Pathfinder
Editor, Senior Moderator
We failed the swine flu test Decrease Increase
September 19, 2009
Article from: The Australian
Mistakes made in the face of the H1N1 influenza virus were potentially deadly, reports health editor Adam Cresswell
AS Queenslander Keven Hadlow kissed his 15-year-old daughter Grace goodbye after driving her part-way to school one Monday morning in July, neither of them had any idea that within 24 hours he would be on breathing equipment in hospital.
"It was the worst health experience I have ever had in my life," says Hadlow, who spent the next nine days in a hospital isolation room battling the H1N1 human swine flu virus.
"It was terrible, an awful thing ... you vomit, you mess yourself, snot is coming out of your nose, and there is not a **** thing you can do to help yourself."
Hadlow, from Eagleby between Brisbane and the Gold Coast, was left on an ambulance stretcher in a hallway of Brisbane's Logan Hospital for two hours, accompanied by paramedics, before he was assessed and spent another six hours in emergency waiting for a ward bed, all with other nearby patients exposed to his germs.
Worst of all in his view, nobody asked his partner or daughter whether they were starting to feel ill, offered them masks or gloves, or suggested avoiding others for a few days in case they were infected. "I think that was a terrible mistake," he says.
Hadlow is far from alone in his disillusion. Many health workers have voiced their own tales of poor planning, inflexible bureaucracy and avoidable mistakes that in some cases made them fear for their safety.
Some focus on the half-hearted and haphazard policy on school closures, the uselessness of airport thermal scanners, the sometimes shambolic communications, or point to organisational debacles such as the notorious case of cruise ship Pacific Dawn, which was allowed to disgorge 1800 passengers when it docked in Sydney in May despite two boys who later tested positive for swine flu having fallen ill during the voyage.
But there are plenty more detailed criticisms and many of them are coming from general practitioners, who say the problems start with the fact that the Australian Health Management Plan for Pandemic Influenza, the 150-page manual supposed to direct the country's response to the virus, barely gives them a sideways glance.
The document relegates primary care to an annex of the report that, even now, remains unfinished. "A lot of the initial pandemic planning really didn't see general practice as front line," says Chris Mitchell, president of the Royal Australian College of General Practitioners. "But the reality is that it is front line because that's where people go to get their general advice."
One big early concern was that health authorities initially advised the public to visit their GP if they feared they might have flu. This was courting disaster, says Mitchell, because GPs were then faced with infected patients turning up unannounced, coughing over reception staff and other patients in the waiting room. The RACGP took it up with the government's chief medical officer, and the advice was quickly amended so that patients were instead advised to ring their GP first, which at least allowed time for masks to be donned and an examination room prepared.
Even so, some experts think this illustrated a wider failing in the overall flu strategy.
Peter Collignon, professor of infectious diseases and microbiology at the Australian National University, says experts here rightly criticised New York parents for hosting "swine flu parties" -- hoping to deliberately infect their children in the belief they would get a mild illness and then be protected -- but what happened here was not very different.
"The reality is in Australia we have swine flu parties all the time. We call them doctors' surgeries and hospital emergency departments," Collignon says. "What happens with all these clinics and everything else we had? Maybe one in 100 or even one in 10 actually have swine flu, but the other nine don't; and they all get mixed together and probably give each other the infection."
Collignon says the evidence was clear from the end of May that swine flu was not going to prove a mass killer and so he says the response was always over the top. But he says that when we do face a virulent virus -- which the authorities in May and June thought swine flu was or might be -- then we "should be telling people to stay home".
"And I think that means we shouldn't have people coming to medical centres," he says. "We need to work out some way of assessing people over the phone and have (doctors or nurses) come to them if necessary", with hospital treatment reserved for the one in 10,000 cases who become seriously ill.
Collignon believes his point is proved by the fact swine flu was not held back and has since become the dominant flu strain, although in fact health authorities always knew stopping flu was an impossible task. The goal instead was to delay its spread as much as possible, creating time for a vaccine to be delivered. The point is moot because we will never be able to measure what if any delay was achieved. We can't even measure the number of people who have been infected.
Latest federal figures put the number of swine flu cases confirmed at 35,143 by September 4, but this is a fraction of the true figure because doctors stopped routine testing of all suspect cases back in June, when it became clear any hope of controlling its spread had evaporated.
