Better health and ageing for all Australians

Departmental Speeches

Pandemic Influenza in Australia and the Impact on Aboriginal and Torres Strait Islander Peoples

Listening to Indigenous people about pandemic influenza. Inaugural Intrernational Workshop, Cairns, 22-23 September 2011

In this section:

PDF printable version of Pandemic Influenza in Australia and the Impact on Aboriginal and Torres Strait Islander Peoples (PDF 445 KB)

Slide Display: Lyn Cribb, Pandemic Planner, OHP
Rhonda Owen, Epidemiologist, OHP
Polly Wallace, MAE Scholar, OHP

Professor Chris Baggoley, Chief Medical Officer
Department of Health and Ageing

Image of front cover for Australian Government Speartment of Health and Ageing Australian Health Management Plan for Pandemic Influenza - Important Information for all Australians

Spoken: Australia’s response to the public health emergency was wide-ranging and followed the Australian Health Management Plan for Pandemic Influenza (AHMPPI). The AHMPPI is a national health plan to guide preparation for and response to an influenza pandemic. During Australia’s response to the 2009 pandemic, it provided the overarching framework for response activities within the health sector. At the state and territory levels, actions were taken in accordance with the AHMPPI and state and territory tailored response plans. The AHMPPI has an “Aboriginal and Torres Strait Islander Health Services Annex”.

A key aspect of the AHMPPI is the use of phases to define the public health actions that will be put in place in response to the specific characteristics of the pandemic. During the response to this pandemic, phases were changed in accordance with the AHMPPI. On 17 June 2009, a new phase called PROTECT was introduced. This phase recognised that pandemic (H1N1) 2009 infection was mild in most people but severe in some vulnerable groups. However, the overall impact of the infection was moderate.

The focus of the PROTECT phase was on identifying the people in whom disease may be severe and providing early medical care and interventions to reduce likely suffering in that population. This phase also targeted laboratory tests at patients in vulnerable groups and those with more severe diseases.[30] This testing policy also reduced the pressure on laboratories nation wide which may have been overwhelmed with specimens from all suspected cases.

With the change in the testing process for the PROTECT phase, the number of confirmed cases may not reflect the number of people in the Australian community who acquired pandemic influenza (H1N1) 2009 infection. The total number of cases reported may actually be an undercount.

Slide Display:

Presentation Outline

  • Pandemic planning in Australia
  • General overview of the Australian pandemic response
  • Outline the impact of the disease in Australia
      • In the general population
      • In Aboriginal and Torres Strait Islander peoples
  • Review of Australia’s health sector response to pandemic (H1N1) 2009
      • Key findings: Aboriginal and Torres Strait Islander peoples; General
  • Conclusions
Spoken: Purpose of this presentation:
  • To outline history of pandemic planning in Australia
  • To provide a general overview of the Australian pandemic response – general and specific to Aboriginal and Torres Strait Islander peoples
  • To outline the Australian epi data
  • Then to focus on the epi data for Aboriginal and Torres Strait Islander peoples
  • To discuss Australia’s review of the health sector’s response and key findings
  • Conclusion
Slide Display:

Pandemic Planning - general

Health Sector

  • 1999 – Framework for an Australian Influenza Pandemic Plan
  • 2005 – Australian Management Plan for Pandemic Influenza
  • 2006 – Australian Health Management Plan for Pandemic Influenza
  • 2008 – Significantly revised AHMPPI – Aboriginal and Torres Strait Islander Health Services Annex
  • 2009 – Revised during pandemic – PROTECT with ‘Guidance for Primary Health Care Workers Providing Care to Aboriginal and Torres Strait Islander People’

Australian Health Protection Committee

  • National Action Plan for Human Influenza Pandemic (NAP) - 2006, 2009, 2010
Spoken: Australian governments have spent considerable time since 1999 developing, testing and regularly updating a series of connected pandemic action plans – health and whole of government; national and jurisdictional – to guide a coordinated response to an influenza pandemic in Australia.
  • The health sector has developed a number of iterations of a national health pandemic plan.
  • The Australian Health Management Plan for Pandemic Influenza (known as the “AHMPPI” for short), provides the health sector with a nationally agreed strategic framework to guide pandemic preparedness and response activities.
  • The 2008 version of the AHMPPI was the result of many years of development through better understanding of the scientific evidence base for policy development, availability of antivirals and a candidate pandemic vaccine (H5N1) in the National Medical Stockpile. Planning was based on having the capacity, capability and flexibility to respond to a severe pandemic i.e. “worst-case-scenario planning”. It was the 2008 version that guided the national response in 2009.
The AHMPPI was revised during the 2009 pandemic to reflect arrangements put in place during the response.

AHPC

Coordination between the Commonwealth and the state and territory governments occurs through the Australian Health Protection Committee, the peak health sector decision-making committee for national health emergencies.

Whole of government

The National Action Plan (NAP) is a Council of Australian Governments (COAG) document and has been in place since 2006. It outlines the roles and responsibilities of each level of government in Australia, with a focus on addressing the broader socioeconomic effects of a pandemic. It includes establishment of a National Pandemic Emergency Committee during a pandemic to provide strategic policy advice to leaders on issues that require a nationally consistent approach, such as communications. This plan was revised early in 2009 to include the new AHMPPI phases, and in 2010 to reflect experience in response to the pandemic.

Jurisdictional

Jurisdictional planning has complemented national level planning, with each state and territory having a pandemic health response plan that integrates with the national plan and whole-of-government pandemic action plans that complement the NAP. Operational level planning has also been implemented at jurisdictional level.

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Pandemic Planning – Aboriginal and Torres Strait Islander peoples

  • Australian Health Management Plan for Pandemic Influenza (AHMPPI) 2008
      • Ethical framework
      • Revised during 2009 response
  • Aboriginal and Torres Strait Islander Health Services Annex to the AHMPPI
      • Commenced but not finalised prior to pandemic
  • Jurisdictional pandemic planning
  • ACCHS and NACCHO Affiliates
Spoken: During the pre-pandemic planning, consideration was given to ways to address the specific needs of Aboriginal and Torres Strait Islander peoples.

2008 AHMPPI

The AHMPPI provides the overarching framework for all Australians, with Aboriginal and Torres Strait Islander peoples implicitly integrated, although under the ethical framework, the special needs, cultural values and religious beliefs of different members of the Australian community are recognised, especially when providing health services to high risk groups, such as Aboriginal and Torres Strait Islander peoples and to those who are culturally and linguistically diverse.
An Aboriginal and Torres Strait Islander Health Services Annex to the 2008 AHMPPI was under development but not finalised
  • A series of Annexes were planned to support the AHMPPI, with the intent to cover arrangements for special groups by professional category or health risk.
  • The Aboriginal and Torres Strait Islander Health Services Annex was one of a number of annexes under development but not finalised prior to the pandemic.

    Jurisdictional health pandemic planning

    Jurisdictional pandemic planning has complemented national level planning, with overarching plans as well as more detailed, operational type plans. Links to these are available through the Pandemic Flu website.

