Australia – and the world - is at risk of a deadly pandemic. But it’s not Ebola.
JENNY BROCKIE: Welcome everyone, good to have you here tonight. Rosemary, you're Victoria's Chief Health Officer, now the public focus very much at the moment is on Ebola and the Ebola virus in Africa, it's been described as a health crisis unparalleled in modern times. What's the likelihood of it becoming a pandemic and getting here?
DR ROSEMARY LESTER, CHIEF HEALTH OFFICER,VICTORIA: Well Jenny I think the likelihood of it coming to Australia is really quite low. The number of travellers that we do have from that part of the country is very low. It's unlikely that someone who became sick with Ebola would get on a plane and come here because the onset is usually quite sudden and they get quite sick.
JENNY BROCKIE: And if it did get here what would be the likelihood of it spreading quickly in Australia do you think?
DR ROSEMARY LESTER: I think the likelihood of it spreading again is very low. Ebola is not like influenza which spreads rapidly between people. To catch Ebola you have to have direct contact with the body fluids of a person. So good infection control measures should be enough to control Ebola and in Australia we have very good systems which would prevent that happening.
JENNY BROCKIE: So the developed world would cope with it much better than the developing world?
DR ROSEMARY LESTER: Yes.
JENNY BROCKIE: Because of the kind of facilities and infection control that we have?
DR ROSEMARY LESTER: That's right, I believe so.
JENNY BROCKIE: You mentioned influenza, so what is the pandemic threat because we hear about the likelihood of a pandemic being fairly high? Where is this threat, what kind of pandemic?
DR ROSEMARY LESTER: Well the influenza virus is almost unique in that it can change it's genetic structure quite suddenly to provide a new virus. So that means that virtually the world has no immunity to that new virus. And because influenza spreads quite rapid between people, so you have a population with virtually no immunity and a virus which spreads very quickly, so that's why influenza develops into pandemics.
JENNY BROCKIE: Okay, let's say that an influenza pandemic has just been declared, it's a new strain of avian influenza, it's transmitted easily, it has severe symptoms and it's killing people. Anne, you know all about this new influenza virus, why do you know so much about it?
PROFESSOR ANNE KELSO, WORLD HEALTH ORGANISATION: I'm part of the WHO, World Health Organisation, collaborating centre for influenza in Melbourne. We're part of a global network of laboratories. We will hear very quickly through that network that a new virus has been found. We'll hear very quickly that we're able to get our hands on that virus in order to be able to work with it because the role of our network and, including our own laboratory, is to monitor influenza viruses infecting humans all the time.
JENNY BROCKIE: Where's it likely to have come from?
PROFESSOR ANNE KELSO: Well of course one can never predict that but if we're talking about a new avian influenza, then the most likely thing is it will have come there somewhere in Asia where there are very high densities of bird populations living closely to humans, mixing with other animals which can also be infected with flu viruses like pigs and so the most likely scenario is that that virus would emerge first in one of the large populations.
JENNY BROCKIE: And transmit from animals to humans and then from humans to humans?
PROFESSOR ANNE KELSO: Pandemics arise, pandemic influenza viruses arise when a new avian influenza virus mixes its genes with either other avian flus or swine flus, or human flus, to make a new genetic mix which is able to transmit easily between humans to which most of the population lacks immunity and which can then spread like wild fire because it's a respiratory.
JENNY BROCKIE: Jeremy, you're driving the response to all of this in New South Wales. You've been aware of this latest pandemic threat for a while. Now I got the flu shot, I'm pretty healthy - I should be fine, right?
DR JEREMY MCANULTY, ACTING CHIEF HEALTH OFFICER, NSW: It will be very good for a seasonal flu but for a new strain for which there is probably very little or no immunity, then the current seasonal flu vaccine won't help.
JENNY BROCKIE: Why is flu so contagious?
DR JEREMY MCANULTY: Well, it's - I think it's the short incubation period, so other diseases are more contagious like measles, but flu has a very rapid turnaround time between somebody getting infected and being able to spread it to another person. Flu is largely spread by droplets, so either direct contact with somebody who's got virus on their hands and then you put it in your face, or somebody coughing, usually within a metre or so of you and you can do something about that but Ebola, it's very much, as Rosemary said, direct contacts with bodily fluids.
JENNY BROCKIE: Dominic, with a pandemic declared, you're furiously testing lots of flu virus samples here in Australia, why are you doing that?
PROFESSOR DOMINIC DWYER, WESTMEAD HOSPITAL: Well, we have the main public health laboratory in New South Wales and we need to provide information to public health and to the WHO network, of which we're part, that there is this new virus present.
JENNY BROCKIE: That it's arrived?
PROFESSOR DOMINIC DWYER: Absolutely.
JENNY BROCKIE: So you're pretty busy?
PROFESSOR DOMINIC DWYER: Oh absolutely we're swamped and this was a big problem in 2009 in most of the public health laboratories around the country. At the peak of it we were getting well over a thousand a day just in our laboratory and we normally would test 50 to 100 in a day, so it's at least ten fold what we were used to.
JENNY BROCKIE: And a lot of those unnecessary?
PROFESSOR DOMINIC DWYER: In retrospect, a lot of those unnecessary.
JENNY BROCKIE: So you're furiously testing, you haven't found a case yet, what are the chances it's already spreading in Australia even though we haven't identified a case here yet?
PROFESSOR DOMINIC DWYER: Oh, I think the chances are quite high that the virus is already present in the country and it then becomes a race to try and identify it and find where the pockets of activity are occurring.
JENNY BROCKIE: Okay, Rosemary, Dominic does get a match in his lab; the first official case is diagnosed, what's the first thing you do in Victoria?
