr WYATT: That would have to be one of our vulnerabilities. Even if I use the example of Heparin, when there was a shortage of that a notification went out to the system saying to reduce or restrict the use of Heparin as it was not available at the moment. Are we likely to be vulnerable like that for a pandemic?

Dr Firman : Just like any other country in the world, we potentially can be and, in that Heparin shortage for example, other countries were also very short. The USA is regularly very short of different drugs and they have quite a robust manufacturing basis. It is a very multifactorial, difficult issue when it comes to shortages and it goes way beyond just the fact that you do not have a manufacturing plant on your shores.

CHAIR: Did you want to comment on this, Dr Morris?

Dr Morris : No.

Dr Smith : There has been a discussion internationally in terms of flu vaccines and it is to do with the total manufacturing capacity and how you build that, which really depends on the use of the seasonal vaccines to have that manufacturing capacity that can then be diverted to pandemic vaccines. There is also a lot of research work going into how you make better vaccines that give longer term protection and better cross-protection so that you are less dependent on suddenly producing new vaccines—but supply will always be a problem even with seasonals. If one of the manufacturers has a regulatory failure or a failure of a run, suddenly there is a two or three month delay in international supplies. We have a stockpile of antivirals for influenza, which was exceptionally valuable because they were—

Mr WYATT: The stockpile would be out of date now, would it not?

Dr Smith : Somebody used the stockpile. That is how it goes. You can have it available. It has a finite lifespan. But having it there and being able to deliver treatment early to people made a huge difference both in the management of an individual but also in the management of a whole outbreak. We have had the same issue with the labs, as to how we guarantee supplies of equipment and reagents we need to deliver the tests, when everyone in the world is wanting to do the same thing at the same time, and make sure we have adequate stocks available to us.

Mr WYATT: The only concern I have is our capability with workforce should we have a significant pandemic. How do we use the existing workforce without burning them out and the contingency plans around people restriction?

Dr Firman : When that question first came up I was thinking about the public health officers and epidemiologists, for instance, who are an important part of the public health response. They are a fairly niche scientific area, just like some of the specialty people within laboratories. In order to improve their skills and gain experience, they need experience of outbreaks and responses, and in order to do that well you have to chase that around the world to a certain extent because they do not happen all the time in Australia. We have people who have a high level of experience and knowledge in those areas. During the pandemic we would have shared epidemiologists with the Department of Agriculture, Fisheries and Forestry—

Dr Lum : Just as we did with equine influenza.

Dr Firman : Their animal epidemiologists came in, because it is a similar science. We would have asked people with those sorts of skills sets from other areas if they could come and help us as well. There were some students and some masters of applied epidemiology students who came in and assisted us, and that is an excellent learning environment for them as well because they are getting that experience—you do not become an experienced epidemiologist without doing it. We certainly train people regularly. They do not always stay in our health departments. They will often go overseas and gain valuable experience in other parts of the world.

We need a multi-layered workforce of very experienced people, some people who are learning, some people to do basic services. Our own departmental officers can do short courses to skill them so that they can do some of the more basic work under supervision. In any pandemic you get to the point where you realise you can not absolutely do everything and, as Dr Smith said earlier, you determine what are the really essential things you do in order to maintain your response.

Mr WYATT: There was a question that Ms O'Neill wanted asked, and that was whether we have a CDC in Australia.

Ms Morris : I am happy to talk to that initially and allow my colleagues to add on. The CDC is a well-respected model and has an excellent reputation, but I think you have to look at what the actual constitutional and governance framework is in Australia. In Australia, the states have responsibility for public health. I am not a constitutional lawyer but my guess is that if we were to set up a CDC we would have to get them to agree to cede responsibility for some things to the Commonwealth. I cannot imagine that they would be that interested in that. What we do, and what you have just heard described for a while, is that we both recognise and respect the role and the capability of states in public health, and the Commonwealth plays a coordinating and, where appropriate, a value-adding or leadership role. We do not try to replicate or override what they do, and that is what a CDC would essentially do.

I would also say that the CDC model looks very good on paper, but my understanding is that on the ground in the US there are still jurisdictional issues where local government actually has to agree to let the CDC in. We do not actually have those problems here because we work on a coordinated, federalist model and we work at it all the time. My last comment would be that some things are better in larger countries. We are not actually that big a population. Gary or Jenny, do you want to add anything to that?