At its peak in mid-July, about 1300 patients a week with flu-like illnesses were presenting to NSW emergency departments, three times the previous highest peak in 2007. But the disease is certainly on the wane. For the first time since the outbreak began in May, presentations of influenza-like illnesses to GPs and hospital emergency departments decreased across all states and territories by the last week of August.
Work sickness rates are improving. One unidentified employer with more than 10,000 employees in NSW has told health authorities that 1 per cent of its NSW workers took sick leave for more than three days in the seven days ending August 26, down from a peak of 1.4 per cent in the week ending July 22. The rate is comparable to that in 2007, during a severe seasonal flu outbreak.
Many doctors say the response to the pandemic was sensible in many aspects. Not surprisingly, health authorities agree. Jeremy McAnulty, director of communicable diseases for NSW Health, concedes the Pacific Dawn incident showed the importance of good communication, but claims the progress of the disease was slowed.
With the emergency on the wane, more GPs are coming forward with tales of what went wrong. Peter Eizenberg, a GP in North Melbourne, one of the areas hardest hit at the start of the epidemic, wrote a blistering account of failings for a Medical Journal of Australia article published in July that mirrored concerns of many doctors nationally.
He wrote that it "quickly became evident that the rhetoric contained in the (pandemic plan) did not match the reality on the ground". Supplies of masks, gloves and gowns, which Roxon promised at the end of May would be made available, arrived a month late and in only a fraction of the amounts sought.
Under the plan, practice staff exposed to infectious patients without protective gear were supposed to receive Tamiflu to reduce the chance they would contract the disease, but this did not happen unless the staff members in fact fell ill, in which case they had to stay in home quarantine themselves. Instead, GPs were told to buy their own supplies, which many did, at least until pharmacy stocks ran out.
Eizenberg also said the Victorian criteria for suspecting swine flu swung from being too narrow initially to being too broad. In the early stages, testing and treatment under the free national pandemic flu program were confined to those who had recently returned from overseas or were in close contact to another confirmed case, even though it was clear the disease was spreading rapidly in the community. From June 3, the criteria was changed to catch up but in Eizenberg's view went too far by allowing anyone to be given Tamiflu if they had experienced flu symptoms for less than 48 hours. Based on sampled figures showing that 24per cent of patients seeing GPs for flu symptoms at that time tested positive for any type of flu, and that only 18 per cent of those had swine flu, Eizenberg calculates this policy probably resulted in up to 15,000 people being treated with Tamiflu when they didn't have flu at all.
"It is only due to the low virulence of the virus that this pandemic has merely stressed our local service delivery and not completely paralysed both our and the statewide response," he wrote.
While all this was happening out of the public gaze, more visible events were denting public confidence. Collignon says Victoria's decision unilaterally to declare a higher pandemic alert phase on June 3 sowed confusion and disarray. At about the same time, schoolchildren visiting Melbourne from the ACT were required to stay home for a week on their return, while busloads of children from Melbourne remained free to visit Canberra's attractions without hindrance.
Some schools remained open while others closed. But closures were haphazard and, crucially, there was sometimes no attempt to dissuade children from socialising outside the classroom, rendering the closures pointless.
GPs in other jurisdictions share Eizenberg's concerns. In Queensland, John Kastrissios says the protocols were "probably somewhat naively conceived" by failing to consider the ease of travel in modern societies and were "sometimes applied too rigidly".
Eizenberg told Inquirer of his disappointment at the backlash against his article from some other health professionals. His original article noted his practice had not received results from some H1N1 tests after three weeks, but in a reply to the MJA, the director of Victoria's central swine flu testing laboratory attacked "misleading generalisations about test turnaround times", and shot back that 10 per cent of test samples arrived at the lab with missing or incorrect information about where results should be sent.
While Eizenberg accepts there may have been sound reasons for prioritising some test results over others, he says the fact remains that referring doctors were poorly informed about results. "There's absolutely no doubt in my mind that if the virus was more severe, it would have had a huge impact, with healthcare workers being infected and our operational ability compromised," he says.
