Building an evidence-base for mitigating public health emergencies

Although public health emergencies are infrequently encountered at a local level, they pose a constant threat and present challenges of increased morbidity and mortality, heightened workload, stress, and management of public anxiety. In addition they test the full range of emergency logistical, operational and planning activities, and often involve multiple agencies and government departments. This thesis seeks to enhance the evidence-base in public health disaster preparation, prevention and operations at a regional health unit level responsible for community and individual care. There are four overarching public health emergency themes. Firstly, disasters do occur. There is rarely any warning and they are extremely labour intensive and traumatic. This thesis covers events from the first six years of my time as an epidemiologist with the Hunter New England Population Health Unit during which I experienced various emergency situations including: a large influenza outbreak in aged care facilities that resulted in the deaths of eighteen residents, a natural storm disaster that caused over AUS$1.5 billion damage, and an influenza pandemic that lasted for more than a year. Secondly, planning and preparedness mitigate the impact of health emergencies. One of the primary responsibilities of a local population health unit is to reduce risk and prepare in advance for such events. This is achieved through generic preparedness, involving training, policy development, maintaining collegial networks and conducting exercises. Although each emergency requires a customised approach, many of the response features are shared. Thus existing plans and protocols, with adequate preceding preparation, can be adapted to changing circumstances. The Unit's biopreparedness focus was aimed at pandemic mitigation as we considered this to represent a highly plausible threat and the most serious health emergency we were likely to confront. We developed comprehensive plans that were tested during various exercises, including a mass vaccination drill conducted in the rural town of Aberdeen, NSW, and an ambitious four day field pandemic response exercise that was held just eight months before the Influenza A H1N1 pandemic of 2009. These exercises had multiple benefits, including raising staff awareness, testing plans, training surge personnel, working within the Incident Command Structure, activating the emergency operations centre and gathering evidence of the ability of planned activities to mitigate an influenza pandemic locally, prior to its arrival. We used the learning experiences to update our population health plans and shared the results with our colleagues from NSW and other states and territories. Thirdly, when the emergency breaks and the immediate response components have been implemented, research opportunities exist. In the immediate aftermath of the declared natural disaster resulting from violent storms that swept the Hunter Valley in June 2007 we conducted a survey to determine the community impact and pre-existing level of public preparedness, and explore communication issues confronting those affected. The community cooperation with this initiative was strong. But it was the 2009 influenza pandemic that really showed the benefit of real-time research. Once the emergency operations centre had been established and response measures were in place, the team embarked on a range of research activities to address unresolved questions of direct relevance to policy revision. Finally, research can guide and direct interventions that provide improved public health benefits. This is demonstrated by work conducted in the aged care industry where improvements to outbreak management capability have benefitted the institutions, residents and the population health unit. In addition the findings from the storm research resulted in the preparation of a memorandum of understanding to cement an agreement between the NSW State Government and the Australian Broadcasting Corporation. In the past, bureaucrats at state and national levels have often based policy decisions on the strength of personal opinion and presumed public sentiment. This thesis documents how scientific data obtained from robust epidemiological studies can be applied to inform policy decisions in a timely manner. The research reported in this thesis has also provided numerous advocacy opportunities to inject science into the decision-making process