Departmental Speeches

Speech to the Medico-Legal Society

Speech by John Horvath AO, Chief Medical Officer, to the Medico-Legal Society, 5 August 2005.

PDF printable version of Speech to the Medico-Legal Society (PDF 33 KB)

5 August 2005

Thank you (special guest, named host etc).

Why am I here? Influenza is a really boring topic especially for an after dinner speech. When as the CMO I was asked to chair my first meeting of the National Influenza Pandemic Committee, I thought this is one of those punishment details we all pay.

Following a meeting of flu SIFs (Single Issue Fanatics) who each were outdoing the other with predictions of horror, I was even more convinced of my punishment. But then came Avian Influenza - that changed my thinking.

So what is an Influenza Pandemic and how will it affect the community? A pandemic of any sort occurs when a community with no previous exposure to an infectious disease agent is exposed to it and the disease rapidly spreads. History is replete with Pandemics. Small Pox did more to defeat the Incas than the sword and measles was a major cause of death of Indigenous Australians after settlement - nothing to say of the Black Death that killed 1/3 of the European population and affected trade and resulted in a discontinuity of world affairs. Do we have a real threat - and if we do, what are we doing about it ?

Anecdotes of severe respiratory illnesses of short duration - spreading rapidly through communities and countries - exist from as early as 1100. Such stories tell us this occurred in cycles every 10 to 40 years. The stories tell us that a fierce pandemic occurred in 1847 in England, it apparently killed 250,000 in London alone and was called “the Great Influenza of 1847”. The Spanish Flue that hit the world on the heels of the First World Was in 1918 however was probably as great or greater. As you are no doubt aware the estimates of death during the Spanish Flu range between 20 to 40 million, others argue it was as high as 100 million.

The 1918 influenza hit young healthy people and transmitted rapidly. The 1957 pandemic is estimated to have killed up to 2 million people. Pregnant women were particularly susceptible. In New York City about half of women of childbearing age who died of influenza were pregnant. The 1968 pandemic killed 1 million but was more like a very severe seasonal epidemic affecting the young and old and those at risk. Some of you may remember the 1968pandemic but for many it just passed by.

The avian influenza virus that is decimating poultry flocks in Asia made its first appearance in 1997 killing 6 of 18 people known to be infected in Hong Kong. It recurred in 2002 killing three people in one Hong Kong family following a trip to southern China. In 2003 it began to spread rapidly in poultry. To date over 100 people have been infected with over 50 deaths. To turn into a pandemic flu capable of spreading effectively among people, the flu virus has to mutate, or to share genes with a human flu strain. To our best knowledge this has not happened yet.

This virus, known as H5N1 is evolving into different subtypes. We know there are genetic changes. We know that there are epidemiological changes. The cases are now occurring in clusters, the case fatality rate is lower - but still high on any account at approximately 35%. All indicating local transmission. There is still not enough evidence that human to human transmission is occurring. The genetic changes and epidemiological changes don’t seem to match, but we know change is occurring. The small adaptive changes I spoke about earlier.

A little bit more about the clinical side of influenza - a key point is that people become infectious a day or two before symptoms begin. Probably the most infectious time is the few hours before the first cough. Generally a person infected with influenza continues to shed the virus for about 5-7 days, children can continue to shed the virus for up to 21 days. There are no laboratory tests that can adequately diagnose influenza before the symptoms begin.

So what are the risks?

The amount of virus in SE Asia is vast, it is increasing in geographic spread and seemingly adapt to the human host. However there is no evidence of human to human spread - essential to establish a pandemic.

Internationally WHO has declared we are at greater risk of a pandemic than at any other time in the last 40 years. The USA is on a level of alert - the Secretary of State gets a daily briefings and the President a weekly brief. Incidentally they have committed in excess of $US1.5b to flu preparedness. So yes....there is a real threat!

The principle aim of our plans is to minimize loss of life and reduce the severity of sickness. It has two planks - in the early phase containment - prevent the disease coming into Australia and if it does to minimize the spread. The second phase is when the disease is in pandemic proportions in Australia and we must maintain essential services and social order. All these actions involve major decisions that extend beyond the scope of doctors or health professionals and involve the whole of society

What is going for us and are we prepared?

Australia is geographically isolated. It is an island so border control measures are possible. They worked in 1918 for a time. Within Australia we have relatively little population density compared to most parts of the world. A Midas map of the world population shows dense black dots everywhere - in Australia you have to strain to see them outside Sydney/Melbourne.

In terms of preparedness we have a good public health infrastructure, well planned national stockpile of antiviral agents and other medical goods necessary in a pandemic. Australia has an onshore manufacturer of vaccines - in fact the only country where capacity is sufficient for the whole population. However there is no security that the current vaccine under construction will be effective against a future pandemic. The vaccine is not a magic bullet so we must have alternative strategies.

The strategies involve the use of quarantine, social isolation, general public health measures as well as antivirals. Quarantine may mean turning away (after refueling) planes from affected countries. Australia has to accept its citizens - we know this - this is constitutional law. The quarantine law of 1908, however, states that the Minister of Health or the Chief Quarantine Officer ‘during the period the proclamation remains in force, give such direction and take such action as he or she thinks necessary to control or eradicate the epidemic or remove the threat of the epidemic.’ This means we can put those returning Australians in quarantine. If the plane stays the entire personnel on the plane may need to go into quarantine.