GP organisations want the government to conduct a proper debrief that will review what went wrong with communications, distribution of masks and other issues, and make sure they are addressed. Collignon argues for a system the US is trying to introduce, which involves a transparent list of actions, such as school closures, that will be triggered when a pandemic reaches a trigger level of severity.
http://www.theaustralian.news.com.au/story/0,25197,26089314-23289,00.html
September 19, 2009
Article from: The Australian
Mistakes made in the face of the H1N1 influenza virus were potentially deadly, reports health editor Adam Cresswell
AS Queenslander Keven Hadlow kissed his 15-year-old daughter Grace goodbye after driving her part-way to school one Monday morning in July, neither of them had any idea that within 24 hours he would be on breathing equipment in hospital.
"It was the worst health experience I have ever had in my life," says Hadlow, who spent the next nine days in a hospital isolation room battling the H1N1 human swine flu virus.
"It was terrible, an awful thing ... you vomit, you mess yourself, snot is coming out of your nose, and there is not a **** thing you can do to help yourself."
Hadlow, from Eagleby between Brisbane and the Gold Coast, was left on an ambulance stretcher in a hallway of Brisbane's Logan Hospital for two hours, accompanied by paramedics, before he was assessed and spent another six hours in emergency waiting for a ward bed, all with other nearby patients exposed to his germs.
Worst of all in his view, nobody asked his partner or daughter whether they were starting to feel ill, offered them masks or gloves, or suggested avoiding others for a few days in case they were infected. "I think that was a terrible mistake," he says.
Hadlow is far from alone in his disillusion. Many health workers have voiced their own tales of poor planning, inflexible bureaucracy and avoidable mistakes that in some cases made them fear for their safety.
Some focus on the half-hearted and haphazard policy on school closures, the uselessness of airport thermal scanners, the sometimes shambolic communications, or point to organisational debacles such as the notorious case of cruise ship Pacific Dawn, which was allowed to disgorge 1800 passengers when it docked in Sydney in May despite two boys who later tested positive for swine flu having fallen ill during the voyage.
But there are plenty more detailed criticisms and many of them are coming from general practitioners, who say the problems start with the fact that the Australian Health Management Plan for Pandemic Influenza, the 150-page manual supposed to direct the country's response to the virus, barely gives them a sideways glance.
The document relegates primary care to an annex of the report that, even now, remains unfinished. "A lot of the initial pandemic planning really didn't see general practice as front line," says Chris Mitchell, president of the Royal Australian College of General Practitioners. "But the reality is that it is front line because that's where people go to get their general advice."
One big early concern was that health authorities initially advised the public to visit their GP if they feared they might have flu. This was courting disaster, says Mitchell, because GPs were then faced with infected patients turning up unannounced, coughing over reception staff and other patients in the waiting room. The RACGP took it up with the government's chief medical officer, and the advice was quickly amended so that patients were instead advised to ring their GP first, which at least allowed time for masks to be donned and an examination room prepared.
Even so, some experts think this illustrated a wider failing in the overall flu strategy.
Peter Collignon, professor of infectious diseases and microbiology at the Australian National University, says experts here rightly criticised New York parents for hosting "swine flu parties" -- hoping to deliberately infect their children in the belief they would get a mild illness and then be protected -- but what happened here was not very different.
"The reality is in Australia we have swine flu parties all the time. We call them doctors' surgeries and hospital emergency departments," Collignon says. "What happens with all these clinics and everything else we had? Maybe one in 100 or even one in 10 actually have swine flu, but the other nine don't; and they all get mixed together and probably give each other the infection."
Collignon says the evidence was clear from the end of May that swine flu was not going to prove a mass killer and so he says the response was always over the top. But he says that when we do face a virulent virus -- which the authorities in May and June thought swine flu was or might be -- then we "should be telling people to stay home".
"And I think that means we shouldn't have people coming to medical centres," he says. "We need to work out some way of assessing people over the phone and have (doctors or nurses) come to them if necessary", with hospital treatment reserved for the one in 10,000 cases who become seriously ill.
Collignon believes his point is proved by the fact swine flu was not held back and has since become the dominant flu strain, although in fact health authorities always knew stopping flu was an impossible task. The goal instead was to delay its spread as much as possible, creating time for a vaccine to be delivered. The point is moot because we will never be able to measure what if any delay was achieved. We can't even measure the number of people who have been infected.
Latest federal figures put the number of swine flu cases confirmed at 35,143 by September 4, but this is a fraction of the true figure because doctors stopped routine testing of all suspect cases back in June, when it became clear any hope of controlling its spread had evaporated.
