Chapter 6 Does Australia need a national centre for communicable disease control?

Infectious diseases are not going to go away—they are a continuing problem. They are influenced by frequent travel and climatic and environmental conditions. In order to control these infectious diseases and protect Australia from potential threats, I believe there is a need for a coordinated dedicated centre for disease control.[1]

6.1                   Throughout this inquiry, numerous roundtable participants supported the proposition that Australia needed a dedicated national centre for communicable disease control.

6.2                   This proposition is discussed in detail below.

What is a CDC?

6.3                   In discussing the proposal for a national centre for communicable disease control in Australia, participants often referred to the need for a ‘CDC’, or a national centre for disease control (a national centre).

6.4                   The main centre for disease control (CDC) model referred to by participants in the roundtable discussions was the model operating in the United States of America. The USA has The Centers for Disease Control and Prevention, which is a United States federal agency under the Department of Health and Human Services.[2]

6.5                   The USA’s CDC mission statement says:

The Centers for Disease Control and Prevention (CDC) serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States.[3]

6.6                   As outlined in its mission statement, the CDC in the USA is not solely focussed on infectious or communicable disease control. It is focussed more widely on disease prevention and control, covering issues outside of infectious diseases such as healthy living, health promotion and chronic disease prevention.

6.7                   The Committee was told by the Public Health Association of Australia Incorporated (PHAA) that Australia is the only Organisation for Economic Co-operation and Development (OECD) country without a recognised separate authority for the national scientific leadership and coordination of communicable disease control.[4]

6.8                   The Committee considers that the CDC model proposed for Australia, as discussed during the roundtable discussions, is based on the premise that it would cover communicable disease control only, rather than disease more broadly. This is discussed in further detail below.

Does Australia need a national CDC?

6.9                   The overview of the current policy environment presented in Chapter 2 highlights the multiplicity of agencies across Commonwealth portfolios and at all levels of government that are involved in infectious disease screening, surveillance and control. The majority of these agencies have pandemic influenza plans which outline the agency’s role in the event of pandemic influenza. These plans are usually developed and supported by one or more expert committees or working groups.

6.10               Given the large number of agencies, expert groups and plans, the Committee questioned whether coordination was effective between Commonwealth agencies, and between Commonwealth and state/territory governments, and other stakeholders.

6.11               Ms Megan Morris, of the Department of Health and Ageing’s Office of Health Protection (OHP), told the Committee that coordination worked well within the current systems of communicable disease control:

It was a very pertinent question about whether the coordination works and whether it ever falls through. That is something we try and check all the time…We are reasonably comfortable that we have the right networks. We are in partnership with those people we need to be in partnership with and we are getting good information exchange on that.[5]

6.12               Ms Morris advised that the expertise of national committees could be mobilised at very short notice to respond to health emergencies of national importance:

If there is a health emergency at any time, AHPC (Australian Health Protection Committee – a subcommittee of the Australian Health Ministers’ Advisory Council) is convened. I have seen it convened with half an hour's notice. It comprises the chief health officers from each jurisdiction, the Department of Defence and also [the Attorney-General’s] Emergency Management Australia. They get together at the drop of a hat and people phone in from wherever they are. Things happen very quickly to address whatever the health emergency is. In a pandemic, as I mentioned earlier, you have to bring in other parts of jurisdictional governance to make things work.[6]

6.13               In contrast to the view that coordination worked efficiently between the Commonwealth, state and territory governments, the Committee heard evidence suggesting that coordination was in fact disjointed in practice and based largely on informal networks of infectious disease experts.

6.14               Dr Deborah Lehmann, of the Telethon Institute for Child Health Research, argued that the current national system for infectious disease control was fragmented:

There needs to be a coordinated, dedicated place where there will be a group of epidemiologists, microbiologists and environmental scientists who are going to address an emergency and also collect optimal data to respond in a rapid manner to outbreaks and to predict future outbreaks. I do not know if you feel that we already have that but it is quite fragmented—there are different organisations—and also to develop a cadre of people who can go out and assist somewhere like Papua New Guinea, Indonesia and elsewhere or in the northern areas of Australia when there is an emergency.[7]

6.15               Professor Peter McIntyre, of the National Centre for Immunisation Research and Surveillance of Vaccine-Preventable Diseases,  agreed that there was fragmentation at a national level:

I think there is one unifying theme … it would be fragmentation. Australia has very strong capacity in lots of areas but there tends to be fragmentation both at the national level and in our capacity to respond regionally and more broadly, because we lack the sort of coordination that would achieve that.

