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Transcript of press conference: 17 June 2009: H1/N1 influenza.



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THE HON NICOLA ROXON MP MINISTER FOR HEALTH AND AGEING

PROFESSOR JIM BISHOP CHIEF MEDICAL OFFICER

TRANSCRIPT OF PRESS CONFERENCE - 17 JUNE 2009

E & OE - PROOF ONLY

Subject: H1/N1 influenza

NICOLA ROXON: I'm joined again today by Professor Jim Bishop. Jim and I are here to announce some significant changes to our handling of H1N1 Influenza '09, the swine flu here in Australia.

What I intend to do is just give you a quick update on the latest figures and then to talk through Australia's response, its movement to a new phase level.

There now are over 2000 cases of swine flu in Australia, in fact 2026: 313 in New South Wales, 1210 in Victoria, 169 in Queensland, 92 in South Australia, 102 in Western Australia, 40 in Tasmania, 65 in the ACT, and 35 in the Northern Territory.

There are nine people currently in hospital: seven in Victoria, three of whom are in intensive care units; one in South Australia; and one in the Northern Territory.

The cumulative number of people who have been hospitalised is 53 out of those 2026, and those who have been hospitalised generally have had existing conditions or complications such as morbid obesity and respiratory conditions.

But Jim and I are here to announce today that Australia is now moving to a new national alert level, and we have developed a new response phase to manage the outbreak of H1N1 Influenza '09 and it's called PROTECT.

This new phase has been recommended and developed by the chief medical officer and the state and territory chief health officers of the Australian Health Protection Committee.

Jurisdictions are going to be making arrangements progressively over the next few days to move to this new level and we anticipate that all states will be at this level by Friday, 26 June. I'm advised that South Australia and Western Australia will move immediately to this new level.

PROTECT recognises that the infection of H1N1 Influenza '09, swine flu, is not as severe as originally envisaged. It's in addition to the existing pandemic influenza plan given the moderate nature of the disease.

This disease, as we know, is mild in most cases, severe in some and moderate overall and the overwhelming majority of patients are making a rapid and full recovery.

PROTECT provides a clear response based on the best medical evidence that we have currently available and is especially targeted to those who we know are most likely to have poor outcomes. It's a measured, reasonable and proportionate health response to the risk that the virus poses to the Australian community.

We will make available for you, for those who don't have as tight deadlines, the copy of the new edition to the pandemic plan that describes in a lot of detail the phase of PROTECT, what it involves, the assumption that it's based upon.

But let me take you through the key elements of that. The new phase of PROTECT, the key elements of it are to focus on early treatment of people who may be vulnerable to severe outcomes, such as pregnant women and those with underlying conditions such as respiratory disease, heart disease or

morbid obesity.

Identification and early treatment of those with moderate or severe disease, especially in those with respiratory difficulties, the control of outbreaks in institutional settings like special schools, voluntary home isolation for those with mild disease with supportive treatment only, such as over the counter

medications.

Testing would focus on the identification of swine flu in people with moderate or severe illnesses, people more vulnerable to severe illnesses or those in institutional settings.

Increased identification and modification of hospital admissions, ICU admissions and deaths in the case of swine flu infection, and monitoring of clinical outcomes throughout the flu season.

Increased sentinel testing to identify levels of community transmission and the strain of circulating influenza viruses, and ongoing monitoring of the virus for the emergence of antiviral resistance or changes in the virus that could herald a change to greater virulence.

The new phase signals a move away from border measures to identifying people in whom the disease will be severe or may be severe and providing medical care and interventions to reduce likely suffering.

Under this PROTECT phase the use of antivirals will be targeted to people with moderate or severe symptoms, particularly those who are deteriorating or

experiencing respiratory difficulty and people with infection who have been clinically assessed as more vulnerable to severe influenza.

As most people will experience this flu as a mild disease and will make a full and rapid recovery, those patients and their household contacts will not be provided with antiviral therapy from the national medical stockpile. Contacts will no longer be placed in quarantine.

This approach is carefully considered, sustainable and a targeted use of resources that is an appropriate and proportionate response to this disease and the fact that it will spread within the community more over the coming months.

