What does Jim Bishop have to say about swine flu?

What will be the impact of the H1N1 pandemic upon public trust in health authorities and campaigns?

This is just one of many questions surrounding the pandemic and the public health response. You can read plenty more about related issues in this article, which has just been published by Inside Story.

Last Friday (January 29), I interviewed the Federal Department of Health and Ageing’s Chief Medical Officer,  Professor Jim Bishop, as part of research for the article. I thought Croakey readers might be interested to see what he had to say about issues ranging from disease-mongering to vaccination of children, and the role of politics in public health policy.  The edited transcript follows:

Q: What are the lessons so far from the pandemic?

There are a lot of lessons. We published an article in the New England Journal of Medicine, which provides a good overview of what happened. And there was a very good NHMRC forum, where all of those fast-tracked research activities came together to report, just before Christmas.

The wash up for me as far as the pandemic is concerned is it’s similar to seasonal flu but different in a number of important ways, including affecting younger people, younger previously well people, on top of those more at risk. It also has a much higher propensity to put people into hospital and intensive care units (ICUs).

Our figures are around 700 people came into ICU with viral pneumonia proven to be H1N1. They were very ill with viral pneumonia, rather than secondary infections so the illness was caused by the virus.

When we look back over the last five years of people admitted to ICU with viral pneumonia during influenza season, the average number was 50 to 55. So it’s a big jump.

The medium time from admission to intensive care was 48 hours. So it’s a very quick, nasty disease for that top end <of the spectrum of illness>. Most people got through it well. Anecdotally we say it’s mild but most people who got it were OK at home. But to say it was mild is an underestimate.

Q: How many people have been exposed already? Why will you be promoting further pandemic vaccination?

I have access to the early results of seropositivity surveys, not yet published. Also to other peoples’ data. What I would say is that in London, which is published data from their first wave, they saw seropositivity rates go up to around 20 percent. That’s also what people are finding through the first wave in the US; and we expect our results would be similar.

Does this mean that 20 per cent of the population are effectively immune?

They should be but we don’t know. We’re just measuring seropositivity, we don’t know whether it’s high or low level protection, but based on history, we’d expect it would be (that they’re immune).

But it tells you that the majority of people are still unprotected. That’s why we think there’s a gap between where we need to get with vaccination and natural immunity. If we’re wanting to protect the population for this coming season, then there’s a gap.

The history of seasonal vaccination is the same every year. They produce enough to cover the special needs groups. That means, in general, supplies will be limited. The government programs are directed to the infirm and the elderly. Pregnant women have always been advised to have it, and take-up has always been lower than we’d like.

If we’re thinking of trying to protect our population against the virus, which is similar but different to seasonal flu, the seasonal flu vaccine is not going to do it.

The US had an autumn wave when it broke out in New York and a few areas, then died down a bit in summer and has come back in a second wave. That second wave, which is what we’re about to have, almost all of it is H1N1.

In the US, the flu in their season was H1N1 and the same in China and elsewhere. The most likely thing, based on the US experience, would be that it’s going to be dominated by H1N1.

Q: Why do you think there will be a second wave of infection?

We think it’s different because it doesn’t behave just like seasonal flu. It does have run-on outbursts.

I’m not disagreeing with people who say the second wave may not come. But they may not be right. What normally happens with pandemic viruses is they start coming in waves all over the place and eventually fall back into a seasonal pattern. This might do that quickly.

My view is that we don’t know so, while that’s a possibility, we can’t be sure. It’s just a matter of covering contingencies to make sure we’ve thought of all the possibilities.

Getting back to the vaccine issue, if we are facing whether it’s a second wave or a flu season, we don’t know what is going to happen but if we’re anything like the northern hemisphere, this will be dominated by H1N1.

Elderly people would probably be better off with the seasonal vaccine. Elderly people who’ve had the pandemic vaccine should have the seasonal vaccine as well.

The group which gives us advice, the ATAGI, they have gone through this whole thing and have provided advice which is now up on our health emergency website, with tables for GPs.

Q: What is the uptake rate for the vaccine?

It was going according to our trajectory up to mid December. We think it might have dropped over the holiday period so we’re going to be making some more public announcements over the next month or so. One of the issues is going back to school. We’re also just interested in younger people in general.

Q: What are the challenges you face?

People have felt it is over and it’s last year’s problem. I think what is helpful now is we are facing up to another winter. We will have more evidence, but we suspect based on the seroprevalence data from around the world that the majority of people are unprotected.

Q: Do you think people have become cynical?

People at the start of this were genuinely unclear about what the virus looked like. We were very fort that we had about seven weeks at the start where we watched what was happening overseas before there were any cases here. That allowed us to understand it wasn’t causing a high death rate in a modern society. That allowed us to modify our response. From the Australian point of view, when we saw that, we changed our plans for a more severe pandemic into one suited for one of this virulence. We put in place the new protect phase. So I think we can say in an Australian context, we tried quite consistently to stick to what we knew about the biology rather than thinking we knew it all. But the framework (used in the initial planning) was useful.

Q: Concerns are being raised that a lot of effort went into border control measures, which were unlikely to make any difference. Is there going to be a formal review of the policy response?

Thank goodness it wasn’t a virus that killed 50 percent of the people infected. So this was a live exercise in many ways. We have a body of information now that we’re sifting through.  We’re doing a number of reviews, I haven’t heard of a formal independent review. The opportunities exist with all the data for academic groups, government groups and researchers to inform us better.

