Executive Summary
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The focus of our audit |
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The existence of new and re-emerging disease threats such as severe acute respiratory syndrome (SARS) and the ongoing outbreak of avian influenza have prompted countries around the world to examine closely their capacity to prevent, detect and respond to serious infectious diseases. |
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There is a small but realistic chance that sometime in the next year or two we could have an epidemic or a pandemic. The impact on New South Wales could be severe, causing more than 12,500 deaths over a two-month period and a 6.6 per cent reduction in the State’s gross domestic product - equivalent to around $20 billion. |
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This audit focuses on the critical role of NSW Health. We wanted to know if the NSW public health system is ready to respond to a public health emergency arising from a major infectious disease outbreak. These diseases include severe acute respiratory syndrome (SARS), smallpox, tuberculosis, new forms of influenza and other newly emerging diseases. |
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The key questions we wanted to answer were:
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Further information on the audit approach and scope can be found in Appendix 1. |
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Audit opinion |
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NSW Health is working to increase its preparedness to respond to a major infectious disease outbreak. It is also contributing to the development of national policies, strategies and capabilities, which affect its level of preparedness. |
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NSW Health has focused on contingency plans to respond to an influenza pandemic and has accomplished much. The plans need to be further developed and tested. There is to be close integration with private health providers. Capacity limits are being analysed and options for surge capacity developed. |
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NSW Health indicated to us that their progress has been dependent upon the need to develop a better understanding of what is required, the need to ensure national consistency in approach, and the need to adequately involve and integrate the Area Health Services in developing the response.
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NSW Health also has plans for the management of some other types of infectious disease outbreaks, such as smallpox, which could be modified to suit types of disease outbreaks that are not documented. Additionally, the work on the influenza pandemic could be used to develop broader contingency plans for other types of major infectious disease outbreaks. |
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We found little evidence that other jurisdictions were significantly further advanced than NSW in preparation and testing of plans for a pandemic. This is a major task. It also needs to be addressed in the face of competing priorities that are much closer to hand. But there is much to do and there may only be a limited time in which to complete preparations. |
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We recommend that NSW Health continue with its good work and: |
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Strengthen organisational arrangements |
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Develop systematic risk assessment processes |
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Assess and |
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Assess and address the need for surge capacity |
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Key audit findings |
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Chapter 1 Is the public health system well organised to respond to an emergency? |
The public health system is well organised to respond to an emergency incident. It is increasingly better organised to respond to an infectious disease epidemic or pandemic, but there is more to be done.
Public health system roles and responsibilities in responding to an emergency incident have been clearly designated. But further work is required to define the roles and responsibilities of outside bodies, whose roles are likely to be critical in a pandemic.
A clearly defined command and control structure is in place for health emergencies. Area Health Services have initial responsibility for case management and containment. A whole-of-health, and possibly whole-of-state, approach would be used if the situation escalates.
The completeness and quality of plans is an important indicator of preparedness. NSW Health has a high level emergency plan known as ‘HEALTHPLAN’, but most of the specific plans that support it are incomplete and in draft form and not available for use. There is a NSW whole-of-government plan and a NSW Health plan for an influenza pandemic. But most of the plans that support this are incomplete and in draft form. The need for some of these plans is being reviewed. NSW Health also has plans for the management of some other types of infectious disease outbreaks, such as smallpox, which could be modified to suit types of disease outbreaks that are not documented.
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Until recently there was relatively little formal testing of plans, although experience was gained with the outbreaks that do occur. The first NSW exercise to test the State’s response to a pandemic was Exercise Warning Shot in 2003. In late 2005 a national exercise known as Exercise Eleusis evaluated the ability to manage an animal disease outbreak with human health risks. The first national exercise testing for a major human disease outbreak was Exercise Cumpston in October 2006. In addition NSW Health is planning to conduct Exercise Paton to test the ability of NSW hospitals to identify and respond to cases in the early stage of a pandemic. |
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Chapter 2 Is the public health system preparing to respond to a full range of emergencies? |
NSW Health is focusing on preparedness for an influenza pandemic and modelling the likely impact using scenarios based on a “moderate”, or 1968-type pandemic, and a “severe”, or 1918-type pandemic. NSW Health continually monitors the risks of a pandemic, based on information from the World Health Organization.