Details of this new PROTECT phase are being publicly released, including some modelling on the possible impact of the disease. These models are based on the current information available about infection rates in overseas countries.

They are also based, I must stress, on what might happen if public health measures are not put in place to treat the disease.

Of course the purpose of us moving to this PROTECT phase is for our efforts to be directed towards protecting and treating those who are most vulnerable. This means that we would, of course, aim for outcomes that are substantially lower than this modelling.

The modelling suggests that without any public health measures, about 20 per cent of the population, that's 4.3 million people, could be infected with the disease. In comparison, seasonal flu infects about 5 to 15 per cent of Australians.

If the disease is similar to seasonal influenza, with no effective treatment, somewhere in the range of 40,000 to 80,000 people could be hospitalised, with about 6000 fatalities. This compares to estimates of about 10,000 hospitalisations and 1000 to 2000 deaths from seasonal influenza every year.

It is, however, very important, and I know that Professor Bishop will be keen to encourage you to use this information sensibly and responsibly, to understand that this material and this modelling is based on what could happen if we don't take public health measures that we have been, of course,

undertaking for the past two months and will continue to undertake in an even more strategic way with the introduction of this phase.

The measures under PROTECT are particularly increasing our focus on those vulnerable to severe outcomes and, of course, the aim of them is to decrease the number of hospitalisations and fatalities from this modelling.

Under a PROTECT response, pathology testing of all potential cases will not be required or desirable. This is because most cases will be mild and will not require treatment.

In addition, confirmation will no longer be required to inform clinical decisions about quarantine or the use of antivirals.

However, it's still important for governments to continue to monitor the disease closely in case it develops any resistance to antivirals or becomes more virulent. Jurisdictional flu clinics, public health units and emergency departments currently report on swine flu cases and they will continue to do so.

In addition, a cross section of about 100 GPs who currently participate in the national surveillance network are being sent a protocol for testing for swine flu for surveillance purposes and I understand that Jim is meeting this evening with some of the GP organisations to discuss this and other measures.

The testing for surveillance purposes is planned to commence from next week, and I expect results to be reported on a weekly basis from the end of next week. We will also be recruiting more GPs to participate in this network to improve the reach of our surveillance.

As I mentioned, under PROTECT the use of antivirals from the national medical stockpile is going to be limited to those with moderate and severe disease or whose underlying conditions, after appropriate clinical assessment, could make them particularly vulnerable to severe outcomes.

States and territories have a range of arrangements in place for access and distribution of antivirals to best reflect local requirements. Some provide antivirals through their influenza clinics, others through public health units. For example, in Victoria they have also been using community pharmacies on prescriptions from GPs.

Other states have alternative mechanisms in place or are establishing them currently to distribute antivirals and in remote centres and small rural towns there will be some additional arrangements. Information on access arrangements for antivirals will be posted on the health emergency website from Monday 22 June.

I need to add - I know these are issues and it's taking a little time, but I think it's worthwhile explaining all of this clearly to you before we open for questions.

In this phase, PROTECT, there are not recommended widescale community social distancing measures, so the suggestions in other alert levels within the pandemic plan of cancelling mass gatherings are not part of the PROTECT phase in response to this particular influenza pandemic.

Such mass gatherings, sporting events, interstate travel and tourism generally should be able to continue unrestricted given the moderate nature of the virus.

However, people who are vulnerable to serious complications from flu should

reconsider their attendance at such events as contact with large numbers of people can increase the risk that they will come into contact with the infection.

In the PROTECT phase, all states and territories have agreed to work towards discontinuing the school exclusion policy. Obviously that's been an effective measure to date to slow the spread of the disease and all are looking towards being able to then be on a consistent level, hopefully by 22 June next week.

As I say, while the school exclusion policies have helped delay the spread of flu, given that this disease is now more widespread, excluding well children from school if they've been in an area of sustained community transmission is now a less practical or useful measure.

Children, though, who are unwell, like adults who are unwell, will be urged to stay at home until they recover in order to protect their classmates.

As I've indicated, the PROTECT phase means a return to normal operations at Australia's international airports. Airlines will still be required to provide mandatory reporting of sick travellers in order to identify and provide medical assistance to those travellers.

But other advanced screening measures, like the use of thermal scanners and positive pratique that have been put in place since the introduction of this disease into the international community will now no longer continue.