    Aboriginal Community Controlled Health Services (ACCHS)

  • A number of ACCHS had commenced work on, or had completed, their own pandemic response plans, and in some jurisdictions ACCHS and Affiliates were included in the jurisdictional level planning processes.
    Slide Display:

    Response Implented - key dates

    • 25 April 2009 – National Incident Room activated
    • 28 April 2009 – Moves from pandemic ALERT to DELAY phase
    • 11 June 2009 – WHO declares global pandemic
    • 17 June 2009 – PROTECT phase
    • 29 November 2009 – NIR deactivated for pandemic influenza
    • 10 August 2010 – WHO declares start of post-pandemic period
    • 1 December 2010 – Australia returned to ALERT phase
    Spoken:
    On 25 April 2009, the World Health Organization declared a “public health emergency of international concern” under the nternational Health Regulations 2005, for the emerging threat from an outbreak of an influenza-like illness in the USA, and in Mexico where in particular it appeared to be causing high mortality in relatively young people.

    Australia commenced its national health emergency response with activation of the National Incident Room in the Australian Government Department of Health and Ageing to respond to the incident. This activation continued to 29 November 2009.
  • Australia moved from the pandemic ALERT phase (which is the default pre-/inter-pandemic phase) to the pandemic DELAY phase on 28 April 2009.
    By the time WHO declared a global pandemic on 11 June 2009, a total of 74 countries and territories, including Australia, had reported laboratory confirmed infections of the new “pandemic (H1N1) 2009 influenza” virus, also referred to as “swine flu”. Its sudden appearance and rapid spread – spreading more in just six weeks than other pandemic viruses in six months – demanded an immediate and coordinated international and national health response.

    Australia moved to new phase PROTECT on 17 June 2009

    The WHO declared the world to have moved to a post-pandemic phase on 10 August 2010, advising ongoing local vigilance.

    Australia effectively declared the pandemic over in Australia on 1 December 2010, at which date we returned to pandemic phase ALERT, which is the default pandemic phase outside an actual pandemic response.

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    Response Implented - key actions

    • Phases
    • Border Measures
    • Surveillance, testing, virology and Public Health Response
    • Stockpile Roll-out
    • Vaccine – Procurement, safety and Roll-out
    • Communications
    • Aboriginal and Torres Strait Islander peoples
    • Governance
    • Impact on non-Health policy areas
    Spoken: Key components of the pandemic response in Australia included:
  • actions according to phases pre-defined in the AHMPPI
  • the implementation of border measures including: thermal scanners, health declaration cards, positive pratique
  • enhanced surveillance, testing, virology and Public Health response
  • Roll-out of the antivirals and PPE from the National Medical Stockpile
  • Frequent widespread and targeted communications
  • Targeted interventions for Aboriginal and Torres Strait Islander peoples described in an Annex to the AHMPPI
  • Governance of activities through the Australian Health Protection Committee
  • Addressing the impact on non-Health policy areas

    Slide Display:

    Response Implemented - phases

    Guided by the Australian Health Management Plan for Pandemic Influenza (AHMPPI) 2008
    Phase
    Date Commenced
    Date Changed
    Duration
    DELAY
    29 April 2009
    21 May
    3 weeks
    CONTAIN
    22 May
    17 June
    4 weeks
    MODIFIED SUSTAIN (Vic only)
    3 June
    17 June
    2 weeks
    PROTECT
    19 June 2009
    1 December 2010
    76 weeks
    ALERT
    1 December 2010
    Ongoing
    Ongoing
    Spoken: Australia’s response was guided by the AHMPPI 2008.
    The Australian pandemic phasing system was developed to guide actions to be taken in Australia independently of the global pandemic phases as declared by the World Health Organization. Response strategies for each phase outline a different set of actions designed to guide decision making with respect to the most appropriate actions to be taken, and also as a way to enable succinct communications to the Australian health sector and the public.
    • The table presents the sequence of phase changes and the duration of each phase.
    • The MODIFIED SUSTAIN and PROTECT phases were not included in AHMPPI 2008. They were developed during the response to address the circumstances of a less severe pandemic in Australia.
    • MODIFIED SUSTAIN was implemented for Victoria only – the first time an individual jurisdiction was at a different phase to the national phase. The overwhelming number of cases in Victoria had strained the capacity of the public health responses outlined in the CONTAIN phase, and the SUSTAIN phase response was disproportionate to the moderate severity of the disease being experienced in Victoria. This included ceasing of extensive contact tracing and the more disruptive school interventions, and reducing the amount of testing.
    • While the AHMPPI had recognised the potential for different response strategies to be in place at the same time in different parts of Australia due to variations in the local stage of a pandemic (as occurs with seasonal influenza outbreaks), how this would be implemented was not described. While there was a strong and legitimate desire to maintain common phasing nationally, the purpose of uniformity was not clear, and communicating different actions through phase-change announcements was problematic.
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    Deveplopment of new PROTECT PHASE


    Image of flowchart showing the timeline for the development of the new PROTECT PHASE

    Spoken: The PROTECT phase was developed in recognition of the fact that that pandemic virus was mild in most cases but severe in some and moderate overall in recognition that while the pandemic influenza virus was mild in most people, with most of those infected making a rapid and full recovery, a greater focus was needed on treating and caring for those people more vulnerable to severe outcomes.
  • In PROTECT the focus was on treating and caring for those identified as more vulnerable to severe outcomes from the pandemic (H1N1) 2009 influenza. Targeted interventions including vaccination and early use of antivirals are warranted for this vulnerable population group.
  • The PROTECT phase included the roll out of the largest vaccination program, the national Pandemic (H1N1) 2009 Vaccination Program, in Australia on 30 September 2009.
    • The PROTECT phase enabled some of the measures of other phases to be implemented where locally appropriate to ensure the public health response is measured, reasonable and proportionate to the risk the virus poses to the community (i.e. “basket of measures”). It does not replace the CONTAIN, SUSTAIN etc phase structure which may be required to guide the next pandemic if it is severe.
  • The rapid development of the new phase PROTECT demonstrated that Australia has a flexible public health response system and the strong commitment from all public health officials to support teamwork across governments and a consistent national response.
    Vulnerable groups identified as: people with underlying medical conditions [chronic respiratory conditions; morbid obesity; and other chronic illness predisposing to severe influenza (cardiac, diabetes, chronic metabolic, renal, haemoglobinopathies, immunosuppressed, neurological)]; pregnant women; Aboriginal and Torres Strait Islander peoples.

    Slide Display:

    Aboriginal and Torres Strait Islander peoples "at risk"

    Early international surveillance data

        • Aboriginal and Torres Strait Islander peoples – severe outcomes
        • People with underlying chronic health conditions also at greater risk

          Early Australian data

        • 20% of confirmed cases
        • 8 times higher rate of hospitalisation
        • No evidence of widespread pandemic influenza in Aboriginal and Torres Strait Islander peoples
    Spoken:

    Early international data

    Early international surveillance information suggested that Aboriginal and Torres Strait Islander peoples were more likely to experience severe outcomes from infection with pandemic (H1N1) 2009 influenza, and that people with underlying chronic health conditions were also at greater risk.
  • This led Australian health authorities to consider and anticipate that the pandemic (H1N1) 2009 influenza virus may pose a high risk for Aboriginal and Torres Strait Islander peoples in Australia.
  • Aboriginal and Torres Strait Islander peoples have higher rates of underlying chronic disease, some of which is undiagnosed; a higher prevalence of risk factors for chronic disease and are more likely to have at least one risk factor for chronic disease; and chronic disease develops at a younger age than in the general Australian population.