DR ROSEMARY LESTER: The first thing that I would do would be to ring the Commonwealth Chief Medical Officer and ask for an urgent meeting of the Australian Health Protection Principal Committee, which is the committee of Chief Health Officers and other emergency management experts.
JENNY BROCKIE: How important is that early stage?
DR ROSEMARY LESTER: Well I think the important thing is how severe is this virus and I think when we get our first case we really won't have a good idea as to the severity of the virus.
JENNY BROCKIE: But what if you've seen very severe cases overseas of the same virus?
DR ROSEMARY LESTER: That can sometimes be a little misleading and we did see this in 2009 where the first cases were identified in Mexico and the pattern there seemed to be very severe. But of course as we know worldwide and in Australia, the pandemic turned out to be sort of mild to moderate severity. So initial indications from an overseas country, particularly early on, can be a bit misleading.
JENNY BROCKIE: Let's say it is severe, just for argument's sake - let's say it is severe and the symptoms are terrible and you know, the death rate is looking like it's quite high, relatively high for an influenza outbreak, can you force someone to stay quarantined?
DR ROSEMARY LESTER: We can force them to say quarantined. Each state and territory has public health laws which can require that people undertake certain actions, including being isolated, but that's a very last step and almost always we would, people would cooperate with a request for isolation.
JENNY BROCKIE: Craig, you're the emergency management commissioner in Victoria, you work very, very closely with Rosemary. Can you ever imagine having to do something like that?
CRAIG LAPSLEY, EMERGENCY MANAGEMENT COMMISSIONER, VICTORIA: Well you'd hope not. However, in 2009, Rosemary and myself had had that discussion about what it would mean to isolate or quarantine an individual, a family, a household, a neighbourhood, and you start to think about the complications of that and you need…
JENNY BROCKIE: What are the complications?
CRAIG LAPSLEY: Well it's starts to go to community goodwill, of the community understanding why they need to be quarantined and then it goes - how do you support those individuals? So all of a sudden quarantining means they're not able to function as they normally would in the community. So how do they get those life lines? How do they get their foods? How and which are they supported and how broad is it going to be? It might be achievable to quarantine a house or a neighbourhood, but if you've got to quarantine large community numbers, you're in a different space and I don't think in our normal way of life we would think that through and understand the restrictions that would place on all of us.
JENNY BROCKIE: Andrew, while all this is going on, you're already working on a sample of this new horrible virus which you got a while ago. Why are you working on it and why did you get it a while ago?
DR ANDREW CUTHBERTSON, CHIEF SCIENTIST, CSL: Okay, well I think it's well accepted that mass vaccination of the population with an appropriate vaccine is part of a very powerful cost effective part of halting the pandemic, so I'm the chief scientist at CSL and our team is very focused on working closely with Professor Kelso, so it's a process in the lab where we make this deadly virus more safe. We retain its features to stimulate the immune system and we modify it so that it will grow in very large amounts in fertilised hen's eggs which is the vehicle where we do the manufacturing at very large scale.
JENNY BROCKIE: So as this virus is spreading, you're working with a whole bunch of chooks eggs?
DR ANDREW CUTHBERTSON: Yes.
JENNY BROCKIE: To work up the vaccine?
DR ANDREW CUTHBERTSON: Indeed. So the other good thing is that because we make seasonal vaccine at very, at the millions of dose scale, we are prepared. So under direction from the Commonwealth, we can switch very rapidly from making seasonal vaccine to making pandemic vaccine.
JENNY BROCKIE: How can you make sure you've got enough eggs?
DR ANDREW CUTHBERTSON: We have long term egg suppliers in place, secure egg suppliers. But literally, providing millions of these eggs that are required to be able to manufacture because we would be asked by the Commonwealth to make 22 million doses to protect Australia, or if two doses per person are required, 44 million doses so it's very large scale in a very short time.
JENNY BROCKIE: So how many chooks are there?
DR ANDREW CUTHBERTSON: There are lots and lots of chooks, lots of hens.
JENNY BROCKIE: Special chooks?
DR ANDREW CUTHBERTSON: They are special, they're housed very, both humanely and in a very isolated sense and we have multiple sites.
JENNY BROCKIE: Where are they?
DR ANDREW CUTHBERTSON: I can't tell you. They're geographically separated and secure, but they are a very important, in 2009 where we went through this, we were able to produce and clinically test the first, at that stage, H1N1 vaccine in the world. So we can do it, we are ready to respond and we can do it very quickly.
JENNY BROCKIE: Do you have to protect them from avian influenza?
DR ANDREW CUTHBERTSON: Absolutely. We have to protect, if it's avian flu, absolutely, because it's a bird flu and there are provisions for making sure that occurs. We also have to protect our staff because we have highly skilled staff in this big facility, the only one in the southern hemisphere, but if our staff get flu we have a problem.
JENNY BROCKIE: I'm sorry to press on the chooks but how many are there? I'm quite fascinated by this..
DR ANDREW CUTHBERTSON: There are quite enough. There are enough.
JENNY BROCKIE: But how many, like are we talking thousands?
DR ANDREW CUTHBERTSON: Yes, absolutely.
JENNY BROCKIE: Are we talking tens of thousands?
DR ANDREW CUTHBERTSON: Tens of thousands.
JENNY BROCKIE: Are we talking hundreds of thousands?
DR ANDREW CUTHBERTSON: It's in that range, yes.
JENNY BROCKIE: Wow.
DR ANDREW CUTHBERTSON: And they produce fertilised eggs and a very famous Australian McFarlane Burnett described the technique quite a few years ago for growing, it happened that flu viruses grow magnificently in these eggs and that's what we need because we need to amplify the virus to be able to then inactivate it and produce the vaccine and that's the technology.
JENNY BROCKIE: You've been developing seasonal vaccines for years, you should be able to whip this up pretty quickly, shouldn't you?