All of these new steps under the PROTECT phase recognise the mild nature of this disease in most people and aim to move our efforts to protecting those who are vulnerable and treat and identify those who are most at risk.

In order to explain the new PROTECT phase, the government will be, of course, updating the print and radio commercials that have been running. They will provide information from tomorrow, particularly on the use of antivirals and the types of people who are considered to be most at risk and therefore need to be on the alert from this disease, to update the community on the flu's virulence, explain the new focus on protecting those who are most vulnerable and, of course, continuing to promote those key hygiene messages.

I'm sorry it's so late in the day to provide you with this information, but it is a very important change and I think you will see that a lot of work has gone in through our jurisdictions, our health officers, to make sure that we have a phase level which is appropriate given the virulence of this disease and can sit alongside the CONTAIN and SUSTAIN levels that are in our current pandemic planning which, of course, had been undertaken anticipating a more lethal disease than this one to date has turned out to be.

So I know Jim is happy to provide his medical views and answer any questions, as am I.

QUESTION: Is it true that community transmission has been going on in

Queensland for some time and that the authorities, particularly in Cairns, haven't been reporting swine flu cases? And what do you say to the Victorian Government's view that the whole swine flu response has been a complete shemozzle?

NICOLA ROXON: Well I don't think it's accurate that Queensland has not been providing information but obviously any questions about other information that hasn't been reported, you would need to direct to the Queensland Health Minister.

But I have been reporting regularly that there has been limited community transmission outside Victoria. We have, of course, over time seen an increase. From my recollection there were only a handful of cases reported in Queensland where there was not an identified source and you need to appreciate that there takes some period of time because contact tracing

continues, so a case may have a non-identified source for some time while that tracing continues, it may then turn out to be a direct contact.

So yes, there have been changes over time. I think we've been perfectly upfront about that. I think the response to date has been a very strong one in Australia. I think the efforts that we've all taken have helped us slow the

spread of the disease. I think we're well positioned to move to this next phase, but Australia is in a different situation to the rest of the world. We are experiencing this disease as we go into our flu season.

We do need to take care, and I certainly understand that there would be some frustrations from the Victorians by quirk of fate, alone they have had large numbers of cases, but it is in the entire community's interest to continue to try to reduce the spread of this disease and identify those who will most be at risk.

Other jurisdictions are now at the point that Victoria was at some time ago, not in a position to continue doing detailed contact tracing on large numbers of new cases, and are increasingly seeing cases that will be community-transmission popping up and understand that using our resources, which are finite, to target those who are likely to suffer the most severe consequences is now the sensible thing for people to do.

It does require a lot of organisational change and that's why there is a period of time when the states and territories will move into this phase, but nationally we are now declaring on Jim's advice and with the prime minister's approval the movement to this new phase level.

QUESTION: But is it not the case that in Cairns, at least the Queensland health authorities, stopped testing and recording new cases of swine flu?

NICOLA ROXON: Well, you'll have to direct the questions to any of the …

QUESTION: You're not aware of it?

NICOLA ROXON: … jurisdictional health. Well, I have a lot of detail about the cases as they come in, I have detail about the cases that are reported, I have detail about school closures. I'm not aware that there are allegations that

the process has been particularly handled differently in Cairns to anywhere else, but I am certainly happy to direct those questions to the Queensland authorities and will check if there's any other information that we have that's available to us.

QUESTION: Can you just confirm that people with mild swine flu no longer have to take Tamiflu, and if that's the case, can adults with mild swine flu go to work?

NICOLA ROXON: What we are encouraging, and I might hand over to Jim on this one, what we're encouraging, of course, people to do if they are unwell is to make sure that they are being considerate of others. It is a disease that can still be spread. It might be mild in you and it might be very serious for your neighbour or workmate, so we do encourage people to be sensible, and it is best to keep yourself in as isolated contact as you can while you have this disease, but Jim might want to add further - more medical

advice.

JIM BISHOP: I will add something, I think the fact is that everyone will get over this - with mild illness will get over this very quickly, and it's a very short illness, and that will happen whether antivirals are used or not, and therefore we want to make sure that the use of antivirals is directed in the most appropriate way, but - so this plan really starts to concentrate on those that may not do so well, and they are people with pre-existing medical conditions often, and other groups that we've identified, particularly I want to identify people who aren't having a mild illness but having a severe one and those that might be even deteriorating.