    Early Australian epi data – Aboriginal and Torres Strait Islander peoples

  • While there was no evidence of widespread pandemic influenza in Aboriginal and Torres Strait Islander peoples, there were some cases in many of these communities across Australia.
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    Aboriginal and Torres Strait Islander peoples - Response implemented

    All Aboriginal and Torres Strait islander people were included as an at risk vulnerable group.

    PROTECT phase:

        • Aboriginal and Torres Strait Islander peoples were one of the highest priority groups
        • Appendix to provide practical advice
            • developed in conjunction with the Aboriginal and Torres Strait Islander peoples health sector
        • Wider use of antiviral medications recommended
    Spoken:

    PROTECT phase

  • In addition to the need for a new annex to define the PROTECT phase, an Appendix specific to Aboriginal and Torres Strait Islander peoples was needed to meet the challenges of the 2009 pandemic.

    Appendix to PROTECT Annex – ‘Guidance for Primary Health Care Workers Providing Care to Aboriginal and Torres Strait Islander People’

  • The ‘Guidance for Primary Health Care Workers Providing Care to Aboriginal and Torres Strait Islander People’ Annex to the PROTECT Annex was developed in conjunction with the Aboriginal and Torres Strait Islander health sector to address the challenges of the 2009 pandemic.
  • It provided practical advice for primary health care workers, outlining issues specific for Aboriginal and Torres Strait Islander peoples including those who had underlying medical conditions or who live in remote communities. Advice was consistent with national guidelines for measures such as infection control and case definitions, with context specific advice for populations residing in remote community settings.
  • It took practical and cultural factors in Aboriginal and Torres Strait Islander communities into consideration for implementing public health measures such as isolation, cough etiquette and hand washing.
  • It identified that early and rapid clinical support was important, particularly for remote communities. This included identifying sources of clinical support, planning for emergency evacuations by liaising with retrieval services and early anticipation of clinical deterioration to allow timely transfer.
  • In recognition that testing and treatment of pandemic influenza cases may be different for Aboriginal and Torres Strait Islander peoples, with a limited laboratory testing capacity in some areas, and less than timely results, a wider use of antiviral medication provided for a means to protect communities that were not yet affected by the virus.
  • Antiviral medications could also be used to protect communities not yet affected by the virus, and to protect the limited number of health care workers who were available in Aboriginal and Torres Strait Islander communities.
    • A number of specific steps were taken to protect Aboriginal and Torres Strait Islander peoples from the severe effects of the influenza pandemic including:
  • Supplies of oseltamivir and Personal Protective Equipment (PPE) to Aboriginal and Torres Strait Islander communities throughout Australia.
  • Aboriginal Medical Services health staff have been trained on pandemic containment, case management and infection control procedures.
  • Several culturally appropriate and relevant messages have been disseminated to alert individuals to their risk and ways to avoid infection. Posters and leaflets developed specifically for Aboriginal and Torres Strait Islander audiences are on prominent display throughout hospitals and have been widely distributed throughout Aboriginal and Torres Strait Islander communities.

    Slide Display:

    Promotion of H1N1 vaccine fo Aboriginal and Torres Strait Islander children


    Image of leaflet promoting H1N1 vaccine for Aboriginal and Torres Strait Islander children

    Spoken: During the pandemic we knew that Aboriginal and Torres Strait Islander peoples were a vulnerable group. In the development of the vaccine we also rolled out a campaign to promote free vaccines to Aboriginal and Torres Strait Islander peoples.

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    Pandemic (H1N1) 2009 Vaccine

    • National program commenced 30 Sept 2009
        • For children 6 mths - <10 yrs on 4 Dec 2009
    • Safety profile as with seasonal flu
    • One injection 15μg protects adults
    • TGA registration
    • Emphasis on priority groups but available to ALL
    • Vaccine uptake
    Spoken: Preparations to rollout the Pandemic Vaccine commenced in September 2009, with vaccine stocks pre-positioned in jurisdictional warehouses to be ready for distribution to immunisation providers at the official commencement of the national Pandemic (H1N1) Vaccination Program on 30 September 2009. This was the biggest vaccination program undertaken in Australia.
    • The timeline for clinical trials [Background Note: delays with recruiting adequate number of children] delayed commencement of the paediatric program until 4 December 2009.
    Clinical trials showed that:
    • The CSL-produced vaccine showed a similar safety profile as seasonal influenza.
    • One injection was sufficient to protect adults.
    • The dosage regime for children varied according to age group, informed by clinical trial results and advice from the Australian Technical Advisory Group on Immunisation (ATAGI).
    The vaccine received [FDA licence and] TGA registration before the Australian vaccination program commenced.
    While the initial program emphasis (and public messages) was on encouraging priority groups to seek vaccination, the vaccine was available for free to everyone in Australia when it was confirmed that only one dose was necessary for an effective immune response.

    Programs for delivery


    Jurisdictions with significant Aboriginal and Torres Strait Islander populations had a particular focus on implementing vaccination programs in remote Aboriginal and Torres Strait Islander communities, which achieved good coverage.
    • The model of delivery varied by jurisdiction, and included local clinics and mobile vaccination teams.

    Vaccine uptake in general


    An Australian Institute of Health and Welfare (AIHW) survey at February 2010 suggested that 3.9 million Australians had been vaccinated against H1N1 virus by the end of February 2010: 18% of all Australians and 21% of adults.
    • The percentages varied across jurisdictions.

    Background Notes:

    • The Department of Health and Ageing funded a 2010 Pandemic Vaccination Survey conducted in January and February 2010 by the Australian Institute of Health and Welfare. The survey showed that the swine flu vaccine uptake as of February 2010 was estimated at 18.1% (or about 3.9 million people). Some of the reasons why people wanted to get vaccinated include the seriousness of swine flu (24.7%), doctor's advice (16.8%), employment-related reasons (13.7%) and being in an 'at risk' group (10.9%).
    • The major barriers to vaccination uptake included the perceived problems with the vaccine (such as side effects and the vaccine was unsafe) and the perception that swine flu is not a serious health risk.
    Slide Display:

    Stockpile Roll-out

    • Antivirals (Tamiflu and Relenza)
        • Use for mild/moderate disease
        • Paediatric solution issues
        • Differences between jurisdictions in approaches to issuing
    • PPE
        • Issues with Medical Practitioners
        • Different approaches of States and Territories
    • Special issues of Aboriginal and Torres Strait Islander communities
    • Impact of mild nature of the disease
        • distribution plan for Tamiflu outlined in the AHMPPI for CONTAIN was not triggered
    Spoken: The Rollout from the National Medical Stockpile went well.

    Antivirals

  • As specified in the AHMPPI, in CONTAIN, antivirals were used universally to try to contain the spread of the virus
  • This caused concerns about of using all the supplies of antivirals before SUSTAIN when the disease was mild to moderate
  • However there was sufficient supplies, except for paediatric solution
  • During SUSTAIN and PROTECT a more targeted use of antivirals is specified
  • There were differences between jurisdictions in the way antivirals were issued
  • In a more severe pandemic fever clinics would be used to issue antivirals
  • In this wave some jurisdictions used fever clinics in a limited way

    PPE

    There were some issues around the PPE from the stockpile.