DR ANDREW CUTHBERTSON: Well yes, thank you, I think we do have a very highly skilled team but I think, in your scenario we're dealing with, we've never met this before. Now to go from Anne providing us with the initial sample to having those first doses is probably around twelve weeks. Then there's a period of testing, both laboratory testing and clinical testing, to determine the dose, how many doses do you need.
JENNY BROCKIE: Craig, you've dealt with a lot of natural disasters during your time in emergency management. How is this pandemic different for you to have to deal with?
CRAIG LAPSLEY: It's broad spread across a community, or has the potential to be that. So unlike a fire, a fire is in a defined area, might have multiple fires, but this is something that can be transmitted from person to person in where people are gathered. So it starts to challenge about the way in which the community starts to interact with each other. So obviously it's got clear messaging about the health issues that people should be doing, the personal health issues, but the next step is do we need to consider where people are? Should they be on the trains together travelling at peak hour where they're actually within, or they're touching each other? So those things have been thought through. Then it's about how you implement it and how you communicate that and when you want people to behave in a certain way they'll want to know the logic, about what do we know and be very open and transparent about it, and also be open and transparent about what we don't know. And I think that's critical.
JENNY BROCKIE: And what are the politicians doing during all of this? You know, as these stories are coming out about how it's spreading and you know, there isn't a vaccine yet and all the rest of it, what sort of pressure are you coming under politically? Yes, Julie?
ASSOC. PROFESSOR JULIE LEASK, UNIVERSITY OF SYDNEY: Yeah, one of the temptations for politicians is to want to reassure the public that everything's going to be managed very well and things are under control and actually in a scenario like this, there may be a lot of uncertainty that you're dealing with. Some things may not quite be under control. So there's also a temptation for politicians to bring in high profile technological solutions that may not actually be appropriate or effective such as…
JENNY BROCKIE: Such as?
ASSOC. PROFESSOR JULIE LEASK: Such as thermal scanners at airports, we know that they may not such a good use of resources and time. And that means that the politicians have to let go of something that looks like they're doing something and is high profile.
JENNY BROCKIE: Interesting, so you think thermal scanners don't do much. Peter Collingnon, you're agreeing with that, yes?
PROFESSOR PETER COLLINGNON, INFECTIOUS DISEASES, ANU: Yeah, I mean I think our experience is that they didn't work during swine flu and they're not like likely to work and I think one of the problems with politics is everybody wants an instant solution but there's not an instant solution to this problem. And I think that's why we need the general public to be part of the equation. If you have lots of people around you dying, you know this is serious and you will do more things to limit your own movement and everything.
If you just see things on television and somebody distant may or may not have died, it makes a lot of difference. Swine flu was a good example. We thought originally there was a 5 percent mortality because of what was in Mexico and it is quite appropriate then to put in big barriers and do lots of stuff. But from the US experience in May, it was obvious that it wasn't anything like that and the early Victorian experience. Yet, you know, yet, we actually have plans that are in place that's based on a 5 percentage mortality but when you find it's really .005 percent you need to actually adapt that and we need the community on side to be part of that because there's a whole lot of issues here other than just the health issues.
DR ROSEMARY LESTER: I think Peter's made a very important point about the need for flexibility of response and I think that's a lesson that we learnt very well in the 2009 pandemic and the current Australian health management plan recognises that we need to be flexible on response. It has a sort of three scenarios, high severity, moderate severity and low severity, and it presents a menu of actions, of public health actions that we will choose from at the time, depending on the severity and the transmissibility of the disease.
JENNY BROCKIE: Let's assume the media is initially reporting this sensibly with headlines like "Killer Flu", "Where's the Vaccine", "End of Humanity"? How do you stop fear from just running rampant Craig?
CRAIG LAPSLEY: Well in the media sense it's engagement, it's been understanding the sensitivity of what they're reporting. Although they might want to put the sensation over the front page, we've got to make sure that they understand what they're saying and what it can do to the best of the interests of the community because it's about the community that we've got to get right.
JENNY BROCKIE: Dominic, is any of this impacting on your work in the lab?
PROFESSOR DOMINIC DWYER: Absolutely it impacts and classic example was getting a telephone call from a sports reporter saying oh, well, the New South Wales State of Origin team's playing in Melbourne and they've got this terrible disease going on in Melbourne, this was in the very early days of swine flu. You know, what are you doing about it? They've been out the night before, they're feeling a bit unwell, you know, should they be swabbed? So then samples are collected and they're rushed to the lab and then people are ringing up for results. All of this stuff completely inappropriately, inappropriate because A, they weren't sick, and B, it's stopping the laboratory from doing the work on the people who really are sick.
JENNY BROCKIE: But the media is trying to find out what's going on as well, you know, and the media might be wondering whether you, Jeremy, are telling everything about what you know. Are you telling absolutely everything about what you know is going on?
DR JEREMY MCANULTY: Experience shows that if you don't and it comes out some other way, then you know, that's going to be losing credibility.
JENNY BROCKIE: So there's never a moment where you people say we can't tell them that? If we tell them that things will go nuts?
DR JEREMY MCANULTY: It's about how to frame the message so that it's in the context of the bigger picture I guess. And so no, it's not about holding back messages, it's about making sure the accurate information has got out in a sensible way.
JENNY BROCKIE: And again, as it gets heightened, is the politics of it more pronounced for you, in your job, in terms of political pressure?
DR JEREMY MCANULTY: Well I think what politicians, if you really want to know we've got robust systems in place for decision making and we've got these great committees of experts that can draw on additional experts to actually guide all of us across Australia in that decision making so that we are using the best evidence and communicating that best evidence to the community.