I think the review process will be done by everybody. The important thing here is that we’ve got to some extent a higher understanding of what happens in a flu season, how it spreads around. We’ve been able to build a surveillance system to make it more real time. Historically those flu reporting systems were reporting at the end of the season. We have turned it into a real time reporting system, which is still there and will be continued. We’ve built a lot more capacity to be able to deal with this.

That is all really positive because we do understand better now about who is vulnerable, who needs to be protected. One of the groups with clear lessons is Indigenous people who were over-represented in bad outcomes and had a much higher hospitalisation rate in people under five, so that is another group we can alert doctors to.

Q: What about concerns that the influenza vaccine may not actually reduce death rates?

Regarding influenza vaccine, the traditional ways we measure effectiveness is its ability to produce seroconversion and cellular immunity, both of which have been measured in clinical trials. The point you’re asking is about clinical outcomes and that’s a good point. We do need to constantly improve the way we measure how effective something is. These vaccines have been developed on the traditional methods. These are all good points for further research. There needs to be more research on efficacy. This one performs very well on the way we’ve always assessed vaccines.

Q: What is your response to the concerns raised about the influence of conflicts of interest, especially at the WHO?

Re WHO, you’ve seen the WHO response to the European Health Council report, which was very unfair. What was alerting everyone back in April was the high death rate in Mexico. I’m not here for the commercial interests of a company.

The facts are that the way WHO handled it is they went down a path that was predetermined on their expert advice over the years. Their pandemic levels had been predetermined. It also threw up a particular issue that they recognised as they went through and addressed – that pandemic levels referred to transmissibility rather than severity. Margaret Chan, to her credit, recognised it very early and began talking about severity issues within first eight weeks, which was additional to whether it was spreading around the world. I understand WHO were very much aware of this and were looking at ways they might develop another system which covers both transmissibility and severity. In Australia, we took the trouble to understand it in terms of severity in our response.

Hindsight is a great thing.

My main concern during this whole thing was that of trying to provide sensible evidence or information we had at that time to be able to inform people so they could understand what it was all about. In the early days there was a lot of press about killer viruses. We all now know a lot in retrospect but at the time you’ve got to remember what we knew at the time so my approach was quite simple – just a medical approach, not political.

I thought the most important thing was to tell people what we knew and that it was turning out to be very moderate in a lot of people and we said that when we knew that. We tried to stick to the evidence.

Q: Was there disease mongering?

The thing that was motivating me was if I was sitting in a lounge room, what would I want to know about this? If I went to my local, well informed GP, what would he tell me?

That’s what I was thinking I should do if I had an opportunity. I wasn’t trying to speak it up or speak it down. I was just trying to stick to the evidence. That’s always over the years held me in good stead.

Q: How did you manage conflicts of interest issues?

We have a number of expert groups all required to declare their conflicts of interests, such as advising a drug company. The Federal Government has a lot of conflict of interest arrangements.

We seek so much advice – and we get a lot of gratuitous advice from our colleagues, whether we like it or not. We really get advice from everywhere. One of the most useful things that we did was we took ourselves outside the national context. There were regular teleconferences with the Department of Human Services in Washington, I spoke to the Canadians, went and visited the CDC in Atlanta and the Health Protection Agency in the UK, and I went to the WHO.

Basically we availed ourselves of every piece of advice we could possibly get. It was not just the local virologist connected to a drug company. We’d listen to them but we’d also be aware of their conflicts. Everyone that provides advice to us in these expert committees is required to deal formally with conflicts of interest. The TGA has the same approach.

Q: If this was a relatively mild pandemic and it caused a great strain on hospitals, what does that say for the system’s capacity to cope in a bad pandemic?

There was a large upsurge in cases. The whole epidemic lasted 16 to 18 weeks. It was the three-week peak period at the end of July that was toughest for the health system.  The last two weeks of July and the first week of August, things were at their worst. The system coped. It didn’t cope equally everywhere at the same time. But it was a rolling issue.

The virus didn’t attack the whole country at the same time because it was rolling around the states and the country, one group would have a stressful week and then some relief. It was manageable. There weren’t wholesale closures of elective surgery but particular hospitals for a particular week. Whereas in the UK they had to shift some pats to mainland Europe to get ECMO. I was quite proud we had the ECMO capacity.

So there’s been a lot of work planning in relation to surge capacity. When the Bali bombing occurred and all the patients arrived in Darwin hospital, they emptied the hospital and put people into the private one next door so a large number of beds were made available.

If it was a very serious epidemic, people will take a different attitude to the normal one. If you ask an emergency department director, can you cope with an extra 120 patients tomorrow, they’d say no. But if it’s life threatening, they would take a different attitude.

Q: What about the opportunity cost – the fact that there was so much focus on H1N1 that other things must have gone missing?

All of us working on this were working under the principle that we’d do what was required for the epidemic, and wouldn’t let anything else slip. We did lots of other things at the same time.

The long term planning has to address the major burdens of disease, such as tobacco, blood pressure, salt, cholesterol, and big ones like cancer, heart disease, mental health. So we can’t take our eye off that ball, it is a case of getting the balance right.

In every hospital every year through the world, there is the winter strategy – that there will be more admissions to an emergency department, and the system will need to buckle up to cope with that while still dealing with the chronic diseases burden and ageing population. This is something that’s around every year and is brought into stark relief, as it was last year.