It is a challenge in a federation, as we know. Everyone would be keen to have one leading centre—as long as it was their leading centre; they would be fine about that—and it is always the challenge as to how to achieve that and come up with a mechanism that will capitalise on all the expertise and get the most effective use of that.[8]

6.16               Associate Professor Thomas Gottlieb, President of the Australian Society for Antimicrobials, told the Committee that there was a need for a more formal structure for disseminating information at a national level:

We have a very good knowledge base among our physicians. Our infectious diseases society has a bulletin board. If someone has an issue, they will bring it to the attention of everyone so people hear it quickly. But we do not have a formalised structure for disseminating information, for linking what states and territories are doing.[9]

6.17               Professor Geoffrey Shellam, of the University of Western Australia, argued that having a dedicated national centre for disease control could improve efficiency and capitalise on the expertise available around the country:

At the moment a lot of the national policy around communicable disease control is put together by these networks and committees from around the country. It is a slow, cumbersome, inefficient process compared to if you have a dedicated unit at national level to say why we need to have a national policy on this and the expertise is there to do it. That does not happen here at the moment. We muddle along[10].

6.18               Professor Jonathan Carapetis, of the Telethon Institute for Child Health Research, told the Committee that there was too much reliance on informal networks and the goodwill of individuals or jurisdictions to take on a coordination role during an emerging disease threat of national concern:

I think that, for something like a communicable diseases threat, relying on the goodwill of people like that without having some systematic way of responding is just not sustainable.[11]

6.19               Professor Carapetis argued that Australia’s current capacity to deal with widespread outbreaks of infectious disease in Australia would be stretched as people movements across borders increased. Professor Carapetis proposed a public health reserve force be developed, composed of a network of professionals with different types of expertise that could be called on in the event of a public health emergency involving infectious disease:

Our capacity to deal with [disease outbreaks] is thanks to individual doctors—infectious diseases people—sharing information through their goodwill. That is fantastic, but, if things get out of control, the coordination bodies sitting in Canberra and other places do not have the capacity or the resources. One of the things that I suggested could be done is to build a public health reserve force that we can move into action, if needs be, but we do not have that in this country right now.[12]

6.20               Dr Kamalini Lokuge, of the Australian National University, advised that Australia did not have a national agency like the CDC in the US, with decision-making authority. Dr Lokuge noted that the Communicable Diseases Network Australia (CDNA), which is expected to play a key role in coordinating any response to an infectious disease outbreak of national significance in Australia, largely had an advisory role:

There is no equivalent in Australia, for example, to the Centers for Disease Control and Prevention in the US or the Health Protection Agency in the UK which has technical capacity but is a statutory body. They can make decisions based on technical advice that are implemented cross-jurisdictionally, whereas for CDNA it is more the willingness of the members to take and to give advice.[13]

6.21               Dr Paul Armstrong, of the Western Australian Department of Health, explained that unlike countries such as the UK, the USA and Canada, Australia had not adopted a larger scale, national approach to control large scale infectious diseases: 

A lot of the expertise—most of the expertise—comes from the states and territories. I think a reasonable argument could be put forward that that is probably not the best model or that that model could be improved by bolstering the resources at a national level.[14]

6.22               While Ms Morris agreed that the USA’s CDC was a well-respected model with an excellent reputation, she questioned whether a federally-based CDC in Australia would raise constitutional issues, given that the states and territories had primary responsibility for public health.[15]

6.23               It was also argued that the formation of a CDC may have more benefit to countries with a larger population such as the USA.[16]

6.24               Dr Jennifer Firman, of DoHA, compared the current CDC models in operation around the globe to the health outcomes of each country:

If you look at that CDC model, the CDC has 15,000 employees in 50 [states] and does chronic health as well as communicable disease. It is a much bigger body than just a CDC in terms of infectious disease. The UK and Europe have a CDC-like model with different levels of employees. If you are looking for a government system that is similar to Australia, Canada has provinces akin to our states and territories. Canada has a CDC with 2,000 to 3,000 employees, and they also do some aspects of chronic health. The European CDC has a core of 270 employees in Stockholm. They cover Europe, but they leave countries to run their own systems. All of these systems are a hub-and-spoke network of communicable disease control. Some people have an enormous hub and do everything in it, and that is the CDC model. Is that the best model? Their public health and health outcomes are not as good as Australia's, by a long shot. That is a model, but does it deliver you exactly what you want in terms of outcomes? Perhaps not. The country's system suits that country really.[17]

Committee comment

6.25               There appears to be general consensus among roundtable participants that Australia has strong infectious disease expertise within the states and territories and within the national expert committees that can be drawn upon, should Australia need to respond to a national health emergency involving the spread of infectious disease.