STEVE NEWTON, FOOD INDUSTRY CONSULTANT: Can I just challenge that because during the swine flu we had arrangements in place with all the state and premiers offices, and the federal government, about how they should respond if we started getting situations of people arriving in Australia and one of the important messages from a non-health side, is people had to start thinking about stock piling of food if they started looking like being quarantined. And we had one Health Minister in Queensland who acted on the advice that's in the state emergency plan saying to the public we need to start advising you about the needs you need to stockpile on and these are the measures you need to consider. But then we had the federal Minister go out and say sorry, don't do that, that's too scary and we're telling the wrong story.
JENNY BROCKIE: Shane Oliver, you're an economist, you've been sitting listening to all of this. How are you feeling at this point in the pandemic looking around at what's going on?
SHANE OLIVER, AMP CHIEF ECONOMIST: Well as a member of the public I'd be feeling a lot concerned and as an economist I'd be worried that everyone else is concerned and what impact that might have. Look at the swine flu pandemic of 2009, it just doesn't register. I think people were too busy spending their stimulus cheques they got from the government at the time. But you see a clear impact from the SARS crises of first half 2003. At one stage there I think Cathay Pacific was losing $3 million a day; air travel through the Hong Kong and Singapore airports was down 70 percent; flights from Hong Kong to North America were down 45 percent, so massive economic impact there and that of course was the reaction on the part of people.
So I guess you'd see something in Australia if you're told we've got this going on, people would stay at home. They wouldn't use public transport, maybe that's a good thing, but the economy would contract. The share market would be going down sharply; people would be feeling a loss of wealth and that uncertainty could continue till they get confidence that a vaccine is on the way and, as we heard earlier, that could be three months away. So you would have a fairly severe economic impact.
JENNY BROCKIE: No pressure Andrew, how's it going, we're four weeks in, how's it going?
DR ANDREW CUTHBERTSON: Being asked where's the vaccine doesn't actually speed up the process. But I mean, because it's going as fast as it humanly…
JENNY BROCKIE: Humanly can? People are starting to absolutely flood the health system Liz, many are turning to their GPs, how are you managing that as GPs?
DR LIZ MARLES, ROYAL AUSTRALIAN COLLEGE OF GPS: Well, it is happening fairly quickly and we're relying on high quality information coming to the practice and being updated fairly regularly. As the College of GPs we're sending out messages, probably on a weekly basis, informing GPs about which patients they need to test, you know, what is the case definition AND which particular people do we need to be worried about or not?
JENNY BROCKIE: But your receptionist is flooded, how are you stopping all those sick people at the surgery from infecting one another?
DR LIZ MARLES: So there's a couple of things. First of all we need to communicate with our patient base so we can send out, you know, we may have ways of communicating electronically and we'll have posters. You may decide to use another room for your, the people that are coming in with flu. You might decide to have anyone who's presenting with symptoms potentially to sit over in a particular area at a distance from the other patients. Or you may be saying to people this is what's wrong with you, you know, maybe you need to stay at home and we will be contacting you at home. We may need to actually see people not in the surgery.
JENNY BROCKIE: We have pretty good technology available to us. What about phone, video consultations, that kind of thing, I mean you can keep people at home?
DR LIZ MARLES: Yes.
JENNY BROCKIE: Most people have computers or a lot of people have computers?
DR LIZ MARLES: Look, they're all possible. There is one problem with that and that is that we don't actually get paid for any of those types of consultations because Medicare only rebates a face-to-face consultation. So that's an issue that we need to take up with the politicians. But yes, of course it's quite possible to have phone consultations and to have Skype consultations.
JENNY BROCKIE: Is this being discussed at part of the plan that it might be necessary to do phone and video consults that doctors get paid for?
DR ROSEMARY LESTER: The principles have been discussed. I mean obviously things like financial arrangements are not something that we as public servants would get involved in. As Liz says, that would be discussed with the Commonwealth government and the politicians.
JENNY BROCKIE: Jeremy?
DR JEREMY MCANULTY: Yeah, and look, since the last pandemic we've looked at issues like having call lines where people can call in and get advice from a centralised service to provide tips on how to prevent or manage illness. And it may be that we target particular high risk people, the ones you mentioned before such as pregnant women and the elderly, to get them with Tamiflu, or whatever the anti-viral is at the time, to seek them to prevent them getting into trouble. So we might be having very targeted messages which includes stay at home rather than go and see a doctor.
JENNY BROCKIE: Anthony, you're a pharmacist, so once the vaccine's ready you want to be able to administer it in pharmacies?
ANTHONY TASSONE, PHARMACY GUILD, VICTORIA: I think there's an opportunity to fully utilise our health workforce. It's been happening in the US in all states since about 2008 so that can alleviate the burden on GP clinics if suitably trained pharmacists can administer an influenza vaccine in an appropriate setting in that pharmacy. So not all pharmacies as we stand here right now may be built to do it, but there is certainly an opportunity there.
JENNY BROCKIE: Liz, how would you feel about that?
DR LIZ MARLES: I mean look, we do have concerns. I mean immunisation is the core business of general practice, we are set up to do it. We have records to say who's been vaccinated and who hasn't. We have recall systems to bring in those patients who need to be vaccinated and you know, we do get a bit concerned about fragmentation within the health system where we don't know who's been managed and who hasn't been managed.
JENNY BROCKIE: But there's going to be a lot of change going on here?
DR LIZ MARLES: There is.
JENNY BROCKIE: And a lot of people are going to have to shift their ground and give up their turf and move and, you know, be flexible. Are doctors going to be part of that?
DR LIZ MARLES: Of course and I think what we know is that most practices have nursing staff and we do have the ability to ramp up, but there will be some areas where, you know, we can't reach and we need to look at alternative solutions in those areas.
JENNY BROCKIE: Rosemary, a couple of mentions about Tamiflu, there's a stockpile of antivirals like Tamiflu which people can take very early on to lessen the impact of this flu, or any flu. With this thing spreading who gets the Tamiflu and how?