    In particular:
  • Whether the Commonwealth should distribute it
  • And whether GPs should receive PPE from the stockpile
  • There were different approaches to the distribution and use of PPE by jurisdictions with some producing starter packs
    Special consideration had to be given to the distribution of antivirals to Aboriginal and Torres Strait Islander communities, particularly remote communities. Pre-positioning was considered and implemented.

    The mildness of disease meant the distribution plan for antivirals outlined in the AHMPPI for control was not triggered.

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    Coordinating the Aboriginal and Torres Strait Islander peoples response

    • Indigenous Flu Network (IFN)
        • National representation of clinicians, public health physicians
        • To coordinate information sharing and to discuss solutions to acute and emerging issues
    • Similar network operational at jurisdictional level
    • Role of ACCHS
        • Worked with state and territory health departments to coordinate specific local responses
    Spoken:

    The Indigenous Flu Network (IFN)

  • was established during the response.
  • Membership: The IFN comprised experienced clinicians and public health physicians, including the Public Health Medical Officers network, from across Australia. It included representatives from peak bodies such as:
  • NACCHO and its affiliates,
  • the Australian Indigenous Doctors Association,
  • as well as the National Indigenous Immunisation Coordinator from the National Centre for Immunisation Research and Surveillance.
    Purpose: The IFN provided strategic advice and support to the Aboriginal and Torres Strait Islander health sector and the Australian Government Department of Health and Ageing, which ensured the needs of the Aboriginal and Torres Strait Islander primary health care sector were incorporated into the national response.
  • Although it took some weeks to set up, once established, the IFN proved to be a useful mechanism and a communication channel to share information and discuss solutions to acute and emerging issues relating to:
      • surveillance and epidemiological trends,
      • communication and community engagement,
      • workforce shift and surge capacity,
      • access to and prepositioning of antiviral medications and PPE from the NMS.
      • advocated for inclusion of the Aboriginal and Torres Strait Islander primary health care workforce in the training facilitated by the Royal Australian College of General Practitioners (RACGP) and the Australian General Practice Network (AGPN).

    Jurisdictional


  • This type of network was also operational at the jurisdictional level in many states and territories.

    Role of ACCHS


  • The Australian Government, state and territory health departments and the Aboriginal and Torres Strait Islander health sector worked closely to ensure timely and appropriate support for case management and delivery and pre-positioning of PPE and antiviral medication supplies.
  • State and territory health departments worked with various ACCHS to coordinate specific local responses, including supplies for case management in remote communities.
    Slide Display:

    Communications for Aboriginal and Torres Strait Islander peoples

    • Pre-prepared communication products
        • Adaptation required
    • National communication strategy to support response activities in PROTECT phase
        • To raise awareness of symptoms
        • Emphasis on recognising who may be vulnerable because of their underlying health conditions
        • In context of protecting family or community members
        • Promote preventative actions i.e. good hygiene practices
        • Encourage to seek early medical attention
    • National Pandemic (H1N1) Vaccination Program
    Spoken:

    Communication products


    Communication products based on standard pandemic influenza messages had been pre-prepared for Aboriginal and Torres Strait Islander communities. Some adaptation was required to ensure relevancy to pandemic (H1N1) 2009. Communication products are likely to require adaption for each pandemic.

    Communication strategy


    A national communication strategy was developed to support the response activities outlined in the PROTECT phase, in particular its strong emphasis on recognising contacts who may be vulnerable because of their underlying health conditions in the context of protecting family or community members. The main objectives were to:
  • increase awareness of pandemic (H1N1) 2009 influenza, its symptoms and the health risks it presented for Aboriginal and Torres Strait Islander peoples;
  • promote preventative actions to minimise the risk of infection or spread; and
  • encourage individuals to seek medical attention early.

    Vaccination program

  • Aboriginal and Torres Strait Islander peoples were an early targeted priority group for the national Pandemic (H1N1) 2009 Vaccination Program.
  • The IFN communicated with jurisdictional immunisation providers so that various models of service delivery for Aboriginal and Torres Strait Islander populations were supported and incorporated into the vaccination communication strategy.
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    Impact of the disease in Australia

    • In the Australian population in general
    • In Aboriginal and Torres Strait Islander populations in particular
    Note: Data limitations

    Spoken: The next part of this presentation I will cover the Impact of the Pandemic on the Australian Population
    and on the Aboriginal and Torres Strait Islander populations in particular.

    For this presentation we define Aboriginal and Torres Strait Islander peoples as “a person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander (or both) and is accepted as such by the community in which they live”.

    Aboriginal and Torres Strait Islander data is frequently incomplete because it relies on health professionals asking for status and on Aboriginal and Torres Strait Islander peoples self-identifying. Many analyses are restricted by the limited data obtained.

    Slide Display:

    Overview of the Pandemic in Australia

    • Generally mild disease, severe in some
    • Particularly affected vulnerable groups:
        • Aboriginal and Torres Strait Islander peoples
        • Pregnant women
        • Obese
        • Those with pre-existing co-morbidities
    • Transmission rate similar to seasonal influenza
    • Pandemic strain quickly became the predominant strain
    • Little drift in the virus and almost no resistance to oseltamivir
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    Pandemic (H1N1) 2009 compared to Seasonal Influenza

    • Occurred outside the usual influenza season
    • Severe illness and deaths occurred in much younger people than is usually seen
    • Unprecedented number of admissions to ICU with viral pneumonitis compared to other years, which imposed heavy burden on intensive care units
    Spoken: The pandemic influenza differed from seasonal influenza in several ways.
  • In many countries there were large outbreaks outside the usual influenza season.
  • Severe illness and deaths occurred in much younger people than is usually seen.
  • Australian ICU specialists reported an unprecedented number of admissions to ICU with viral pneumonitis compared to other years, which imposed heavy burden on intensive care units.
    Slide Display:
    • 37,000 laboratory confirmed cases
    • 5,000 hospitalisations
        • 13% of laboratory confirmed cases.
    • 700 ICU admissions
        • 336 cases of viral pneumonia(<57 per year for seasonal influenza)
        • 14% of hospitalisations were admitted to ICU
        • 1/3 had no known risk factor
        • 61 patients treated using ECMO
    • 191 deaths
        • Median age of death 50 years, compared with 83 years from seasonal influenza
        • 1/3 of deaths occurred in people with no known risk
        • Deaths reduced by:
            • Apparent immunity in older Australians
            • Use of ECMO
    Spoken: This slide gives an overview of the key statistics from the pandemic.

    Slide Display:

    Summary of severity indicators of pandemic (H1N1) in Australia at 5 March 2010

    Confirmed pandemic (H1N1) 2009 cases
    Hospitalised cases
    ICU cases
    Deaths
    Total number
    37,763
    13% (4993/37736 confirmed cases)
    14% 681/4993 hospitalisations
    191
    Crude rate per 100,000 population
    172.1
    22.8
    3.1
    0.9
    Median age (years)
    21
    31
    41
    50
    Females
    51%
    51%
    53%
    44%
    Vulnerable groups (Indigenous, pregnant and individuals with at least 1 co-morbidity)
    n/a
    58%
    74%
    67%
    Aboriginal and Torres Strait Islander peoples
    11%
    17%
    16%
    12%
    Pregnant women*
    n/a
    27% (287/1056 hospitalised females aged 15-44 years)
    16% (47/289 hospitalised pregnant women)
    4%
    Cases with at least 1 co-morbidity
    n/a
    46%
    67%
    68%
    Spoken: Further detailed statistics.