NSW Health also monitors the risks of other infectious diseases, such as through participation in the national Communicable Disease Network Australia. It issues epidemiological reviews of selected infectious diseases and publishes an annual review. Although we found NSW Health to be very much aware of the risks associated with infectious diseases, we did not see any structured and systematic assessment of the threats they present to NSW, as outlined in the Australian risk management standard.
Monitoring and modelling are only parts of a risk assessment. Assessment also involves consideration of other factors such as the likelihood of an event occurring in the first place and the effects of actions available to deal with the risk. The aim is to ensure that efforts are optimally focused. |
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In our view, NSW Health needs to consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases. Such a measure would assist in more informed decisions, greater transparency and improved capacity to manage competing demands on limited public health resources. |
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Chapter 3 Is there likely to be sufficient and timely advice to all? |
NSW Health’s surveillance system is a critical part of its preparedness. Its systems are well established and it has a program for their further development. It needs to continue to develop and test its surveillance systems and the capability of its contact tracing system to deal with a public health emergency. |
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There has been considerable emphasis on effective communications with the public. NSW Health has established improved systems for rapid communication of urgent advice to GPs and other medical practitioners and is working on further improvement.
In NSW much of this information is collected and used at Area Health Service level. NSW Health developed an information system for use in Exercise Cumpston. The system relied on regular situation reports from the Area Health Services. There is scope to further develop such systems. |
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Chapter 4 Is there likely to be sufficient capacity in the health system? |
We were able to conclude that NSW was likely to have adequate supplies of vaccine and antiviral drugs, due to the size of the National Medical Stockpile. NSW Health is examining how this may be deployed, but actual plans will depend on circumstances at the time.
NSW Health has indicated that there is likely to be adequate laboratory capacity to handle a major outbreak. Further planning should confirm this.
Depending on its severity, a pandemic could severely stress the current healthcare system. The increase in patients requiring hospitalisation and critical care could result in shortages of staff, resources and supplies. We were unable to establish whether there was likely to be sufficient capacity. Key areas include emergency staffing needs, isolation facilities, intensive care units, assisted ventilation services, hospital beds and medical supplies.
NSW Health has identified some possible ways of temporarily increasing capacity. But there is further work to do to determine surge requirements, capabilities and formal escalation processes. |
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Response from NSW Health |
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Thank you for the opportunity to provide comments on the performance audit report Major infectious diseases outbreaks: readiness to respond.
The report acknowledges the demonstrated commitment from NSW Health to prepare the NSW public health system for major infectious diseases outbreaks, describes the many planning and preparedness initiatives that have been undertaken, and makes recommendations on how NSW Health might improve its readiness to respond. In this letter, I aim to provide some context to the challenges that exist in preparing for major infectious disease outbreaks, and describe how NSW Health aims to respond to the specific recommendations in the report.
“Major” infectious disease outbreaks are taken to mean those that have the potential to give rise to a significant public health emergency because of their capacity to cause illness, death, public fear and panic, and economic loss on a large scale. Such outbreaks have been recorded throughout history but not in recent times. However, certain events over the past decade have led to renewed concerns about major infectious disease outbreaks. With this increased concern, there has been a commensurate increase in preparedness activities around the world, including in Australia.
Major infectious disease threats over the past decade have included the outbreak of severe acute respiratory syndrome (SARS), the emergence of H5N1 avian influenza in domestic poultry flocks across Eurasia and Africa and the consequent perceived increased risk of an influenza pandemic developing, and the risks of bioterrorism. The report mostly focuses on these “large-scale” infectious disease threats but it also includes discussion of preparations for more “usual” communicable diseases outbreaks, such as measles, tuberculosis, Legionnaire’s disease, and salmonellosis. It is important to differentiate between these two broad groups of infectious disease because the readiness to respond to each of them is at a different level.