DR ROSEMARY LESTER: It really depends on what we're seeing as the picture of severity and transmissibility at the time. So you can use antivirals like Tamiflu for treatment of cases; you can use them for what we call post exposure prophylaxis of their contacts so giving it to contacts of cases after you've identified the case to stop the contacts becoming ill. And the third use would be to give them proactively to health care workers to make sure that they don't get sick and keep them in the health workforce. So use early on when we don't know much about the severity of the virus.
JENNY BROCKIE: Let's say we know it's severe though right now.
DR ROSEMARY LESTER: Yes.
JENNY BROCKIE: Who gets the Tamiflu?
DR ROSEMARY LESTER: Well if we're seeing severe cases we would persist with giving all the cases Tamiflu for longer, if we're seeing a severe disease.
JENNY BROCKIE: Okay, so how much is there?
DR ROSEMARY LESTER: The national medical stock file is controlled by the Commonwealth so that's a matter of them.
JENNY BROCKIE: Where is it?
DR ROSEMARY LESTER: I personally don't know that myself, that's a matter for the Commonwealth government.
JENNY BROCKIE: It's with the chickens. Probably somewhere near the chickens.
DR ROSEMARY LESTER: Probably next to the chickens.
JENNY BROCKIE: Okay. Tamiflu works only if you get the thing early, is that right?
DR ROSEMARY LESTER: That's correct. Both for treatment and for prevention.
JENNY BROCKIE: Anthony?
ANTHONY TASSONE: With Tamiflu, for it to be effective, you have to initiate treatment within 48 hours so the time clock is ticking so for it to be effective and it does completely eradicate or stop progression. It will reduce the symptoms in duration by one to two days but that does significantly reduce further spread.
JENNY BROCKIE: Jeremy, people are turning up at hospitals in huge numbers, at hospital emergency, how are you handling that?
DR JEREMY MCANULTY: Well first of all it's communication about whether they need to and whether emergency is the appropriate place for them because emergency departments are busy looking after a range of things.
JENNY BROCKIE: Emergencies?
DR JEREMY MCANULTY: Emergencies, that's right. And so within the plans there are, you know, scope for alternate models. And this would need to be considered by a range of people about what the best model of care is in a particular locality. But it could include using working with the GPs, it could include setting up special flu clinics which would divert people with flu to a special clinic that just looks after flu and then saves the Emergency Department, and for that matter GPs, to do their regular business.
JENNY BROCKIE: So are the flu cases quarantined in the hospital?
DR JEREMY MCANULTY: Well, for any infectious person there's a process of infection control which includes isolation until they're no longer infectious.
JENNY BROCKIE: And what capacities do our hospitals have for this kind of thing in terms of infection control?
DR JEREMY MCANULTY: So it's variable but early on in a pandemic when there are just a few cases, then there are single rooms where you'd put somebody and use the appropriate infection control PPE. But then there are, you know, when you get multiple people with the infection, there are, you know, you can cohort people into common wards as long as you're sure they have the same disease.
JENNY BROCKIE: Peter, what did you want to say?
PROFESSOR PETER COLLINGNON: Well, I was going to say one of the problems, if we look at the pandemic in 2009, but even before, is that you have lots of people turning up and swamping your health system that don't have to be there because they're getting better anyway. Yes, they're sick, but they're so worried they want to get the Tamiflu but they don't need it because they would have got better anyway. They need to stay home and get better. What we need is for the media to get that message out because what we do want to do is get to the pregnant women, the people with underlying risk because they're the ones we do want to give it to. And more particularly, even if you like at 1918, the people who died, the majority died of bacterial infections, not influenza. It was a secondary complication. So we've got to identify those who develop the secondary pneumonia and make sure we get them the antibiotics because the antibiotics will make more difference for stopping mass people dying probably rather than Tamiflu.
JENNY BROCKIE: Lyn, there's an example of what happened in Canada in 2003 with the SARS outbreak where two hospitals handled it very differently. Can you just quickly tell us that story about what the ramifications were?
PROFESSOR LYN GILBERT, MARIE BASHIR INSTITUTE: Sure. There were two people, two Canadians who acquired SARS in Hong Kong and flew home. One want to Toronto, was an elderly woman who died at home after being looked after by her son, he became ill and was, went to hospital himself. He sat in the Emergency Department for something like sixteen hours without being isolated and over a period of the next few weeks he infected, directly or indirectly, a large number of both health care workers and other patients and ended up with some hundreds of cases of SARS throughout the Toronto region. A high proportion of whom were health care workers, some of whom died, so this was a massive disaster in a city where you would expect really good hospital services and infection control.
By marked contrast with that in British Columbia the one patient who went to the Emergency Department was isolated within fifteen minutes, they treated him as a patient with a respiratory infection who needed to be isolated immediately and throughout the whole course of SARS, Vancouver I think had something like four cases, three of which had been acquired in Hong Kong and there was only one health care worker infected, so that is a marked contrast.
JENNY BROCKIE: So that early response is critical?
PROFESSOR LYN GILBERT: Absolutely.
JENNY BROCKIE: Okay, Allen, what arrangements did you have at the Alfred Hospital in Melbourne in 2009? What did you do with cases of swine flu?
DR ALLEN CHENG, INFECTION PREVENTION, ALFRED HEALTH: We went out and we actually got the medical centre that was used in the Grand Prix, it's a mobile building and we split it into two, put one in one hospital and a larger bed in the Alfred Hospital and that became our flu clinic. I think most hospitals had some arrangement similar to that or they had an arrangement with their Community Health Centre nearby or their local services to do similar things.
JENNY BROCKIE: What about intensive care, what happens in intensive care during a serious pandemic?