6.26               However, the Committee understands that there are a large number of Commonwealth agencies, and networks within and outside those agencies, that have responsibility for emergency management and pandemic planning. Similarly, each state and territory has its own agencies, networks and plans for monitoring and responding to infectious diseases.

6.27               Noting the number of agencies involved across portfolios and different levels of government, it is vital that there are clear lines of communication. Responsibilities must be clearly defined and understood, so that any plans can be implemented efficiently and effectively when required. 

6.28               The Committee was informed that the CDNA is developing an overarching communicable disease framework, the National Communicable Disease Framework.[18] Advice provided by DoHA indicates that this framework may be completed in the latter half of 2013.[19]

6.29               The Committee assumes that this framework will detail the relevant policies and procedures in place to respond to infectious disease emergencies of national significance, including outlining the respective responsibilities of DoHA, AHPC, CDNA and other national expert committees. It is unclear to what extent this framework will apply to agencies outside of the health portfolio.

6.30               The majority of participants agreed that Australia’s resources and the coordination of national expertise may be stretched beyond capacity, should Australia experience an outbreak of infectious disease or pandemic that is more significant than what Australia has so far experienced.

6.31               The Committee shares the concern expressed by several participants that some of the most effective networks in place regarding infectious disease control are informal networks, maintained by the goodwill and enthusiasm of a number of hard-working infectious disease physicians and individuals around the country.

6.32               In the Committee’s view, there is a strong case for giving further consideration to the need for an overarching national structure to oversee policy development and coordinate responses to infectious disease outbreaks issues at a national level. A national centre for communicable disease control could serve as a central coordinating agency, overseeing infectious disease policy development and managing any response to a large-scale outbreak of infectious disease.

6.33               The Committee acknowledges that there may be jurisdictional and/or constitutional issues that need to be considered in the creation of such a national centre. However, the Committee is of the view that the concept has merit and warrants further investigation.

6.34               The Committee considers what a national centre for communicable disease control might look like below.

What would a national centre for communicable disease control look like?

6.35               The Committee heard a range of evidence regarding possible models for a national centre for communicable disease control in Australia.

6.36               Dr Richard Gair, of Queensland Health, outlined the following functions as essential elements of a national centre:

• Coordination;
  
  
• national surveillance – to provide a national picture of what is going on;
  
  
• expert advice – a national centre for expert advice on infectious disease control issues; and
  
  
• a national centre for education and advice to government.[20]

6.37               In considering what model might work best in Australia, participants considered international CDC models. CDCs currently in existence around the world include:

• Centers for Disease Control and Prevention (United States);
  
  
• Health Protection Agency (United Kingdom);
  
  
• Public Health Agency of Canada; and
  
  
• European Centre for Disease Prevention and Control.[21]

6.38               Dr Paul Armstrong, of the Western Australia Department of Health, advised how Australia might adapt the idea of a national CDC from other international models:

We could look at all of those and work out what the best would be for Australia. We would have to decide whether the national centre would be dedicated to communicable diseases only or whether it would be like the one in the United States, which is a centre for disease control. It is not a centre for communicable disease control but a centre for a national approach to all types of diseases. We have that in Australia for preventable diseases [Australian National Preventive Health Agency]. We have parts of the model in place already. We do not have a good one for communicable diseases. Pulling all of that together would be a good aim, I would think.[22]

6.39               Chief Executive Officer of the Public Health Association of Australia Incorporated (PHAA), Michael Moore, argued for a CDC in line with the Canadian model (with variations), rather than basing it on the US model:

We do not see it as being a need for a whole new bureaucracy. We think it is actually a coordinating function, taking people from within bureaucracy, where you have many good people, and making sure that these issues are coordinated properly.[23]

6.40               Professor McIntyre also considered that Canada’s experience in creating a national public health agency was instructive to Australia:

I think looking at the Canadian experience in more detail and what they did in establishing this public health agency for Canada—which did not mean that everything else got trashed; it just meant that there were additional resources brought to bear and the coordination capacity at the laboratory level and at the epidemiologic investigation level was strengthened.[24]

6.41               Professor McIntyre said better coordination would improve the good work that was already taking place nationally:

I think the thing which would really strike you if you were a Martian coming down and looking at the Australian system now is that we have all these fabulous initiatives and groups—some of whom are represented at the table today—which are doing great work, but we do not have one coordinating group that we can look to as happens in the US, Canada or the UK.[25]

6.42               Dr Adam Kamradt-Scott, of the University of Sydney, told the Committee that a CDC could ideally be placed under DoHA, similar to the United States model:

The technical expertise and the people that we have to do the jobs already exist, so we are further ahead than a lot of other countries in that we have got capacity there. What we are lacking and what we struggle with unfortunately is our federal-state structure and it is the responsibilities before it.[26]

6.43               Professor Carapetis stated that in reviewing Australia’s current capacity to respond to infectious disease issues of national concern, the National Centre for Immunisation Research and Surveillance was a model worthy of consideration:

One of the things I did was to try to look through to see what our current capacity is. That included the Communicable Diseases Network of Australia, the Public Health Laboratory Network and other bodies which no longer exist, such as the Biosecurity CRC, AusReady and the Northern Australia Emerging Infectious Diseases Alliance. We do not have much left. There are some academic bodies that focus on infectious diseases, but they are not strongly linked to policy or practice. The example I use of a body that acts in the way I think this should act in communicable disease is the National Centre for Immunisation Research and Surveillance. It is a body that is charged with supporting government responses and policy around immunisation, that does have the capacity to link with networks around this country and that acts as a secretariat for the immunisation committees. It does not really have the capacity to draw in the extra workforces needed, but it is a model for what I would imagine one could create in the communicable diseases area.[27]

6.44               The Committee heard evidence from a number of participants that the basis of a strong CDC type model in Australia already existed.

6.45               Associate Professor Thomas Gottlieb told the Committee that the Australian Society for Antimicrobials had called for a coordinated national system drawing from the structures that were already in place:

The point I would like to make is that we do not need to create a new structure that needs something to be built; we already have very good agencies. We just need to link these things together very effectively.[28]

6.46               Dr Peter Markey, of the Northern Territory Centre for Disease Control, also told the Committee that Australia already had many of the elements of a CDC:

My view is that a lot of what will constitute the future CDC exists already. I know politicians are always concerned about funding, and maybe this is what puts them off a bit. But institutions like the National Centre for Immunisation Research and Surveillance, the Kirby Institute[29] and bits of the Department of Health and Ageing as they exist at the moment I see would come under the umbrella of the CDC.[30]

6.47               The Committee heard evidence that a suitable CDC model in Australia was one that could effectively capture the expertise of people and agencies working in the states and territories, without taking control away from the people ‘on the ground’ – i.e. the experts in the state and territories.

6.48               Professor Scott Ritchie, of James Cook University, gave an example of how the CDC might work in the case of a dengue outbreak:

With dengue, the way I would see the CDC is as a sort of centralised area of real expertise and capacity to do investigations and to do epidemiological work. I did not see it as the guys on the ground fighting dengue; I see the CDC as supplementing …

… But I do see that the responsibility for a lot of the nuts and bolts control stuff will still be with the states and/or local government. The CDC will have a lot of the technical expertise and research to help us do the job better.[31]

6.49               Dr Armstrong envisaged that a national CDC could set the national policy, with the states and territories adopting and implementing the policies uniformly across the states and territories:

It is a lot more efficient than having seven state departments writing a particular policy or a particular factsheet about dengue fever. There are seven around the country. If there were one and we all used it, there would be efficiencies of scale, which are very obvious. You would have to continue to have expertise in the states and territories—there is no doubt about that—because that is where the issue would be managed. That is the effector arm of this national policy. The national people would be largely policy development people rather than on-the-ground, operational people.[32]

6.50               Professor Shellam proposed that an educational infrastructure underpin any national centre, as this would in turn strengthen Australia's ability to respond to outbreaks of disease.[33] This was discussed further in Chapter 5.

Committee comment

6.51               Infectious diseases do not recognise state and territory borders. Effective coordination of surveillance and response activities at a national level is therefore crucial to effectively managing infectious disease risks.

6.52               A consequence of running public health primarily at a state and territory level is that there is little uniformity in policies and procedures. For example, the Committee was told that an infectious disease listed as notifiable in Queensland, may not be listed in Western Australia. The Committee was also told that there may be a different policy in each state and territory to respond to and manage the same infectious disease issue.