    Note:
  • the increasing age with increasing severity
  • 1/2 of hospitalisations, 3/4 of ICU admissions and 2/3 of deaths were from vulnerable groups
  • 1/2 of hospitalisations, 2/3 of ICU admissions and 2/3 of deaths had at least one co-morbidity
  • This means a subtantial number of people who suffered for severe disease had no known underlying health condition
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    Laboratory Confirmed Cases of Pandemic (H1N1) in Australia to 5 March 2010


    Graph depicting confirmed cases of pandemic (H1N1) cases per state

    Spoken:

    The data collection


    Laboratory confirmed Influenza is a notifiable infection in Australia. Cases are notified to the Commonwealth Department of Health and Ageing’s National Notifiable Disease Surveillance System by doctors, hospitals or laboratories. During the pandemic of 2009, cases of lab-confirmed Influenza A (H1N1) infections were notified to state and territory health departments. In turn, these were notified to the National Incident Room using NetEpi, a web-based outbreak case reporting system, by the state and territory health departments. The resulting national dataset was then cleaned and used for analysis.

    This epicurve of laboratory confirmed cases of pandemic influenza shows the course of the pandemic, starting in late May in Victoria then moving through the other states and territories, peaking in mid July and declining to background levels by October

    Overall there were more than 37,000 notifications

    The epidemic curve shows that the first wave lasted approximately 18 weeks, making it a relatively short influenza season in comparison to the previous 5 years (range 21-29 weeks).

    Slide Display:

    Crude rates of laboratory confirmed cases of pandemic (H1N1) 2009, by jurisdiction, to 2 October 2009


    Graph depicting laboratory confirmed notifications for pandemic (H1N1) 2009 (crude rate per 100,000 population) by state

    Spoken: The timing of the outbreak and notification rates varied by jurisdiction. In the early stages, almost all of the activity was in Victoria, and South Australia was the last to peak.
    This epicurve indicates that the number of notifications in Victoria had fallen at the same time as they were starting to increase in other states and territories. This reflects the fact that the amount of testing was reduced when Victoria moved to the MODIFIED SUSTAIN phase, with a focus on testing vulnerable individuals rather than the more widespread testing. It also indicates the variable rate of notifications between jurisdictions over time. The variations in the reported rates of illness across Australia may also be due to variations in testing practice.
    The focus of the PROTECT phase was on identifying the people in whom disease may be severe and providing early medical care and interventions to reduce likely suffering in that population. This phase also targeted laboratory tests at patients in vulnerable groups and those with more severe diseases. This testing policy also reduced the pressure on laboratories nation wide which may have been overwhelmed with specimens from all suspected cases.

    With the change in the testing process for the PROTECT phase, the number of confirmed cases may not reflect the number of people in the Australian community who acquired pandemic influenza (H1N1) 2009 infection. The total number of cases reported will be an undercount.

    Top of pageSlide Display:

    National Serosurvey

    • Several serosurveys across country
    • National serosurvey on healthy adult blood donors:
        • Increase of 10% in seropositivity from before the pandemic to after the first wave and before the vaccination rollout
        • The low seroprevalence suggests some degree of prior immunity to the virus
        • No significant differences observed between states
    Spoken: Several serosurveys were conducted around Australia to determine the level of infection with pandemic influenza experienced during the pandemic

    Assessment of the severity of disease due to the 2009 pandemic influenza A(H1N1) in Australian states and territories has been hampered by the absence of denominator data on population exposure.
    We compared antibody reactivity to the pandemic virus using haemagglutination inhibition assays performed on plasma specimens taken from healthy adult blood donors (older than 16 years) before and after the influenza pandemic that occurred during the southern hemisphere winter.

    Pre-influenza season samples (April – May 2009, n=496) were taken from donation collection centres in North Queensland (in Cairns and Townsville); post-outbreak specimens (October – November 2009, n=779) were from donors at seven centres in five states.

    Using a threshold antibody titre of 40 as a marker of recent infection, we observed an increase in the influenza-seropositive proportion of donors from 12% to 22%, not dissimilar to recent reports of influenza A(H1N1)-specific immunity in adults from the United Kingdom.

    No significant differences in seroprevalence were observed between Australian states, although the ability to detect minor variations was limited by the sample size. On the basis of these figures and national reporting data, we estimate that approximately 0.23% of all individuals in Australia exposed to the pandemic virus required hospitalisation and 0.01% died.
    The low seroprevalence reported here suggests that some degree of prior immunity to the virus, perhaps mediated by broadly reactive T-cell responses to conserved influenza viral antigens, limited transmission among adults and thus constrained the pandemic in Australia.

    Slide Display:

    Severe Pandemic (H1N1) 2009

    Hospitalisations

        • Co-morbidities
            • respiratory, diabetes, obesity, chronic cardiac, renal, immuno-compromised
        • pregnancy
        • rapid deteriorating flu patient
        • Higher proportion of Aboriginal and Torres Strait Islander peoples
        • Over 50% admitted within 48 hours of onset
        • Higher ICU Admissions than expected
    Spoken: Approximately 5,000 people were hospitalised with pandemic (H1N1). Around 50% of cases admitted to hospital had underlying health conditions including respiratory illness, diabetes, obesity, cardiac conditions, renal illness or were immuno compromised.

    Others were pregnant or were rapidly deteriorating flu patients.

    A higher proportion of Aboriginal and Torres Strait Islander peoples were hospitalised compared to the remaining Australian population.

    Over 50% of patients were hospitalised within 48 hours of onset of their illness.

    And 13% of hospitalised patients were admitted to ICU – a higher level than expected.

    Top of pageSlide Display:

    Age-sex profile of hospitalisations

    Age specific rates of hospitalised confirmed cases of pandemic (H1N1) 2009 to 3 October 2009, compared with average annual age specific rates of hospitalisations from seasonal influenza 2004-05 to 2006-07*, Australia


    Graph depicting Age specific rates of hospitalised confirmed cases of pandemic (H1N1) 2009 to 3 October 2009, compared with average annual age specific rates of hospitalisations from seasonal influenza 2004-05 to 2006-07*, Australia

    Spoken: The age-sex profile of hospital cases of pandemic influenza was quite different to that of seasonal influenza.

    The rates were higher in the very young and lower in the aged, the two groups traditionally affected by influenza.

    In addition adults between the ages of 20 and 60 were much higher than normally seen with seasonal influenza.

    Slide Display:

    Hospitalisations, ICU

    Comparison of hospitalisations, ICU admissions and deaths, by age group to 2 October 2009


    Graph depicting comparison of hospitalisations, ICU admissions and deaths, by age group to 2 October 2009

    Spoken: This graph shows that the age profile of pandemic flu changed with severity.

    The number of hospitalisations was evenly spread over adult age groups.

    The number of ICU admissions increase with age and the number of deaths was highest in older age groups.