Although this performance audit was focussed on the public health sector’s readiness for a major infectious disease outbreak, it should be noted that responsibility for preparing for these events does not rest solely with the health sector. Since influenza pandemic preparedness activities have gathered momentum over the past two years, there has been a growing realisation that a whole-of-government framework is required in preparing for, and responding to, such an event. As a result, high-level working groups have been established at the federal and state levels to ensure collaboration between all relevant government sectors in pandemic planning and to prepare whole-of-government pandemic plans. I will confine my comments in the remainder of this letter to activities within the health sector. |
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The report correctly asserts that the majority of planning efforts by NSW Health for major infectious disease outbreaks is currently directed towards pandemic influenza. NSW is not alone in focussing on pandemic influenza preparedness – there is an Australia-wide, and indeed, a world-wide focus on pandemic preparedness – and there is good reason for this. Compared to other known major infectious disease outbreaks threats, influenza pandemics present the greatest potential risk to the public health owing to their ability to rapidly spread within a population, the mortality rate is likely to be high, and the entire population will be at risk at the same time. The magnitude of the threat to the public health posed by an influenza pandemic compared to other major infectious disease outbreaks means that preparing adequately for such an event will go a very long way to preparing for all major infectious disease threats.
There are thirteen recommendations in the performance audit report and these fall into two broad groups. The first group comprises six recommendations that acknowledge NSW Health’s considerable preparedness efforts to date and urge a continuation of these efforts. NSW Health agrees that elements of planning and preparedness encompassed in these recommendations are, indeed, high priority areas and intends to implement them in full.
The second group of recommendations are those that recommend how NSW Health may improve current preparedness efforts. The seven recommendations in this group are listed below with comments and a planned course of action. |
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Recommendation. Establish a time-table to finalise all emergency and contingency plans.
Comment. It is widely acknowledged that an effective overall response to a major infectious disease outbreak is crucially dependent upon (i) national consistency in policy around preparing for, and responding to, such an event, and, (ii) harmonisation of plans at the national, state, and local levels. The time-table for finalising some plans is therefore contingent upon outcomes at the Commonwealth level.
Emergency plans are, by their nature, iterative documents. They need continual review and updating in light of new information or changes to higher order plans.
Planned course of action. NSW Health will establish a timeline for completion of emergency and contingency plans. In addition, the value of consolidating some plans will be assessed to ensure clarity of planning documents and avoid duplication in plans. |
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Recommendation. Consider building on influenza pandemic preparedness planning to develop broader contingency plans to address the emergence of other new, highly transmissible and/or severe infectious diseases.
Comment from NSW Health. Although the focus for the past two years has been on pandemic influenza preparedness, national plans that deal with other major infectious disease outbreaks have also been prepared, including plans for SARS, anthrax and smallpox.
Planned course of action. Preparing NSW for major infectious diseases emergencies will continue to focus on pandemic influenza. Following this, NSW Health will build on the experience when revising and developing plans for responding to other emergencies arising from major infectious diseases. |
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Recommendation. Apply the lessons learnt from Exercise Cumpston to further improve preparedness for major infectious disease emergencies.
Comment from NSW Health. Exercise Cumpston was a 3 ˝ day national pandemic simulation exercise held in October 2006. It was an important opportunity to test national and state level pandemic plans for the early stages of a pandemic and was considered an extremely valuable event, with many lessons learned. These lessons are currently being captured and recorded during a series of state and national exercise debriefs to which NSW Health is playing a key role. Feedback to date from the Australian Government Department of Health and Ageing, the convenors of the exercise, and reiterated by international observers, is that Exercise Cumpston demonstrated an impressive ability of Australian states and territories to mount an effective response to pandemic influenza.
