Chapter 6 Does Australia need a national centre for communicable disease
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.
Throughout this inquiry, numerous roundtable participants supported the
proposition that Australia needed a dedicated national centre for communicable
This proposition is discussed in detail below.
What is a CDC?
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).
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
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.
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
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.
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?
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.
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
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.
Ms Morris advised that the expertise of national committees could be
mobilised at very short notice to respond to health emergencies of national
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.
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.
Dr Deborah Lehmann, of the Telethon Institute for Child Health Research,
argued that the current national system for infectious disease control was
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
It was also argued that the formation of a CDC may have more benefit to
countries with a larger population such as the USA.
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.
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.
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.
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.
The Committee was informed that the CDNA is developing an overarching
communicable disease framework, the National Communicable Disease Framework.
Advice provided by DoHA indicates that this framework may be completed in the
latter half of 2013.
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.
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.
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
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
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
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?
The Committee heard a range of evidence regarding possible models for a
national centre for communicable disease control in Australia.
Dr Richard Gair, of Queensland Health, outlined the following functions
as essential elements of a national centre:
- 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.
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.
Dr Paul Armstrong, of the Western Australia Department of Health,
advised how Australia might adapt the idea of a national CDC from other
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.
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.
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.
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.
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
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
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
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.
The Committee heard evidence from a number of participants that the
basis of a strong CDC type model in Australia already existed.
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.
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
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
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.
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.
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.
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.
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. This was discussed further
in Chapter 5.
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.
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.
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.
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.
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.
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
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
evidence-based and consistent policy advice and guidance on policy development
to Commonwealth, state and territory governments, and expert committees as
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
- Capacity building to
develop and maintain a ‘public health reserve workforce’, comprising experts in
the infectious diseases field
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
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).
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.
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.
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.
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.
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.
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.
The Australian Government, in consultation with state and
territory governments, conduct a comprehensive national audit and mapping
all of the agencies (not limited to those within the health portfolio) and expert
committees/working groups involved in managing infectious disease risks;
roles, responsibilities and map hierarchies and lines of communication;
all relevant infectious disease policies and plans, explain how these operate
in relation to one another;
any duplication and present options for streamlining; and
any policy or response gaps that need to be addressed.
The outcomes of the audit and mapping exercise should be
made publically available.
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
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
Ms Jill Hall MP
19 March 2013