Dr Lum : What I can say from the pathology, laboratory and diagnostic aspects in particular, is that while we do not have a national microbiology laboratory per se, like the United States or Canada or the UK, what we do have in place is the Public Health Laboratory Network and a range of other networks. But that should not just be seen as a network of laboratories. We also have national and internationally recognised reference laboratories headed by pathologists, senior medical laboratory scientists or research scientists who have the expertise and the capability to handle questions for the country. We would go to them always. So while the Public Health Laboratory Network is always there, it is a subcommittee of the principal Australian Health Protection Committee. Part of that network is made up of reference laboratories. There are also reference laboratories outside the network that we can call upon whenever necessary. Under that one-health banner that Dr Smith was alluding to we have the Australian Animal Health Laboratory which is a premier, world-class laboratory, where we can do a lot of work with exotic pathogens. From that aspect I am not sure that a national set-up is needed. We certainly do have a very good network, very good communication and a very good system whereby people share specimens and share information. Despite the difficulties sometimes with getting a specimen because of aeroplane flights or what have you, almost always it is a case of where there is a will there is a way to get something to a place where it is necessary.

Dr Smith : There has been a lot of discussions over this year. There are models in the US, the UK and Canada. I think the most robust models mix the laboratories and the epidemiology together. We work closely with our public health colleagues, and we would like to continue and build those interactions, because they are mutually beneficial. There are a number of models around the world whereby they have created CDC-like structures. Europe has a slightly different model now. I think there are some weaknesses of the straight US model, where you have this great big structure in Atlanta, which is the CDC. Australia, as I said, has a population that is spread out over a large geographic area. The expertise and the capacity is spread across the country, and you would create it in one place by robbing those jurisdictions of that. It seems a little pointless. Also, laboratories are expensive pieces of gear. You do not want to replicate things unnecessarily. So the PHLN as a network has addressed a number of these issues, as Gary Lum explained, and has certainly been an advance forward.

Certainly we, as laboratories, have been interested in looking at how we establish more formalised network structures that allow us to look, particularly in highly specialised areas, at how we address national capacity in those areas where we only want one laboratory to be doing these very highly specialised things—how does that become national capacity, and how does that balance against jurisdictional capacity because each of us are funded by our jurisdictions?—because each of us is funded through our jurisdictions. So certainly we would be keen to progress any discussions that look at how we manage that coordinated national capacity, and I think there are hybrid models which look at having your facility distributed but the way you manage it more centralised. That way we can get address smooth national coordination, avoid duplication, ensure that we get the maximum from it and ensure that we have the capacity. And perhaps I could drag in my colleagues from NHMRC to, as you mentioned, really look at capacity to develop a more strategic approach to some of these targeted research areas and say that these are really the areas we need to target and in which we need to get output from research to make sure, again, that we get the maximum value back out of the research funding.

Dr Firman : If you look at that CDC model, the CDC has 15,000 employees in 50 countries and does chronic health as well as communicable disease. It is a much bigger body than just a CDC in terms of infectious disease. The UK and Europe have a CDC-like model with different levels of employees. If you are looking for a government system that is similar to Australia, Canada has provinces akin to our states and territories. Canada has a CDC with 2,000 to 3,000 employees, and they also do some aspects of chronic health. The European CDC has a core of 270 employees in Stockholm. They cover Europe, but they leave countries to run their own systems. All of these systems are a hub-and-spoke network of communicable disease control. Some people have an enormous hub and do everything in it, and that is the CDC model. Is that the best model? Their public health and health outcomes are not as good as Australia's, by a long shot. That is a model, but does it deliver you exactly what you want in terms of outcomes? Perhaps not. The country's system suits that country really.

In Australia we are going to maximise, if we can, that hub-and-spoke model, recognise where our centres of expertise are, improve that and make sure that we coordinate. As everyone said, we do not want to be duplicating effort in two different states in two specialist areas if we can actually do that in a much more coordinated way. We want to work toward understanding what are the functions that are really important that you might need to do centrally. Frequently they are ones of leadership and providing policy, but in a way that can all be networked together. The centre does not have to do everything. Some of it is done peripherally in different areas, but it is all coordinated centrally as well.

CHAIR: Thank you. As there are no further questions, I thank all the participants for participating today and contributing your insights and your observations to us. I thank you very much for turning up. I know you are all very busy, and giving up two hours of your time is very important. If there is any further information you may wish to pass on to us, please feel free to do so at any time. I also thank Broadcasting for recording everything today, the secretariat and members of the public who attended to observe.

Resolved (on motion by Mr Irons):

That this committee authorises publication of the transcript of the evidence given before it at public hearing this day.

Committee adjourned at 14 : 41