Planned course of action. NSW Health has already begun applying lessons learned from Exercise Cumpston to enhance state-wide preparedness for major infectious disease emergencies. |
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Recommendation. Formally establish and oversight a comprehensive program of training, testing and evaluation of plans at the state, area and facility level.
Comment from NSW Health. NSW Health has a demonstrated commitment for testing emergency plans to help ensure response capacity is kept current, as articulated in the State Health Plan, currently being revised.
The NSW Department of Health has responsibility for coordinating health emergency exercises that involve the whole state. Since 2003, NSW Health has been involved in one state-wide (Exercise Warning Shot in 2003) and two nation-wide (Exercise Eleusis in 2005 and Exercise Cumpston in 2006) infectious disease emergency simulations, and another state-wide exercise is planned for November 2006 (Exercise Paton).
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NSW Area Health Services are responsible for planning and conducting health emergency exercises at the local level. Agreement between the Department of Health and Area Health Services to carry out such tests are written into the Population Health Service Agreement 2006-07, due for release by the end of 2006.
A training tool for exercising disaster plans at the health facility level, EmergoTrain, was purchased by NSW Health in early 2006. Although not specific for infectious diseases emergencies, there are many key response elements tested in EmergoTrain exercises that are generic for all types of emergencies, such as the facility surge capacity. A program of testing NSW health facilities is being rolled out across the state, which includes the testing of each of the metropolitan trauma centres at least once per annum, and eight major regional centres over the period 2007-2008. |
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Planned course of action. NSW Health will continue to encourage and participate in national simulation exercises.
NSW Area Health Services will continue to take the lead in the preparation and conduct of local exercises, with input and advice from the Department when required. |
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Recommendation. Establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies.
Comment from NSW Health. The need for a performance management framework for preparing for all types of disasters at the Area Health Service and health facility levels, and in the development of local surge capacity plans, was identified by NSW Health in 2005. Since then, such a framework has been developed in consultation with Area Health Services and it is anticipated to be in use by late 2006.
A performance management framework is being incorporated into a revised version of the pandemic influenza plan template for NSW Area Health Services that is currently under development.
Planned course of action. Once endorsed, the performance management framework currently under development for all types of disasters will be utilised in future preparedness activities for major infectious disease outbreaks. |
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Recommendation. Consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases to assist transparency and decision making.
Comment from NSW Health. The Audit Office acknowledges that NSW Health continually monitors risks posed by major infectious diseases using a variety of methods and is very much aware of the risks posed by these threats. NSW Health does not, however, undertake a formal risk assessment of these threats using the Australian risk management standard AS/NZS 4360:2004 Risk Management. Applying this formal risk assessment method would require a redirection of current resources from other disease control activities, and it is uncertain whether the outcome would be an improvement on existing methods of risk assessment.
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Planned course of action. NSW Health will scope the utility and resource requirements involved in changing existing methods of assessing risk posed by infectious diseases to align with AS/NZS 4360:2004 Risk Management. |
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Recommendation. Develop distinct surge capacity plans within each area health service to manage emergency staffing needs, isolation facilities, intensive care units, assisted ventilation services, hospital beds and medical supplies.
Comment from NSW Health. During a large-scale infectious disease emergency, considerable additional strain will be placed on human and material resources in the hospital system and, in order for it to cope, will require a temporary change in usual practices. NSW Health has strategies planned to cope with this surge in demand for health services.
Planned course of action. NSW Health will continue with its planning efforts in this area.
Preparing a health system to respond to major infectious disease outbreaks is a major undertaking in that virtually every aspect of the health system will, in some way, be affected during the preparedness and response stages. It should be emphasised that the report gives a snapshot of preparedness activities at a particular point in time - these are continuing apace and level of readiness in NSW is improving commensurately.
I am very pleased with the level of co-operation that existed between NSW Health and the Audit Office in the preparation of the report, and thank the staff of both agencies for their professionalism and co-operation.
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(signed)
Robert McGregor Acting Director-General
Dated: 10 November 2006
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