DR ALLEN CHENG: In intensive care they actually have a network at the moment to try and distribute the load. There's a very finite number of intensive care beds and there's some ability for that to increase where there's a crisis. For example, the Alfred normally has about 35 patients in intensive care - one of our local responses would be to try and scale lack on elective surgery, so surgery that could be put off safely in patients to give us a bit more capacity, and then we'd obviously be talking to Rosemary and the Department of Health about future plans.
JENNY BROCKIE: Health care workers are obviously at risk. What rights do they have? Do they have the right not to work?
PROFESSOR LYN GILBERT: Look, I think this is real issue that people worry about a lot. My feeling is that if health care workers start to refuse to work, the systems failed. It seems to me that if health care workers are properly informed about what's happening, by and large they don't refuse to work.
JENNY BROCKIE: Yeah, they mostly do keep working?
PROFESSOR LYN GILBERT: They do keep working and the risk is that they'll keep working when they're sick so that's the other…
JENNY BROCKIE: The flip side?
PROFESSOR LYN GILBERT: …side of it, that they've got to be encouraged and given treatment.
JENNY BROCKIE: Rosemary, are kids till going to school at this point?
DR ROSEMARY LESTER: Look, the evidence on school closures is that really, to have any effect, you really need to do it early in the pandemic, you need proactively close schools. But that has an enormous flow on effect in terms of particularly the health workforce, we've got many female workers in the health workforce and they're usually the ones that if the children are home from school, they're usually the ones that stay home to look after them. So we have to weigh up the potential benefits of limiting spread amongst children versus the huge social and health disruption, disruption that that would cause.
JENNY BROCKIE: You closed some schools in 2009; would you do it again in those circumstances do you think?
DR ROSEMARY LESTER: We closed schools, sorry, reactively in 2009 after cases had been identified in schools. The sorts of - looking at the evidence since then suggests that that's probably not a particularly effective intervention to prevent spread. So I suspect we probably wouldn't do that next time.
JENNY BROCKIE: Jodie, all these people are being asked to stay home from work though, a lot of those people are casual workers, what implications does that have for people?
ASSOC. PROFESSOR JODIE MCVERNON, UNIVERSITY OF MELBOURNE: So I was involved in a study in 2009 where I was horrified to realise that one in four workers in Australia doesn't have access to sick leave or carer leave. So it's all very well to say I don't want to go to work today but I have to go to work today or I can't put food on the table is a different set of decisions.
JENNY BROCKIE: So does that mean more sick people go to work and therefore spread disease?
ASSOC. PROFESSOR JODIE MCVERNON: There was a good study in the US, we know there was an association in many countries with lower socio economic status and infectious disease risk for the pandemic flu and in one study in the US that was tied to people not having leave entitlements, going to work and infecting their colleagues.
JENNY BROCKIE: What about mass, people have mentioned mass gatherings, what about mass gatherings? Like the footy grand finals, for example, we're in the thick of this pandemic, it's spreading like wild fire, the footy grand finals are on, what do you do? Jeremy, do they go ahead?
DR JEREMY MCANULTY: Well maybe not and that's a decision that needs to be carefully weighed up.
JENNY BROCKIE: Gasps everywhere.
DR JEREMY MCANULTY: And you'll find, in SARS what we found, even though we didn't have an outbreak in Australia, that people were naturally staying at home because there was a lot of fear about an outbreak occurring. So part it might be, you know, naturally people not choosing to go and expose themselves if it is a really severe pandemic, and part of it might be really tough decisions we have to make.
JENNY BROCKIE: Who makes that call?
DR JEREMY MCANULTY: It's a group so it's going to be political part, political part driven by the advice we get from public health.
JENNY BROCKIE: Yeah, they're big decisions, I mean big money involved in these things, you know, big health dangers involved potentially in them. I mean it's not an easy task, is it?
DR ROSEMARY LESTER: No, it's not. As Jeremy said, look, it's got enormous social and economic consequences but then if we're dealing with the scenario that you're talking about where we have the very severe disease, well we have to weigh up that very carefully.
JENNY BROCKIE: And Shane, you're watching the economic impact of all of this playing out in front of you.
SHANE OLIVER: The experience in Singapore, they did cancel various trade fairs and things, public gatherings, and of course Singapore is renown for that sort of quick reaction to those sort of things. But at the end of the day you could also argue that it helped bring the crises to an end fairly quickly. So there is light at the end of the tunnel and these sorts of measures, even though they do have massive economic impact at the time, could quickly bring the crisis, slow it down and that could ultimately have better economic consequences as the economy then rebounds.
JENNY BROCKIE: Steve, you've looked at planning around food; I want to talk about food. When would you expect a run on supplies?
STEVE NEWTON: Well, the experience in SARS, there's two points to make about what you've just said. On the SARS experience, the take away stores, for example, because they were mass gathering points, you were talking about the restaurant chains, they actually had an 80 to 90 percent cut in their sales. So straight away, take away food is not being consumed and people are now having to rely on more food at their homes because they're not going out for food.
The problem we've got in Australia, and it's pretty much a western civilisation problem, is 95 percent of households now only have two to four days of food. We expect very early on there will be a rush to try and grab things. What we would like people to do, and we've done a lot of work on this, is get them to grab the right thing. When they go to a cyclone event, right now they go and hit the stores and the stores are bare within hours. What we found with Cyclone Yarnsey, with messaging out there through the weather channel and other stuff we did, people started grabbing the items that we had identified on an emergency pantry list. It's on …
JENNY BROCKIE: What sort of things?
STEVE NEWTON: Well it's actually dry goods and dry foods that allows them to survive at home longer periods of time and they can stockpile it which will last longer. So we're talking about cereals, cereal bars, biscuits.
JENNY BROCKIE: Why dry food and those sorts of things and not fresh food?
