Sunday, August 2, 2009

H1N1 Update: Frontline Lessons and Glitches similar in Australia...

The general practice experience of the swine flu epidemic in Victoria — lessons from the front line

  • The swine influenza (H1N1 09) outbreak in Victoria has provided an excellent opportunity to review the Australian Health Management Plan for Pandemic Influenza (AHMPPI) and to assess its performance in practice.

  • General practitioners play a major role in seasonal flu management, and it was expected that the AHMPPI would enable GPs on the front line to maintain this central role during the swine flu pandemic.

  • The role of front-line GPs has been made extremely difficult by deficiencies in implementation of the AHMPPI, including resource supply failures, time-consuming administrative burdens, delays in receiving laboratory test results and approval for provision of oseltamivir to patients, and a lack of clear communication about policy changes as the situation progressed.

  • We must use this experience to ensure timely and appropriate review of the AHMPPI and the way it is implemented. Better consultation with front-line clinicians, particularly GPs, is crucial and must occur as a matter of urgent priority.


The current issue of the Medical Journal of Australia (MJA) discusses various aspects of the H1N1 flu and its impact on Australians and doctors.

From the abstract above, one can see that no nation's Action plan i.e. Australian Health Management Plan for Pandemic Influenza (AHMPPI) is foolproof, and implementation has been fraught with difficulties.

Malaysians are getting impatient with the authorities and the health ministry for their perceived failure and incompetence to address this pandemic which appears to be surging ahead in full steam!

But as I have stated repeatedly, this is no fault of any agency or authority—ground level practices are not simply about to run smoothly just because some of these policies have been articulated and announced.

The actual implementation and roll-out of these plans are often more difficult to foresee than has been thought about—patients and citizens react differently and in many instances outside the expected script of what we thought they should be!

In Australia, some of these main deficiencies and grouses have been identified:
  • resource supply failures,
  • time-consuming administrative burdens,
  • delays in receiving laboratory test results,
  • delayed approval for provision of oseltamivir to patients, and
  • a lack of clear communication about policy amendments
Bearing these in mind, we should note that this will sound like a recurring echo of the unhappy scenario the world over, like it or not. As this pandemic surges, the rapidly growing number of ill flu-infected people will grow, and will test the capacities of all health systems, no matter how supposedly well-prepared these have been made out to be.

This is part and parcel of the chaotic nonlinear non-expected eruptions of an infection which is fairly contagious as well as capricious in terms of severity predictions.

2 young children joined the list of Malaysian H1N1 fatalities in the past day or so. Flu death toll rises to six
The unpredictable nature and the 'absent' risk factors of these 2 deaths, serve as alarming reminders that no one can be certain how this pandemic will pan out.

Clearly, it is time to inform and remind people that this may become the likely scenario in the days and weeks to come, and that while we try and improve our logistics and implementation of policies and technical expertise—that no matter the preparedness or lack thereof—adverse outcome statistics will continue to shock us, until an equilibrium is reached...

Perhaps as a comparative note, it would be useful to relook at the updated Australian response:

Position Statement:
ASID/TSANZ guidelines: treatment and prevention of H1N1 influenza 09 (human swine influenza) with antiviral agents

The abstract is reproduced below:
  • To date, there have been thousands of cases of H1N1 influenza 09 (human swine influenza) worldwide, with established community transmission in parts of Australia.
  • Timely diagnostic tests can enable targeted antiviral treatment early in the course of the pandemic. Rapid antigen tests will be less useful once the pandemic is established.

  • Recommendations for use of antiviral treatment for influenza:

    • Neuraminidase inhibitors (oseltamivir and zanamivir) are the antiviral agents of choice for H1N1 influenza 09.

    • In otherwise healthy children and adults with confirmed or suspected influenza, antiviral treatment is of greatest benefit when given within 48 hours of symptom onset.

    • Treatment should be prioritised for patients with risk factors for severe disease, such as older people (> 65 years), pregnant women, patients with chronic disease (eg, asthma, cardiorespiratory disease, diabetes and renal failure) or immunosuppression, and young children.

    • Antiviral treatment can be given to children as young as 1 year. However, animal studies suggest central nervous system accumulation of oseltamivir in infants <>

    • Antiviral treatment should be offered to pregnant women with suspected or confirmed influenza because of the risk of severe disease in this group; there is limited evidence suggesting safety during pregnancy.

    • Antiviral treatment should be given to hospitalised patients with severe influenza infection (especially pneumonia), even > 48 hours after symptom onset. Antibiotics should be given to such patients according to established guidelines for community-acquired pneumonia.

  • Recommendations for use of antiviral prophylaxis:

    • Antiviral prophylaxis can be given to health care workers and close contacts of patients with influenza following exposure, and to residents of institutions to terminate outbreaks. Contacts not provided with prophylaxis should have access to early treatment with antiviral agents.

    • Long-term prophylaxis can be given to “first responder” health care workers for durations of up to 6 weeks for oseltamivir and 4 weeks for zanamivir. Use of antiviral prophylaxis for these groups should be in the context of agreement to use the national stockpile.

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