Where do we put them and who do we put them with? A room each with no contact? We will request them to take antivirals to prevent the disease. The use of quarantine and its effect on people’s lives, the economy will all need to be considered. In this early containment phase there will be a lot of local action in order to minimize spread.

For example if a serious outbreak were to occur in a neighboring country, the steps to prevent infection spreading to the Australian population would require rigorous isolation and quarantine measures of Australians returning to the region.

Will exposed people who are “well” and asymptomatic be willing to take medication? Generally people who have a quarantineable illness are pleased to take medication because they are infected and usually ill. In this scenario we want to give medication to people who do not have symptoms and in fact may not be infected.

If there is an infected person in the community that person will need to be isolated and cared for. The contacts of the person will need to be traced, put in quarantine (possibly home quarantine), given antivirals and monitored. What if the index case refuses to give his contacts, what if they refuse antivirals and/or quarantine?

What if an infected person informed of his infectivity decides to travel on a bus, go to work. In essence this person is knowingly infecting others with a deadly disease. Most states and territories have laws that are applicable to such a scenario. I believe thre States in Australia have used criminal law to charge people believed to have knowingly transmitted HIV. One I am told was successful.

This is very hypothetical, based on previous pandemics and severe epidemics. Change some variables and it is completely a different picture. We don’t know how infective the pandemic virus will be when it begins to transmit from human to human, we don’t know the severity of illness it will cause or whether it will be different in different age groups. We don’t know exactly how effective the antivirals will be.

The difficult choices during this early containment phase requires the co-operation of business, the community leaders and population as a whole.

I am now going to talk about some questions and conundrums with a potential legal aspect. We have been considering such questions, but they might be interesting to hear your views about it.

One of the dilemmas is when to start the debate – what details to go into – on the one hand the community at large may say they were unprepared if there is too little debate and information, but on the other hand the pandemic may not occur for years if at all and the risk of Avian flu fatigue is great!. And most people don’t listen well to public messages until they have a real close and personal need to know. When it occurs it may be mild and barely noticed or even enough to disrupt national and international trade. The SARS crisis though it effected less than 5,000 people had economic costs in the tens of billions of $s. I would welcome feed back from you on this.

Let’s look at a worse case scenario. Hypothetically.

Let’s imagine we can no longer contain the virus. We have tried putting Melbourne in quarantine with all roads out closed, all flights prevented. Yet cases begin occurring not only in New South Wales but all along the Eastern border. The rabbit proof fence however appears to be holding and there are no cases in Western Australia. The East coast moves into maintenance phase. Each State and Territory has designated essential service teams. Minimum sized teams consisting of people who agreed to take antivirals continue to work. But some forgot that schools and day care centres may be closed and they want to stay home to look after their kids. There is no law, is there? - saying we can force them to work (nope). If there are power outages, water supply disruptions who takes the blame? And who is exposed to legal risk? Is Avian flu an act of God?

What if a member of an essential worker’s family becomes sick? He pretends to take the antivirals but slips it into his pocket to give to his sick child on return home. He agreed to take the medication to play a key role in on going social functioning. Australia is in an emergency situation. Are his actions illegal? Probably not. Is his employer responsible for making sure he takes the antiviral? Can we ask them to take such responsibility?

If a pandemic happens it is possible to produce a pandemic vaccine in Australia. The vaccine would however not have all of the safety and efficacy studies required by Australian law. It would be an unlicensed vaccine that we would be putting into the arms of Australians.

If we do have a vaccine and offer it to the population – it may be genetically modified and not fully tested.

Are people happy to have a genetically modified organism pumped into their arms even if they know the danger of the pandemic? Multidose vials would have to be used to expedite delivery – they haven’t been since the eighties for fear of cross infection.

In 1976 a soldier in the USA came down with an influenza only previously found in pigs. Others in the barracks became ill. The USA government decided it was on the verge of a pandemic. The USA produced a pandemic vaccine and also made companies cease manufacturing contracts to Canada in order to concentrate on getting enough vaccine for the USA population. The pandemic didn’t happen, instead a serious illness ‘Guillain Barre syndrome’ began to occur in a sporadic fashion across USA in a number of vaccine recipients. Those law suits are still occurring; it has cost the USA government billions of dollars in compensation.

I haven’t come to the end of the conundrums – what about school and daycare closures – hotbeds of transmission of any respiratory virus – what is the impact of closures? Can people claim loss of income from this? The Canadian Government is still facing legal action in relationship to SARS over this issue.

What about general practitioners – those who monitor and treat people in their homes. If they get sick and their practice closes who pays compensation? Is it different because the country is under quarantine law?

I think I have covered most – but the more detailed the planning process becomes - the more of these darn challenges we find. They affect not only health care workers but society as a whole. Everybody is sure they are essential. In this society of a “just in time” economy, a lot of people we may not think of as essential – most probably are.

A lot has been done to reduce the impact of a Pandemic – the questions raised although hypothetical and may never need to be implemented are best addressed now, not in haste later.

We are in a different period to any previous pandemic. We have better science, better health care but society is more mobile and our economy is based on “just in time” philosophy and that has its own unique challenges, faster international travel, but also better communications – both for fact and for rumour and scaremongering.

I remain an optimist and view much of what I have outlined as a challenge.

Thank you.