So those sorts of considerations are much more important now that the disease is more widespread as we always had expected, but because of its mild nature, I think we're very fortunate that the great majority of people more or less have a very mild experience.

So this new plan recognises the facts that we've got, the numbers that we've talked about before in terms of what could happen I think are very theoretical, because we've also seen a large amount of mitigation of what we might expect based on Mexico or whatever, and I expect to see as a result of that, that we can dampen down.

And one thing about staying at home is that you'll stop - you'll reduce the peak that we've talked about before about, the peak of cases, and we'll reduce the number of people that are potentially vulnerable from being - having a bad outcome from the flu.

QUESTION: [Indistinct] to enforce quarantine as there has been.

JIM BISHOP: Voluntarily. We're asking people to stay at home if they've

got the flu.

QUESTION: Can I just clarify: so are they - the minister said that people with mild cases aren't going to get drugs from the stockpile, but will doctors, GPs, still be able to prescribe Tamiflu?

JIM BISHOP: The GPs will be using their clinical judgment. So a mild case that's got a very severe co-morbid condition, in other words severe case of asthma or something like that, they'll be able to use their clinical judgment, but in general doctors won't be prescribing Tamiflu for a person that's got a very mild symptom who's recovering quickly, and we're encouraging that. The general practitioners are very good at picking up those cases where there's particular issues.

This is very consistent also with the WHO approach. The WHO, in raising its level, said quite clearly that this is a moderate disease overall, mild in most, and that they also said that we should therefore always look at a proportionate response to the disease, even though it's declared a pandemic based on spread.

And so this is now an adjustment which allows us to I think take a very sensible clinical approach to what's facing the country at the moment.

QUESTION: How is this different from the modified SUSTAIN level that Victoria's been on in - for a couple of weeks? You're inventing new stages as you go along. I mean how does that sit with planning for a pandemic?

NICOLA ROXON: Well, I mean how it fits, I think, is quite easy to explain. We have to plan for diseases, particularly those that might be severe and more lethal than this one. The planning is to make sure that anything that can be done in advance of a new disease is done, but we need the flexibility, as we've seen, and we've seen the World Health Organization itself make different comments and arrangements and recommendations because this disease is not as lethal as the ones that had been planned for.

So I think it is reasonable when we're talking about a novel flu strain that there will be different things that arise, and the planning is to ensure that we have done as much as possible to understand what the health response will be, what the quarantine response will be, how the relationships will work between the Commonwealth and the states and territories.

All of those mechanisms have been being used and have been working well, but it would not be right for us to continue on the CONTAIN level given the spread now within the community, and it would also not be appropriate to be on the SUSTAIN level for this type of disease which is mild in most, severe in some and moderate overall, and that's why we've received the advice from our public health officials to develop this new phase.

Compared to modified SUSTAIN, which was really introduced, as you know, for the particular situation that there was in Victoria, it does allow for a more

targeted response to the disease, and of course we still know more about the disease, and one of the key changes, of course, is the use of antivirals more strategically for those with serious complications or at risk of serious complications, modified SUSTAIN for Victoria didn't change our response, for example, at our borders, which this level does.

So there are a number of changes and as I say we're happy to provide that addendum to you to the plan. That will be something that exists for future influenza planning if we have diseases in the future that are similarly mild but nevertheless novel, and obviously this is something that we need to continue developing along the way when we are presented with new challenges as diseases change over time.

QUESTION: What triggered the decision to make this announcement as to the change on this particular day, at this particular time?

NICOLA ROXON: We've had a range of negotiations in place, we've had a range of committees meeting to provide us with advice, we've been watching closely the developments in different states and territories.

As I think you would recall when Victoria's status was changed, there does get to a point where it is stretching the capacity of the states and territories to be able to continue to do the very intensive contact tracing, and where we are using resources that could be better provided to targeting those who are most at risk of serious outcomes. All of those pieces needed to be together for us to make this announcement.

I don't know, Jim, if you want to add anything about the various committee meetings, but that's the basic reason.

