By RAINA MACINTYRE
To understand the case for a National Centre for Disease Control, we must first think about what the term public health means.
Public health is the organised response to protecting the health and wellbeing of the population and is a core responsibility of government. It has three essential components: health protection, prevention and promotion.
Health protection is the use of legislation for public health, such as smoking restrictions and bans. Prevention is a large category including screening, vaccine programs, testing and surveillance. Health promotion is enabling people to increase control over their health and to improve it.
Effective disease control requires these three pillars to be organised by government, supported by legislation, leadership, lines of accountability, evidence and functional structures. It also needs to recognise the relationship betweenseparate areas of disease control r (like mosquito control, livestock and human disease, in the case of Japanese Encephalitis) and ensure that response does not become siloed.
While Australia does have a number of existing mechanisms to respond to pandemics and epidemics, a National Centre for Disease Control (CDC) will likely strengthen our health security. The debate about a national CDC is decades old, and one I remember having 30 years ago as a young public health trainee with founders of the Communicable Diseases Network of Australia (CDNA), including the late Professor Aileen Plant, Dr Robert Hall and Dr Cathy Meade.
CDNA was formed as a stop gap, voluntary measure 30 years ago to bring together States and territories and make up for the lack of a CDC. It was later formalised under the 2007 National Health Security Act as a sub-committee of the Australian Health Protection Principal Committee (AHPPC). It has a role in information sharing and in formulating guidelines, but has no operational response capacity.
The existing mechanisms to respond to pandemics and epidemics include the CDNA and the AHPPC, both of which have representatives of states and territories, and a public health laboratory network. They also include vaccine recommendations, which are made by The Australian Technical Advisory Group on Immunisation (ATAGI) and recommendations on implementation by the National Immunisation Committee. However, pandemic response committees which existed at the time of the 2009 influenza pandemic no longer exist, and decision making has not been transparent during the COVID pandemic.
We have a National Incident Room for information processing and decision support, but no federal operational response capacity for global or cross-border epidemic response. On-the-ground response capability exists only in States and Territories. The National Critical Care and Trauma Response Centre (NCCTRC) manages The Australian Medical Assistance Team (AUSMAT), which deploys teams of volunteers to international medical emergencies. It was established in response to the 2002 Bali Bombings, primarily as a capability in trauma and disasters. But out of necessity, together with DFAT, it has filled some of the gaps in public health response. In addition, Australia has a number of National Centres, in areas like immunisation, drug and alcohol and HIV, which fulfil surveillance and other requirements for various diseases and are part of a fragmented national landscape.
Public health workforce training, registration and operational field response should be an important part of any new CDC. In terms of public health workforce, State-based workforce training programs have gradually been eroded, with NSW having the last of such programs. Dedicated funding for our only internationally accredited Field Epidemiology Training Program at ANU was axed in 2010 without so much as a whimper, along with funding for the Public Health Education and Research Program (PHERP) that provided funding for Master of Public Health programs around the country.
Our public health workforce is not registered alongside other health workforces with the Australian Health Practitioner Regulation Agency (AHPRA), so we do not even know how many qualified public health practitioners we can draw upon during an emergency, nor how to contact them. These are important gaps which we must address.
But a CDC in itself is not a panacea. Countries such the US, with CDCs or other centralised structures have performed poorly during COVID-19, not for lack of technical expertise but due to political interference. This must be front of mind in any national health response, and in consideration of whether to form a national CDC.
In many countries including the UK and Canada, the health of populations has taken a back seat to other agendas.
Conversely, Australia without a CDC boasts some successful responses including to HIV, which had bipartisan support and excellent community engagement. In Australia, some of the historical reasons we have not had a CDC include the tiresome old rivalry between Sydney and Melbourne, each of which has substantial capacity including high security laboratories. While parties with skin in the game jostle and push for position and advantage with the promise of a new CDC, some advocate retaining the existing patchwork of structures and networks with more funding so that no-one’s turf is threatened.
A new structure created in Canberra would be the other option, but would require substantially more investment. A hybrid approach somewhere between the two could also work, as long as centralised accountability was part of the package. One option may be networking of existing labs, but centralisation of surveillance and response capacity in Canberra.
There also needs to be an interim plan to bring together, phase out or integrate the many separate pieces that form our current capability. A CDC that covers infectious and chronic diseases, occupational and environmental health and safety, as well as climate change, would be ideal. Legislation to ensure that any new CDC is independent and protected from political interference is essential. We also need guaranteed longevity of a new CDC that outlasts the short political cycle, or it may be torn down when the government changes. Most of all, we must remember what public health is, and ensure that a new CDC meets the needs of all Australians, strives to protect health, prevent disease and empower all people.
Falling Through the Cracks
During the 1918 pandemic, Australia used its unique island geography to keep out the pandemic for a whole year, and when it did hit the impact was less than in many other countries. The Sydney quarantine station closed its doors in 1984, and is now a tourist attraction at the hauntingly beautiful location of North Head.
There you will see the first, second and third class accommodation for passengers, giant autoclaves for passenger luggage, hospital wards and, carved into the sandstone rock, a plaque reading ‘RMS Niagara, Influenza October 1918.’ You can even do ghost tours at night to glimpse souls of passengers who perished there.
Before that, we never used mass vaccination against smallpox, relying instead on quarantine of ships to keep it out of the country. Ad hoc vaccination campaigns were used in response to outbreaks.
I am recognised internationally as an expert in smallpox and have also published on monkeypox prior to the latest epidemic. My research showed the surge in cases in Nigeria since 2017 is related to waning smallpox vaccine immunity. In my research we estimated only 10% of the current Australian population has been vaccinated against smallpox, and there is virtually no immunity in the population. That may be important for us when considering the current epidemic of monkeypox, but my professional opinion about this latest outbreak has, so far, not been sought by governments within Australia — only by WHO.