At its peak in mid-July, about 1300 patients a week with flu-like illnesses were presenting to NSW emergency departments, three times the previous highest peak in 2007. But the disease is certainly on the wane. For the first time since the outbreak began in May, presentations of influenza-like illnesses to GPs and hospital emergency departments decreased across all states and territories by the last week of August.
Work sickness rates are improving. One unidentified employer with more than 10,000 employees in NSW has told health authorities that 1 per cent of its NSW workers took sick leave for more than three days in the seven days ending August 26, down from a peak of 1.4 per cent in the week ending July 22. The rate is comparable to that in 2007, during a severe seasonal flu outbreak.
Many doctors say the response to the pandemic was sensible in many aspects. Not surprisingly, health authorities agree. Jeremy McAnulty, director of communicable diseases for NSW Health, concedes the Pacific Dawn incident showed the importance of good communication, but claims the progress of the disease was slowed.
With the emergency on the wane, more GPs are coming forward with tales of what went wrong. Peter Eizenberg, a GP in North Melbourne, one of the areas hardest hit at the start of the epidemic, wrote a blistering account of failings for a Medical Journal of Australia article published in July that mirrored concerns of many doctors nationally.
He wrote that it "quickly became evident that the rhetoric contained in the (pandemic plan) did not match the reality on the ground". Supplies of masks, gloves and gowns, which Roxon promised at the end of May would be made available, arrived a month late and in only a fraction of the amounts sought.
Under the plan, practice staff exposed to infectious patients without protective gear were supposed to receive Tamiflu to reduce the chance they would contract the disease, but this did not happen unless the staff members in fact fell ill, in which case they had to stay in home quarantine themselves. Instead, GPs were told to buy their own supplies, which many did, at least until pharmacy stocks ran out.
Eizenberg also said the Victorian criteria for suspecting swine flu swung from being too narrow initially to being too broad. In the early stages, testing and treatment under the free national pandemic flu program were confined to those who had recently returned from overseas or were in close contact to another confirmed case, even though it was clear the disease was spreading rapidly in the community. From June 3, the criteria was changed to catch up but in Eizenberg's view went too far by allowing anyone to be given Tamiflu if they had experienced flu symptoms for less than 48 hours. Based on sampled figures showing that 24per cent of patients seeing GPs for flu symptoms at that time tested positive for any type of flu, and that only 18 per cent of those had swine flu, Eizenberg calculates this policy probably resulted in up to 15,000 people being treated with Tamiflu when they didn't have flu at all.
"It is only due to the low virulence of the virus that this pandemic has merely stressed our local service delivery and not completely paralysed both our and the statewide response," he wrote.
While all this was happening out of the public gaze, more visible events were denting public confidence. Collignon says Victoria's decision unilaterally to declare a higher pandemic alert phase on June 3 sowed confusion and disarray. At about the same time, schoolchildren visiting Melbourne from the ACT were required to stay home for a week on their return, while busloads of children from Melbourne remained free to visit Canberra's attractions without hindrance.
Some schools remained open while others closed. But closures were haphazard and, crucially, there was sometimes no attempt to dissuade children from socialising outside the classroom, rendering the closures pointless.
GPs in other jurisdictions share Eizenberg's concerns. In Queensland, John Kastrissios says the protocols were "probably somewhat naively conceived" by failing to consider the ease of travel in modern societies and were "sometimes applied too rigidly".
Eizenberg told Inquirer of his disappointment at the backlash against his article from some other health professionals. His original article noted his practice had not received results from some H1N1 tests after three weeks, but in a reply to the MJA, the director of Victoria's central swine flu testing laboratory attacked "misleading generalisations about test turnaround times", and shot back that 10 per cent of test samples arrived at the lab with missing or incorrect information about where results should be sent.
While Eizenberg accepts there may have been sound reasons for prioritising some test results over others, he says the fact remains that referring doctors were poorly informed about results. "There's absolutely no doubt in my mind that if the virus was more severe, it would have had a huge impact, with healthcare workers being infected and our operational ability compromised," he says.
GP organisations want the government to conduct a proper debrief that will review what went wrong with communications, distribution of masks and other issues, and make sure they are addressed. Collignon argues for a system the US is trying to introduce, which involves a transparent list of actions, such as school closures, that will be triggered when a pandemic reaches a trigger level of severity.
http://www.theaustralian.news.com.au/story/0,25197,26089314-23289,00.html