6.53               The Committee is concerned that the lack of uniformity in infectious disease control and inadequate coordination between portfolio agencies and across all levels of government, could potentially compromise Australia’s preparedness to respond to a nationwide outbreak of infectious disease in the future.

6.54               As noted earlier in this chapter, there was consensus among the majority of participants that establishing a national centre for communicable disease control would enhance Australia’s capacity to respond to nationally significant infectious disease risks and outbreaks.

6.55               In considering what a national centre for communicable disease control might look like, participants observed that while international models provide useful points of reference, a national centre for Australia would need to be specific to operate effectively in Australia’s federal system of government, and to address the unique demographic and regional issues.

6.56               In response to questions from the Committee about the role of an Australian centre for communicable disease control, participants proposed the following:

• Coordination of robust and uniform national surveillance activities
  
  
  • enhancing national surveillance activities such as the National Notifiable Diseases Surveillance System to monitor infectious diseases at a national level and identify emerging threats
    
    
• Provision of expert policy advice and guidance on policy development
  
  
  • providing evidence-based and consistent policy advice and guidance on policy development to Commonwealth, state and territory governments, and expert committees as required
    
    
  • undertaking and supporting targeted research into emerging infectious disease threats and issues of concern to Australia, that can inform policy and assist in planning for a widespread national infectious disease emergency
    
    
• Oversight and coordination of cross-agency and cross-jurisdictional responses to national health emergencies involving the spread of infectious diseases
  
  
• Provision of national leadership in communicable disease control prevention programs and public awareness campaigns
  
  
• Capacity building to develop and maintain a ‘public health reserve workforce’, comprising experts in the infectious diseases field
  
  
  • providing national oversight, coordination and support for training and development of infectious disease experts (eg laboratory, epidemiology, clinical, entomology, environmental health) in Australia, to build up a workforce which is sustainable during ‘surge’ times[34]

6.57               When asked to describe the key components of the ‘ideal’ model for supporting the role of a national centre, alternative proposals were put to the Committee. Proposals incorporated various suggestions for structure (eg an actual or virtual centre), location (eg centralised or distributed), governance (eg embedded within a government department, an academic department or set up as an independent statutory authority) and staffing (eg staff drawn from existing structures or designated staff).

6.58               As a broad principle, however, the majority of participants emphasised that establishing a national centre should not involve ‘reinventing the wheel’ or creating unnecessary and additional layers of bureaucracy.

6.59               On the basis of evidence presented, it is clear to the Committee that there are a number of effective national networks already in place, comprising infectious disease experts from around the country, tasked with protecting Australians from the threat of infectious disease.

6.60               The Committee also recognises that state and territory governments have an important role to play in implementing public health policies at a local level, by engaging medical practitioners and infectious disease experts who can act ‘on the ground’ and at the forefront of infection control.

6.61               Nevertheless, at a national level, the Committee considers that a national centre for communicable disease control could assist in encouraging more uniformity, improved efficiency and better coordination between public health departments in each state and territory and the Commonwealth, and across a range of portfolio agencies.

6.62               A national centre could also ensure that there is a visible central coordination point for any national response to an emerging infectious disease threat or disease outbreak from an international source or within Australia.

6.63               To progress consideration of the case for establishing a national centre of communicable disease control in Australia, the Committee recommends a two stage process. The first stage would comprise an audit and mapping exercise of existing structures, networks, policies and plans. In the context of the outcomes of the audit and mapping exercise, the second stage would comprise an independent review of the case for establishing a national centre for communicable disease control.

Recommendation 14
6.64	The Australian Government,  in consultation with state and territory governments, conduct a comprehensive national audit and mapping exercise to: identify all of the agencies (not limited to those within the health portfolio) and expert committees/working groups involved in managing infectious disease risks; clarify roles, responsibilities and map hierarchies and lines of communication; identify all relevant infectious disease policies and plans, explain how these operate in relation to one another; identify any duplication and present options for streamlining; and identify any policy or response gaps that need to be addressed. The outcomes of the audit and mapping exercise should be made publically available.

Recommendation 15
6.65	The Australian Government, in consultation with state and territory governments, commission an independent review to assess the case for establishing a national centre for communicable disease control in Australia. The review should outline the role of a national centre and how it might be structured to build on and enhance existing systems. It should examine different models, considering a range of options for location, governance and staffing. The review should incorporate a cost-benefit analysis for each of the models presented. The outcomes of the review should be made publically available.

Ms Jill Hall MP

Chair

 

19 March 2013