STEVE NEWTON: Because the fresh food takes two to five days to be picked and get to central points, and then get to your supermarket so you can take it to your household, there's only two to five days of food in the fresh food market. So that's a big problem straight away, if people aren't picking it you're not going to get it within two to five days. We actually do see metropolitan cities, unless you've got something in your backyard all ready to pick, you're going to be short of fresh food. So you're going to have to then rely on frozen and chilled food. But eventually, depending on the severity and if it is severe there will be problems with people keeping existing power systems going, we will have risks now of not being able to maintain frozen and chilled food because you may have intermittent power problems. So that then leads to people having to rely on dry goods.
JENNY BROCKIE: How would shopping be different?
STEVE NEWTON: There will be only certain supermarkets that will be open and they will have a health and hygiene station out the front. That's already been pre-designed and ready to go. They're like a polling station where we can erect the polling station up very fast out the front of the store, stores that can't have those facilities won't be open.
JENNY BROCKIE: Who decides that in the industry, who decides which stores shut and which ones stay open?
STEVE NEWTON: Well we've been working for seven years on a monthly basis with retailers in the food industry working out, and we have a data base and a modelling tool that identifies every store in Australia from a supermarket point of view - Woolworths, Coles, Metcash, IGAs and Aldi stores have been involved with the planning.
JENNY BROCKIE: What about walking down the aisle, I'm interested in the minute detail here, you've even got plans for that haven’t you?
STEVE NEWTON: It actually starts before you get to the store. When you're coming into the carpark there'll be a chicane arrangement on how you park because as you're coming in, if you're already infected we can't actually let you start infecting other consumers coming in their cars so we'll be trying to limit people coming in in their cars for a start. We won't be mum with three kids in the car, we'll be encouraging only one person drive to the centre. As they come through they'll then have to go through what we call a one metre trolley rule. They grab a trolley and they must keep that trolley between them and the next person.
JENNY BROCKIE: Oh, good luck with that?
STEVE NEWTON: I know. There's lots of trolleys usually in carparks so hopefully that will be --
JENNY BROCKIE: So a metre, like driving?
STEVE NEWTON: Exactly. That's because of the droplet problem from, you know, people sneezing that we need to keep that distance for the public's benefit.
JENNY BROCKIE: And it's one way through the supermarket?
STEVE NEWTON: It's one way through the store with extra security on how controlling people through the store.
JENNY BROCKIE: What if you forget the vegemite?
STEVE NEWTON: Well then we'll work out something with you.
JENNY BROCKIE: So you're going to be trying to make people do these things?
STEVE NEWTON: Through a major media and communication campaign.
JENNY BROCKIE: And I know you've said it's a benefit of the monopoly situation, I mean we hear a lot about the lack of benefits in a monopoly situation?
STEVE NEWTON: Because Australia is one of the most concentrated retail groups in the world with four major retailers supplying 95 percent of the food to every household in Australia, it was much easier for us to sit in a room and try and set up a set of agreed action plans which we have done.
JENNY BROCKIE: Okay, Craig?
CRAIG LAPSLEY: We've got the ability to get access to food, it's a life line, and we've got to do it in an organised way. It's also got to do with the economics, it's got to do with the supply line end to end. The cows don't know a pandemic's on and they'll still be producing milk every day, that milk has to come down the system and be distributed so the plans we've got mightn't have the answers for everyone but what it has got is a plan that can be applied to deal with communities in a logical way.
JENNY BROCKIE: Steve, you think fast food chains can be used to help limit infections, how?
STEVE NEWTON: Yeah, we've done some development of planning with, you know, the Yums and KFCs and so we've identified with them that their drive through facilities would be a place that we could put ration packs of food through the drive through facility that would protect them, their staff from direct contact with infected people, and we would be directing people from the health and hygiene station who we can't let into the store because they were putting our staff or other consumers at risk, we would direct them through a drive through arrangement, provided the ration packs have been already put together and stock piled and that's where some work needs to be done.
JENNY BROCKIE: Okay, Darren, you run the Funeral Directors Association, how is the pandemic impacting your industry?
DARREN EDDY, AUSTRALIAN FUNERAL DIRECTORS ASSOC.: Well, I guess if we're finding mass fatalities it's starting to have a big effect. If there was mass gatherings were cancelled, then I would presume funerals would fall under the same. And then we need to try to find a way to reconcile the need for a funeral service with also the need for health.
JENNY BROCKIE: Andrew, you've cracked the vaccine, you've got the vaccine, how quickly can you get it out now?
DR ANDREW CUTHBERTSON: Well, there'd be about twelve weeks of development work and then the first lots would start to come off the production line. And there's a very important testing period the big issue is the amount of clinical testing.
JENNY BROCKIE: So for side effects and things like that?
DR ANDREW CUTHBERTSON: Absolutely. Well we don't know the dose, we don't know whether one dose will be protective or you might need two.
JENNY BROCKIE: How long would it take to get to a point where you know that?
DR ANDREW CUTHBERTSON: It depends, well it's a negotiation with the regulatory agency, the health authorities as to how fast do you want to make this available? I think probably in this circumstance you would go with limited information, but it's a very fine judgment call as to how much. We'd be directed by the health authorities in government essentially as to the degree of urgency and the risk benefit.
JENNY BROCKIE: Okay, Peter, how do you weigh the risks versus the benefit of rolling it out quickly?
PROFESSOR PETER COLLINGNON: Well I think you need to know or have some idea on how wide spread this virus is and what its mortality rate is. For instance if you're back in 1918 a quarter of the population are being infected and 2 percent of them are dying, that's quite different I think in retrospect to what happened in 2009, where if you were a child, for instance, your chance of dying if you didn't have a risk factor was less than one in a million. Now the problem with that is if you've got lots of people dying and lots of spread, then you will, I think really rapidly roll this out and do very limited testing and do the testing afterwards because you've got so many people dying.
