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ScienceWise - Sep/Oct 2009

Forewarned is Forearmed

Article Illustration
Associate Professor Kelly and Dr Anna Reynolds

Establishing a Rapid Alert System for Severe Influenza

Even though avian, and more recently, swine flu have caused a relatively small number of fatalities worldwide they are taken very seriously by the scientists and health professionals responsible for maintaining Australia’s health. A large part of the reason for this is that based on past experience, such pandemics can escalate with devastating effect, often in the form of a potent second wave of infection that occurs up to a year after the initial peak subsides.

This is exactly the behaviour that was exhibited by the deadly Spanish flu pandemic of 1918-20. The initial wave of infections in June 1918 killed 0.25% of the UK’s population, which was bad enough, but the following winter a second more deadly wave killed ten times as many. In fact worldwide, Spanish flu is estimated to have killed over 50 million people.
Associate Professor Paul Kelly is the Director of the highly acclaimed Masters of Applied Epidemiology (MAE) Program at the National Centre for Epidemiology and Population Health at ANU. The MAE program offers graduate students an opportunity to undertake practical and policy based placements in areas with a focus on public health.
One such area of special interest at the moment is the H1N1 virus responsible for swine flu. From a clinical perspective, more research is needed to identify the detailed operation of the virus and appropriate treatments for patients. But it’s also vitally important to understand the spread of such infections in order to better manage our response.
Every year Australia experiences a flu season from mid winter to spring, during which the number of new cases rises rapidly. It’s important for hospitals to have up to date information on infection rates because this enables them to predict how many cases they are likely to receive over the coming days and weeks and to adjust their staffing levels and elective surgery workloads accordingly. This becomes particularly important when dealing with new and potentially highly virulent strains of influenza that appear from time to time.
“Although we have rapid reporting of laboratory confirmed flu cases to DOHA  (The Department of Health and Ageing), the lines as they stood were somewhat ad-hoc and incomplete for the severe cases requiring hospitalisation.” Associate Professor Kelly says.
Pathology labs forward statistical information on positive flu tests along with that on other diseases on the notifiable list. But not everyone who displays flu-like symptoms will be tested. Emergency departments report flu admissions directly to public health authorities but this only happens in two states (WA and NSW). Some GP’s participate in reporting schemes and even Australia Post reports the number of their employees off sick, but the latter doesn’t include details of the reasons for absence so this information covers all sickness.

Of course detailed clinical data is collected on all hospital admissions but this information only filters back to DOHA over far longer long time scales than are effective in assigning hospital priorities on a week by week basis.
“What we wanted was to be able to create a regular snapshot of the current situation, and get this information quickly to a central body such as DOHA so that it could be processed and turned into reliable estimates of the likely number of future cases”

The reasons for the often deadly second wave flu infections are not entirely understood, it may be that the virus changes in some way or simply that a larger number of people become affected resulting in far more deaths. “What is known though is that early clinical intervention, especially in high-risk groups, is a big factor in saving lives. But in order to do this effectively, hospitals need to know how many cases to expect and when.” Associate Professor Kelly explains.

Together with second year MAE student Dr Anna Reynolds, Associate Professor Kelly came up with the idea of working with the Thoracic Society of Australia and New Zealand (The peak professional body of thoracic physicians, scientists and other health care workers involved in lung disease) to create a rapid response reporting system that can do just this. Co-investigators at the Alfred Hospital in Melbourne, Associate Professors Tom Kotsimbos and Allen Cheng have led the clinical side of the project and provided an important link to the H1N1 Thoracic Society task force members who are the local investigators in the field sites.

They applied for and successfully secured a significant grant from the National Health and Medical Research Council to develop their rapid alert system for severe respiratory illness in adults.

“The establishment of the rapid alert system is in many ways a typical MAE project,” Associate Professor Kelly says, “It’s practical and it has a strong focus on fieldwork and policy.”

The system operates by having a dedicated clinical nurse in each of the 10 participating hospitals, whose job it is to collate data on the number, severity and progress of confirmed flu infections and transmit this information quickly to the central data base. This information can then be processed by DOHA to provide fortnightly reports to public health authorities in each state and territory.

The implementation of the new system has been amazingly rapid. The first data from the first participating hospital arrived just three weeks after the grant award was announced!

“I hope that the current H1N1 infection doesn’t have a potent second wave,” he says, “But sooner or later it’s almost inevitable that a respiratory infection like this will pose a really big threat to Australia, and the better information we can supply to clinical practitioners and public health authorities, the more effective they can be in reducing the number of fatalities.”

The new rapid alert system is novel in Australia and is also attracting a lot of interest from other countries. European authorities are currently looking at the possibility of setting up something similar there.

 “In a strange kind of way Europe and Australia have a similar situation when it comes to healthcare management” Associate Professor Kelly says, “Europe has the European CDC as a central body looking after what are essentially independent nation states, and in Australia we have DOHA doing a similar job with our states and territories. It would be great if we could utilise these similarities to create a similar rapid response system in Europe, which would allow important comparisons to be made about the evolution of the pandemic in the southern and northern hemispheres in our respective flu seasons.”

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