JIM BISHOP: We really get a lot of advice and it's a case of putting that advice together in the best way, and we feel we've got a very good level of agreement by the experts about how we should deal with this at this time. We've also been on teleconferencing with WHO as they went to change their particular response, and then subsequently in discussing the worldwide view of the virus, so all of this has to come together and it's just come together at this point.

QUESTION: What about the under 21 Australian lacrosse team that's currently in quarantine in Korea? Will this affect them in any way?

NICOLA ROXON: No, it won't affect them. Of course, other countries will continue to have their particular health responses and quarantine arrangements in place. I know it is a very stressful situation for the team. Actually, a number of them come from my electorate. They've fund raised and done all sorts of things to be able to go and participate, and of course their hopes of doing that have been dashed, but in the same way that people need to adhere to laws of other countries, they also need to adhere to health regulations in other countries.

I think over time we will see changes in other countries as the disease spreads elsewhere, but the unfortunate reality is travellers need to respect both the laws and health quarantine arrangements that are in place, and I understand there has been a lot of contact between the coach and my department, particularly the incident room. We've spoken to a number of parents. I think the sports minister has spoken to a number of people. We are making sure they're getting all the consular support and advice that they can.

The latest information I have before coming in here was that there was some assessment that was being made by the Korean officials if the quarantine period was now over, but that is a matter over which we can have no

influence, and of course we ask for the team's understanding, their families here who are, no doubt, frustrated and anxious, that this is for a short period of time. I understand they've been provided with good care and that's, of course, our top priority.

QUESTION: Minister, or Dr Bishop, have you done any modelling based on these public health responses on how many people could get infected with swine flu?

JIM BISHOP: Perhaps I just mention that we're - at the moment, as we've talked about in here before, we are limited in some of this in terms of what we know from overseas. What we've found is that we're going to get more

information coming forward now from Australia and I'd say the preliminary information shows that our mitigation programs are working well, and we're seeing a substantial improvement in the low virulence of the organism overall.

And that's why we've come forward and felt that the models, in fact, probably don't apply as well, and so that's why we've got the surveillance program in place, that's why we're going to monitor the virus, that's why we're going to be monitoring hospitals and admissions, those sorts of things.

I think within a few weeks we'll have much better information. What I expect to see is that the public health programs we've had in place will already have shown that we've been able to substantially mitigate the illness and I think we're getting that information anecdotally, but we really want to see good evidence and that's why we put the surveillance - upgraded surveillance programs in place.

QUESTION: You say 6000 people could die in the absence of mitigation, though. You must have some idea of, you know, a ballpark figure in the event of mitigation.

JIM BISHOP: Well, that's going to be something we'll see. We've seen it well mitigated in some parts of the United States, and we think that we can mitigate it down to a similar experience with ordinary seasonal flu, but we don't have evidence of that yet, but I think we will have evidence over the next few weeks and the surveillance and monitoring program will help us.

All we can do is do some theoretical things, which are not as relevant as we'd

like, and then we can then just carefully look at our own situation based on all the work that we've done and I believe that we would be able to substantially improve on that.

QUESTION: Given the relax in the quarantine measures, is there any need to revisit the contracts for the CSL vaccine, or is the government prepared to reconsider some of the terms of that?

NICOLA ROXON: No. Look I think at this stage we are comfortable that we have entered into an agreement with CSL. I understand that they are hoping during the course of July to be doing some of their testing to see if it's an effective vaccine, as other manufacturers would be around the world.

We still know that this disease is dangerous for some people. We are comfortable that it is mild for most people and the reason - the key reason we were moving to this new PROTECT phase is to make sure that our resources,

both drug and health workforce et cetera, can be targeted strategically to those who will most need our assistance.

Now all the information that's gathered between now and the first line of the vaccine being available will also similarly help us work out who should be targeted first with the vaccine, and we don't have any intentions that we should be revisiting that contract with CSL.

JIM BISHOP: I’ll just mention one thing about vaccines if I can, and that is just that our aim is to essentially protect the population given that we've talked about here before whether the disease in the future may become more dangerous than it is now, so this is part of the broad protection for the Australian population.

NICOLA ROXON: Okay, thanks very much.