    Top of pageSlide Display:

    Hospitalisations

    Hospitalised confirmed cases of pandemic (H1N1) 2009, by length of hospital stay and age group, to 2 October 2009, Australia


    Graph depicting hospitalised confirmed cases of pandemic (H1N1) 2009, by length of hospital stay and age group, to 2 October 2009, Australia
    Spoken: Hospitalisations increased to a peak of 600 cases per week. Intensivists reported that ICUs coped but would have been unlikely to maintain the peak level for much longer. This would be an issue in a more severe pandemic.

    Information on length of stay is available for 73% (3,534) of the 4,844 hospitalised cases.

    The median length of stay in hospital for all confirmed cases was 3 days (range 0–100 days).

    Overall approximately 19% of all hospitalised patients stayed in hospital for >7 days. Although children aged <5 years were more likely to be hospitalised, they tended to be hospitalised for shorter periods than older children and adults.

    Only 10% (67/662) of children aged <5 years remained in hospital for >7 days, compared to 26% (476/1798) among those in the age groups ≥30 years.

    This suggests that hospitalised confirmed pandemic influenza cases in older children and adults was relatively more severe than that in younger children aged <5 years.

    This is consistent with the observed upward trend in the median age of the various severity indices for Pandemic influenza

    A factor in length of stay in hospital was the use of ECMO machines. Some cases remained on ECMO machines for several months.

    Slide Display:

    Co-morbidities

    Co-morbidities for hospitalisations associated with pandemic (H1N1) 2009 by age groups


    Graph depicting co-morbidities for hospitalisations associated with pandemic (H1N1) 2009 by age groups
    Spoken: The presence of co-morbidities in hospitalised cases varied with age, from 78% having no co-morbidities in the 0-4 age group, decreasing to a low of 25% having no co-morbidities in the 75-79 year age group.

    Top of pageSlide Display:

    Pregnancy

    Hospitalised confirmed cases of pandemic (H1N1) 2009 in pregnant women by weeks of gestation, to 2 October 2009


    hospitalised confirmed cases of pandemic (H1N1) 2009 in pregnant women by weeks of gestation, to 2 October 2009
    Spoken: Of the hospitalised confirmed cases in whom further information was available, approximately 6% were pregnant women.

    About 32% of women aged between 20–39 years who were hospitalised for pandemic (H1N1) 2009 were pregnant.

    These proportions were substantially higher than the proportion of women who were pregnant in the general population – the estimated age-specific fertility rate in Australia in 2008 was 57 births per 1,000 for women aged 20–24 years, 106 per 1,000 for women aged 25–29 years, 128 per 1,000 for women aged 30–34 years and 71 per 1,000 for women aged 35–39 years.51 The age-specific prevalence of pregnancy in the population would be approximately three-quarters of the age-specific fertility rate.

    Information on gestational age is available for 68 of the pregnant cases. Approximately 6% were in their 1st trimester 25% were in their 2nd trimester and 69% (47/68) were in their 3rd trimester

    These proportions were similar for pregnant women were admitted to an ICU.

    Pregnant women stayed an average of 15 days in hospital (range 1–63 days).

    Of the 183 reported deaths with confirmed pandemic influenza, 3 were pregnant women.

    Slide Display:

    Aboriginal and Torres Strait Islander peoples

    Age sex pyramid - Aboriginal and Torres Strait Islander peoples vs remaining Australian population


    Pyramid depicting age sex pyramid - Aboriginal and Torres Strait Islander peoples vs remaining Australian population
    Spoken: And what about our Aboriginal and Torres Strait Islander peoples in particular, how did the pandemic affect them?

    Aboriginal and Torres Strait Islander peoples comprise 2.5% of Australia’s population, are younger and have higher rates of co-morbid illnesses than the remaining Australian population.

    Data show that of the 570,000 Aboriginal and Torres Strait Islander peoples, nearly one third live in major cities (32%), 22% in outer regional areas, 21% in inner regional areas, 9% in remote areas and 15% lived in very remote areas.

    Top of pageSlide Display:

    Epidemic curve, H1N1 by onset week Australia, April—December 2009


    Graph depicting Epidemic curve, H1N1 by onset week Australia, April—December 2009
    Spoken: This slide shows the national epidemic curve of confirmed cases of pandemic influenza in Australia during 2009 for Aboriginal and Torres Strait Islander peoples and the remaining Australian population.

    Of the 37,000 notifications of pandemic influenza reported nationally to NetEpi during 2009, 11% or 4,063 cases were listed as Aboriginal and Torres Strait Islander peoples, 50% were not Aboriginal and Torres Strait Islander peoples and 39% did not list Indigenous status or listed Indigenous status as unknown.

    The completeness of Indigenous status data varied greatly across jurisdictions.

    For the analyses following, unknown and missing responses to Indigenous status were treated as non-Indigenous, and therefore part of the remaining Australian population. This method was chosen because of the low proportion of Aboriginal and Torres Strait Islander peoples in the Australian community and gives a more conservative assessment to the effects of pandemic influenza on Aboriginal and Torres Strait Islander peoples.

    Aboriginal and Torres Strait Islander notifications were highest in the week following the peak week, with 698 cases notified.

    Extra information:

    In this analysis, 39% (14,841) of cases reported Indigenous status as “unknown” or “missing”. A sensitivity analysis was not undertaken and these cases were retained for this analysis and treated as not Aboriginal and Torres Strait Islander for the following reasons:
    • To maintain a consistent departmental approach with data in-line with the approach taken throughout the pandemic. During that time, DoHA reported patients with “unknown” or “missing” status as non-Indigenous.
    • This approach is the standard used by the Australian Institute of Health and Welfare.
    Slide Display:

    H1N1 National data by severity Australia 2009

    Total
    Indigenous
    Risk Ratio
    Notifications
    37,763
    11%
    4.3
    Hospitalisations
    4,993
    17%
    7.5
    Admission to ICU*
    ANZICS
    489
    711
    16%
    10%
    7.6
    Deaths
    191
    12%
    5.3
    Spoken:

    Notifications


    Of 37,736 Notifications of pandemic influenza 11% were Aboriginal and Torres Strait Islander peoples.

    The risk of being a confirmed pandemic influenza case for Aboriginal and Torres Strait Islander peoples was 4.3 times that of the remaining Australian population.

    Hospitalisations


    Of the 4,993 hospitalisations recorded in Australia, 17% were Aboriginal and Torres Strait Islander peoples.

    The risk of being hospitalised with pandemic influenza for Aboriginal and Torres Strait Islander peoples was 7.5 times that of the remaining Australian population.

    Admissions to ICU

  • Of the 489 reported admissions to ICU in Australia, 16% were Aboriginal and Torres Strait Islander peoples
  • The risk of being admitted to ICU with pandemic influenza for Aboriginal and Torres Strait Islander peoples was 7.6 times that of the remaining Australian population
    Note that this is data reported nationally to NetEpi and Victoria and Queensland are not represented. These jurisdictions used the Australian and New Zealand Intensive Care Study (ANZICS) to record ICU admissions.

    ANZICS data reported a total of 711 admissions to an ICU in Australia, 10% (72) were Aboriginal and Torres Strait Islander admissions with the remaining ethnicities accounting for 90% (639) of ICU admissions.