During COVID-19 too, we shut the international borders and had a honeymoon period of almost two years without facing the brunt of the pandemic as other nations did. We lagged other countries in vaccination, being mostly unvaccinated when the Delta wave hit in mid-2021, triggered by a failure to mitigate risk in airport transport, and compounded by a delay and lack of diversification in vaccine procurement. Still, we bought more time than other countries, enough to boast low death rates until the Omicron wave. Many cling to the glories of 2020, boasting about low mortality while simultaneously telling us the pandemic is over.
The ABS is already showing excess mortality from COVID by May 2022, but our 2-year period of grace will not be fully reflected in excess deaths data until 2023. In the US, life expectancy dropped by a whopping 2 years by 2022. The Omicron wave in the first 6 months of 2022 alone brought over 8000 deaths, more than the 2200 or so deaths in all of 2020 and 2021. Hundreds of these were in younger adults and some were in children, and the deaths far exceed the national road toll.
In 2022 we saw supply chains affected, supermarket shelves empty, delays in essential services all due to mass workplace absence. During business-as-usual, 2-5% of workers may be off sick at any one time, but this has been around 20% at the peak of the Omicron wave. Mass cognitive dissonance is on display when people complain of chaos at airports all over the world, wondering why their luggage didn’t arrive or their flight was cancelled. It’s partly because workers are sick with COVID-19. But hey, the pandemic is over, so smile and live a little while the B.A4 and 5 waves gather momentum before crashing over us.
Vaccines alone are not enough, but we have not used other layers of prevention, like ventilation, safe indoor air, masks, testing and tracing to mitigate the incidence of infection. Workplace absence, disruption to schools and households, hospitalisations and deaths are all a fraction of total case numbers. To reduce these, we must reduce transmission using a vaccine-plus strategy and ventilation. We have some antivirals, but not enough to use them on a mass scale to add another layer of mitigation. We don’t have data yet, but perhaps in the future rapid use of antivirals will cut the period of isolation and mean people can return to work sooner. They may even reduce the burden of long COVID.
Yet to realise the promise of antivirals, testing is essential — they can never benefit the economy until testing is widespread, accessible and cheap or free. Use of the QR codes too, will help reduce case numbers, because contacts are the next tranche of cases. Giving people forewarning using digital tracing will help. Meanwhile, good luck if you need to access health services or call an ambulance. Or if you get Long-COVID.
I heard someone complain on social media that a Long-COVID clinic in a large hospital prescribes Tai Chi as a treatment, another example of gaslighting of patients with persisting symptoms. Long-COVID probably has a heterogeneous cause — the virus attacks the heart, the lungs, the blood vessels, the immune system and the brain, and can persist in the body long after the initial illness. Research shows that some of these effects need specialised tests and imaging to diagnose, and will not be seen on routine tests. Fatigue can be the result of brain inflammation, immune dysfunction, reduced lung function or heart failure — all of which are described as possible after COVID-19. It is likely we will face a COVID-related increase in chronic disease and disability. A quarter of employers in the UK are already reporting that long COVID has impacted their workforce.
What this will do to our children is still unknown, but the available research suggests it is wildly reckless to sit by nonchalantly while the adults of tomorrow are infected en-masse today, the youngest still ineligible for vaccination. The epidemics of hepatitis in children is most likely caused by COVID-19, but that too has been obfuscated and spun as anything but COVID. Now that the evidence for COVID is accruing, there is silence around it, especially in the UK, which actively denied vaccination to children and teenagers for the longest time. After all, when you take an ideological position to trivialise COVID-19 in children, there is shame and accountability in admitting it is actually worth preventing and in the same ballpark or even worse than other infections we routinely prevent in children with vaccines. We have slavish acolytes of the UK approach here, some who campaigned against vaccinating our children. Fortunately we did not go down that path, although delays in procuring paediatric vaccines meant Australian children returned to school in 2022 unvaccinated to face the peak of the first Omicron wave.
As for preparedness for monkeypox, we have known since 2017 there was cause for concern, when Nigeria began seeing unprecedented epidemics of what had been a rare infection previously. Travel imported cases have occurred in the UK, Israel and Singapore since 2018. As a smallpox expert I know there were many prompts over the last six years, if not as far back as 2001, to prepare for orthopoxviruses, but we were not as prepared as we should have been. Nor has the world ever considered the risk-benefit equation of smallpox vaccines for monkeypox.
The second generation vaccines have a serious side effect profile that would make it risky to use during the current monkeypox epidemic, but third generation vaccines can be safely used in the current outbreak. When the first cases occurred, we did not have this option, nor the new smallpox antivirals. If monkeypox becomes established in animals here, we will live with it forever.
We also missed the boat entirely with Japanese Encephalitis (JE), a serious and potentially fatal mosquito-borne virus that has never occurred on the Australian mainland until 2022. It had been described in the Torres Strait, but the main mosquito vector was absent from Australia until it was detected in the NT in 2019. What happened between then and 2022, and how did JE silently spread as far as South Australia, Victoria and NSW?
Has the mosquito also migrated south, or is it being spread through a related mosquito that carries Murray Valley Encephalitis and Ross River Fever? This national failure illustrates the fragmentation of Australia’s public health response and how easily things can fall through the cracks.
Raina MacIntyre is the Professor of Global Biosecurity within the Kirby Institute at University of New South Wales and a National Health and Medical Research Council Principal Research Fellow, who leads a research program on the prevention and control of infectious diseases. She is an expert media advisor and commentator on Australia’s response to COVID-19.