JENNY BROCKIE: Who gets it first Rosemary when it does come out?
DR ROSEMARY LESTER: Is this so severe that we want to give it to everybody as quickly as we can? It is less severe so that we want to make sure that we protect those who are most at risk. So I think we need to look very carefully at the data, look at the objectives and then look at how quickly we can get it from CSL and prioritise those who are most at risk of severe effects or death.
JENNY BROCKIE: And how useful is it if pandemic has peaked, Allen?
DR ALLEN CHENG: Well it really depends on what phase you are. You can have a second wave that often comes a little bit later and obviously that would be useful to vaccinate the population to protect them from that. But there is a two week lead time between when you receive a vaccine and when you make the antibodies that protect you. So if it's sort of at the tail end, then it may not be that useful.
JENNY BROCKIE: Anne, you're watching the virus very closely while all this is going on in case it changes. Why?
PROFESSOR ANNE KELSO: Well there are a couple of things that could happen. It could of course become more virulent in which case public health measures might need to be enhanced. We're also looking for evidence of anti-viral drug resistance because that might completely change a decision about how to deploy Tamiflu or any other anti-viral drugs that are available at the time. So we're looking for those sorts of changes in the virus itself in order to be able to provide technical advice to the authorities who will decide what responses need to be made at the population level.
JENNY BROCKIE: There's so much in this, isn't there? I mean there are so many decisions that you're making all the time, yes?
ASSOC. PROFESSOR JULIE LEASK: Yeah, look one of the things missing out of this discussion is what the public want and value and when you're making decisions under, sometimes quite high levels of uncertainty, it's that communication in a pandemic cannot just be top down from us to them, it has, it has to involve ways of listening to the public.
JENNY BROCKIE: That's a really good point that you raise, that for all the plans that authorities have to have, there has to be a bottom up kind of information flow as well. Yeah, Dominic?
PROFESSOR DOMINIC DWYER: I think there's also an example where we've seen in France with influenza vaccine where the government took a very aggressive approach to vaccination in 2009. They took the responsibility of a vaccination away from general practitioners and had the military provide this in vaccination centres and so on. Then it turned out that the whole thing perhaps wasn't as severe as everybody thought, there were some concerns about the safety of the vaccine and so on, and so now the public have become suspicious of vaccination in France and in fact the influenza vaccination rate in France has decreased since 2009 and this is even starting to spill over in other, completely unrelated vaccines like measles and mumps and rubella you know, the public will respond and the response may not certainly be what one would expect or want.
JENNY BROCKIE: Raina MacIntyre in Latvia, you’re an infectious diseases specialist, do you think we're as prepared and we need to be for a pandemic?
PROFESSOR RAINA MACINTYRE, INFECTIOUS DISEASE EPIDEMIOLOGY UNSW: I think we're reasonably prepared but there are many gaps. Aboriginal and Torres Strait Islander communities, most of the plans don't really cater for the unique circumstances and differences there. And I think in terms of critical infrastructure, we could be doing better. I think it's all very well to say our plans are terrific but they really don't get tested out until we actually have a pandemic and generally when that happens we learn on the go, I guess.
JENNY BROCKIE: Is it a case of you're damned if you do and you're damned if you don't though?
PROFESSOR RAINA MACINTYRE: Absolutely. You know, pandemic planning is a no win game and you know, I've just heard at the European Influenza conference where I was speaking, a presentation from the UK and they did a really fantastic job of planning for the pandemic in 2009. They rolled it out very systematically and thoughtfully, but they were criticised because the pandemic was perceived as not as severe as it might have been.
Now I have to say I think there's been a lot of spin around the presentation of the data in the pandemic, you know, and I had the experience in 2009 of the then Health Minister publicly criticising me for comments I'd made about the expected, the potential expected rate of deaths. And I simply quoted out of our own pandemic plan - the average age of death in 2009 was 53 years compared as to 83 years in a normal seasonal flu year. So we had much younger people dying, the intensive care units were very full and the people dying were much, much younger than you would expect in a seasonal flu. So I think it actually did have quite a major impact which is underplayed and minimised in the way it's reported.
JENNY BROCKIE: Rosemary, we do have to wrap up quickly now but you released an Ebola plan for Victoria. How likely do you think it is you will have to use it?
DR ROSEMARY LESTER: I do think it's very unlikely that we will have to use it but I think going through the process with our health care services has been very useful to brush up on our plans and make sure that every one's well prepared. So it's been a very useful planning exercise but I do hope that we don't have to use it.
JENNY BROCKIE: Okay, so you think that the likelihood of having to use that compared to your flu pandemic plan is much lower?
DR ROSEMARY LESTER: Yes, I do.
JENNY BROCKIE: Okay, and just finally Anne, are there any particular flu viruses that you're having a close look at, at the moment?
PROFESSOR ANNE KELSO: There are two that we'll keep an eye on in particular, they're both bird flus. One is the H5N1 virus that's been circulating in the world since 2003 and has diversified a lot. A single vaccine will no longer cover these viruses everywhere in the world and they're edging towards being more dangerous. There's another that emerged last year in China, H7N9, another bird flu virus that we're very concerned about, hasn't been controlled completely yet. But of course the reality is with pandemic flu you never know where it's going to come from. We were completely blindsided in 2009 when the virus emerged in North America from pigs, so in a sense we can't predict, we have to have the systems where we're keeping an eye on what's circulating and hope to pick it up quickly.
JENNY BROCKIE: And the likelihood of an influenza pandemic?
PROFESSOR ANNE KELSO: There will be one day be another influenza pandemic but we don't know when or from where or what it will look like.
JENNY BROCKIE: That's a great note to end on. Thank you everybody, thank you very much for your conversation tonight, it's been really interesting and that's all we have time for here but let's keep talking on Twitter and Facebook.