    Deaths

    Of the 191 pandemic influenza-related deaths reported in Australia 12% were Aboriginal and Torres Strait Islander peoples.

    The risk of a pandemic influenza-related death for Aboriginal and Torres Strait Islander peoples was 5.3 times that of the remaining Australian population.

    Background note: rates in Aboriginal and Torres Strait Islander peoples were indirectly standardised using five year age groups to the remaining Australian population by calculating standardised ratios (dividing the number of observed notifications by the number of expected notifications) which assumed the Aboriginal and Torres Strait Islander population had the same age and sex specific notification rates as the reference population. As a ratio of observed to expected notifications, a standardised notification ratio >1 means more notifications than expected actually occurred. Standardised hospitalisation and mortality ratios were calculated in a similar fashion.

    Top of pageSlide Display:

    Serologic survey – Northern Territory

    • Post-pandemic proportions of immune persons was:
        • around double in Aboriginal and Torres Strait Islander peoples (compared with 4.9 times estimated from surveillance data)
        • geographically heterogeneous, particularly among remote living and Aboriginal and Torres Strait Islander peoples
          Trauer JM, Laurie KL, McDonnell J, Kelso A, Markey PG. Differential effects of pandemic (H1N1) 2009 on remote and indigenous groups, Northern Territory, Australia. Emerg Infect Dis [serial on the Internet].
        • 2011 Sep [cited 14 Sept 2001]. http://dx.doi.org/10.3201/eid1709.101196
    Spoken: Other studies estimated the increased burden of pandemic influenza on the Aboriginal and Torres Strait Islander population.

    Results of two cross-sectional serologic surveys on specimens from Northern Territory showed that the:
  • Postpandemic proportions of immune persons was around double in Aboriginal and Torres Strait Islander peoples - this is lower than the 4.9 times estimated from surveillance data.
    • And that
  • Postpandemic proportion immune was geographically heterogenoeus, particularly among remote living and Aboriginal and Torres Strait Islander peoples.
    Slide Display:

    H1N1 notifications for Aboriginal and Torres Strait Islander peoples and the remaining Australian population - Age specific rates / 100,000 Australia, 2009


    Graph depicting H1N1 notifications for Aboriginal and Torres Strait Islander peoples and the remaining Australian population - Age specific rates / 100,000 Australia, 2009

    Spoken: This graph shows how the age group profile for Aboriginal and Torres Strait Islander peoples differs to that of the remaining Australian population.

    It shows that the age group with the highest rate of Aboriginal and Torres Strait Islander notifications were 50-54 year olds and for notifications in the remaining Australian population, 15 to 19 year olds.

    Top of pageSlide Display:

    Age Group Comparisons

    Median Age (years)
    Age group with Highest Rate per 100,000 (years old)
    Indig
    Non-Indig
    Indig
    Non-Indig
    Notifications
    18
    21
    50-54
    15-19
    Hospitalisations
    31
    31
    50-54
    <5
    ICU admissions
    39
    41
    55-59
    50-54
    Deaths
    50
    50
    55-59
    55-59
    Spoken: However, while there was some variation in the groups most affected, there is little difference between the median ages of Aboriginal and Torres Strait Islander cases compared with Aboriginal and Torres Strait Islander cases for notifications, hospitalisations, ICU admissions or deaths.

    This slide shows a comparison of ages affected by pandemic influenza between Aboriginal and Torres Strait Islander peoples and the remaining Australian population for notifications, hospitalisations, ICU admissions and deaths.

    The median age increases by approximately 10 years for each level of severity.

    Slide Display:

    Aboriginal and Torres Strait Islander patients and patients in the remaining Australian population with at least one co-morbidity by severity, Australia 2009

    Category
    Indigenous (% of total)
    Non-Indigenous (% of total)
    Risk Ratio
    Notification
    2.8%
    2.7%
    1.0
    Hospitalisations
    21.7%
    13.9%
    1.6
    Deaths
    74%
    67%
    1.1
    Spoken: Where possible, co-morbidity data was collected for all influenza notifications.

    Reporting of co-morbidities was low, with 10% of all cases completing those fields. This made analysis of the effect of co-morbidities on the severity of H1N1 infections difficult to interpret as numbers were small.

    However, In general the data showed prevalence of at least one co-morbidity in notifications and deaths was similar between Aboriginal and Torres Strait Islander peoples and the remaining Australian population and was slightly higher in Aboriginal and Torres Strait Islander cases that were hospitalised.

    Results obtained in a Western Australian study by Goggin et al. which is currently in press showed similar results, that no difference in frequency of having 'any underlying medical condition' in Aboriginal and Torres Strait Islander cases and cases hospitalised with pandemic H1N1 in the remaining Australian population.

    The Western Australian study showed that only age and the presence of two or more medical conditions were independent predictors of hospitalisation, with Indigenous status not contributing further.
    These results suggest that the Aboriginal and Torres Strait Islander population suffered higher rates notification, of hospitalization and of death from pandemic H1N1 by virtue of their higher prevalence of risk factors for severe disease rather than any innate genetic predisposition on vulnerability.

    This suggests that the increased frequency of cases and hospital admissions in Aboriginal and Torres Strait Islander peoples was because of the greater prevalence of risk factors for severe disease in those populations.

    Top of pageSlide Display:

    Co-morbidities in H1N1 Notifications, for Aboriginal and Torres Strait Islander peoples and the remaining Australian population, Australia, 2009

    Co-morbidity
    Indigenous
    Non-Indigenous
    Odds Ratio (95% CI)
    Renal failure
    84
    119
    5.7 (4.4-7.5)
    Metabolic disorders
    22
    64
    3.4 (2.1-5.4)
    Diabetes
    182
    522
    2.7 (2.4-3.2)
    Cardiac conditions
    118
    407
    2.7 (2.6-3.4)
    Chronic Respiratory conditions
    258
    2,106
    1.5 (1.3-1.7)
    Obesity
    65
    351
    1.5 (1.2-2.0)
    Spoken: The top 6 co-morbidities identified in H1N1 national notifications were:
    • Renal failure, Metabolic disorders, Diabetes, Cardiac conditions, Chronic Respiratory conditions and Obesity
    These data showed that for the top 6 co-morbidities notified, these conditions were between 1.5 and 5.7 times were more likely to be found in Aboriginal and Torres Strait Islander cases notifying of H1N1 than cases in the remaining Australian population.

    With Renal failure, Metabolic disorders, Diabetes, Cardiac conditions being the highest.

    Slide Display:

    Summary

    The effect of pandemic H1N1 on Aboriginal and Torres Strait Islander peoples vs. the remaining Australian population

    • Higher risk of severe outcomes compared to cases in the remaining Australian population
    • Similar median age as cases in the remaining Australian population for notification, hospitalisation, ICU admissions and deaths
    • No difference in frequency of having 'any underlying medical condition' in Aboriginal and Torres Strait Islander cases and cases hospitalised with pandemic H1N1 in the remaining Australian population.
    • Only age and the presence of two or more medical conditions were independent predictors of hospitalisation, with Indigenous status not contributing further 1
    • Higher rates notification, hospitalization and death by virtue of their higher prevalence of risk factors for severe disease rather than any innate genetic predisposition or vulnerability
    • Higher rates chronic conditions especially Renal failure, Metabolic disorders, Diabetes, Cardiac conditions
    1 Goggin et al, Chronic Disease and Hospitalisations for Pandemic (H1N1) 2009 influenza in Indigenous and Non-Indigenous Western Australians, in-press

    Top of pageSlide Display:

    Pandemic Influenza in Aboriginal and Torres Strait Islander peoples: Conclusions

    • Evidence supports Aboriginal and Torres Strait Islander peoples being a vulnerable population
    • Co-morbidities and age make the difference to severe outcomes, not indigenous status alone; and Aboriginal and Torres Strait Islander peoples tend to have more existing co-morbidities
    • Current government policies are appropriate in priority for treatment, intervention, vaccination
    Spoken: The evidence collected during the pandemic supports Aboriginal and Torres Strait Islander peoples being a vulnerable population.

    Aboriginal and Torres Strait Islander peoples were more likely to have been notified and have serious outcomes from pandemic (H1N1) 2009 than the remaining Australian population.

    We know from previous research, and experience, that Aboriginal and Torres Strait Islander peoples are socioeconomically disadvantaged compared with the remaining Australian population which places them at greater risk of unhealthy factors such as smoking and alcohol misuse, as well as chronic disease and obesity.

    Analyses of Surveillance data suggests that co-morbidities (both type and number) along with age make the difference, not being Aboriginal and Torres Strait Islander itself.

    Aboriginal and Torres Strait Islander peoples have a high prevalence of underlying chronic disease, much of it undiagnosed. As a result they have a much higher risk of severe disease and complications from H1N1 influenza than those that aren’t Aboriginal and Torres Strait Islander. In the first wave, Aboriginal and Torres Strait Islander peoples were hospitalised at nearly 8 times the rate of the remaining Australian population and had nearly 6 times the death rate. The first H1N1 Influenza related death was an Aboriginal and Torres Strait Islander person.

    Targeted interventions including vaccination and early use of anti-virals are warranted for this vulnerable population group.

    Slide Display:

    Lessons Learned from 2009 – Aboriginal and Torres Strait Islander peoples

    • Review of Australia’s Health Sector Response to Pandemic (H1N1) 2009: Lessons Identified
    • Australian Health Protection Committee report to be published online this year.

    Recommendation

    • Further develop and incorporate Indigenous Health Services and the cultural, social and environmental values of Indigenous Australians into pandemic planning.

    Key Findings

    • Aboriginal and Torres Strait Islander peoples were more vulnerable to severe outcomes.
    • Appendix to the PROTECT Annex addressed specific Aboriginal and Torres Strait Islander peoples issues.
    • Consideration should be given to maintaining an Indigenous Flu Network, or similar.
    Spoken: So what did we learn with respect to Aboriginal and Torres Strait Islander communities during the pandemic?

    Pandemic Review Report – general comment


    The Review of Australia’s Health Sector Response to Pandemic (H1N1) 2009: Lessons Identified (the Report) examines the Australian health sector’s response in the context of what was planned, and what actually occurred during the 2009 pandemic.
  • The Report identifies what worked well, as well as identifying issues that require further consideration to strengthen the planning, management and operational aspects of pandemic health response arrangements in Australia.
  • Recommendations accordingly focus on the later issues and will inform a review of the Australian Health Management Plan for Pandemic Influenza 2009 (AHMPPI).

    Key findings for Aboriginal and Torres Strait Islander peoples response


    More vulnerable

  • Aboriginal and Torres Strait Islander peoples were more vulnerable to complications from pandemic (H1N1) 2009 virus, with a 6-fold higher death rate compared with the remaining Australian population.
  • The reasons are likely to be multi-factorial, including social and cultural factors as well as the physical environment.
  • The information on Aboriginal and Torres Strait Islander populations from other parts of the world and early recognition of this threat to Aboriginal and Torres Strait Islander peoples aided Australia’s response.
  • The disease burden for this group may have been even higher without this prioritised attention.

    Appendix


    It proved necessary to develop an Aboriginal and Torres Strait Islander peoples Appendix (on the run) to PROTECT. Had to consider a range of issues and liaise with the Aboriginal and Torres Strait Islander health sector to develop.

    IFN

  • Consideration should be given to maintaining or establishing a similar forum, to inform future planning and response.
  • Representation of network members on key national and jurisdictional bodies was critical. These included the Interjurisdictional Pandemic Planners Working Group, the GP Roundtable, the National Immunisation Committee, and the AHPC as required.

    Other relevant findings

  • Targeted communication with high risk groups could be improved. While there were clear messages about which groups were at high risk of severe outcomes, it has been identified that earlier engagement with Aboriginal and Torres Strait Islander audiences is needed, where unsupported mass media has not been shown to be effective.
  • Logistics issues with delivery of cold chain medications to rural and remote communities. The logistics of remote area access should feature in emergency plans as should the need to involve members of the Aboriginal and Torres Strait Islander health and social sectors, as well as community Leaders.

    Top of pageSlide Display:

    Future Planning to Include

    • Expectation that Aboriginal and Torres Strait Islander peoples will be disproportionately affected
    • Appropriate responses - cultural, social and environmental values
    • Consider re-establishing IFN
    • Involve members of Aboriginal and Torres Strait Islander health and social sectors, as well as community Leaders
    • Good linkages between jurisdictional and national level planning to implement response in urban, regional and remote settings
        • Limited trained workforce in remote community settings
        • Surge capacity to support established clinical workers
    • Logistics of remote area access
        • Based on solutions put in place in 2009 for PPE, antiviral medications and vaccine
    Spoken:

    Future pandemic planning

  • Aboriginal and Torres Strait Islander peoples are likely to be disproportionately affected in another pandemic.
  • Planning needs to incorporate this expectation and include appropriate responses that incorporate Aboriginal and Torres Strait Islander peoples-specific cultural, social and environmental values.
  • The role of the Indigenous Flu Network should be re-examined, with consideration to re-establishing the group, or a similar group, for planning purposes. This could include a review its membership and identifying additional members, to ensure the necessary aspects of pandemic and/or health emergency planning are adequately covered.

    Strategies for obtaining Aboriginal and Torres Strait Islander peoples’ input into pandemic and health emergency planning

  • An important area identified where further work is needed is to collaborate with the Aboriginal Community Controlled Health Services (ACCHS) to ensure appropriate planning, communication and training for a pandemic response.
  • Involvement of Aboriginal and Torres Strait Islander health and social sectors in planning
  • There needs to be good linkages between jurisdictional and national level planning and implementation of a response in urban, regional and remote settings.
      • Limited trained workforce.
      • There was a limited trained workforce for the pandemic response in remote community settings.The Indigenous Flu Network advocated for inclusion of the Aboriginal and Torres Strait Islander primary health care workforce in the training facilitated by the Royal Australian College of

        General Practitioners and the Australian General Practice Network.

      • Need for surge capacity
      • Establishing a surge capacity to support the established clinical workers who were delivering health care services in Aboriginal and Torres Strait Islander communities would have been a great advantage.

      Logistics
      • The logistics of remote area access should feature in emergency plans.
      • While there were difficulties in providing PPE, medication and vaccine to Aboriginal and Torres Strait Islander peoples in remote areas, the solutions that were put in place in 2009 to overcome the logistical transport challenges need to inform future plans.

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