Health Committee on Aug. 12th, 2009

[The Chair, Conservative, Joy Smith]

Okay, sure. Absolutely. Thank you.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

My question is for our witnesses from the Federation of Canadian Municipalities. Since the cities come directly under the responsibility of the provinces, would you say the lack of communication you referred is a general problem, or are there some places where things are working better? Are you able to answer that question?

[Berry Vrbanovic]

What I would say in response to your question is that we need to remember that a situation like a pandemic does not recognize jurisdictional boundaries, whether they are municipal, provincial, territorial, or federal. The reality is that we need to have a comprehensive plan that relates to each and every Canadian from coast to coast to coast and helps ensure that the needs of all our communities are being addressed--and specifically, in the case of municipalities, the needs of our front-line workers--in order to ensure that we can respond to our citizens if and when the situation were to get worse.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

So, you are saying that in terms of developing the action plan, there is very little, if any, consultation with the municipalities. Is that correct?

[Berry Vrbanovic]

As I indicated in my response earlier, since our letter to the minister in early May from our president, we have had dialogue with federal officials about this issue. In recent weeks we've been encouraged by some of the announcements that have been made in terms of public statements around the need to address the protection of front-line workers and also some of the announcements with respect to the acquiring of both antivirals and vaccines. However, we still have not seen or heard of a national plan that specifically addresses the needs of those front-line workers in our municipalities that, we believe, are absolutely essential in terms of the implementation of a successful national pandemic strategy.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Thank you, Madam Chairperson.

In three or five minutes, let me first ask Mr. Normand. You are an expert in the whole area of emergency preparedness. Obviously, all of you together are not exactly enamoured of the federal government's approach and you are feeling there's a need for a national plan with funding and consultation and with teeth. Let me ask some specifics, though.

Right now we're at August 12 and they're predicting that an outbreak could happen in September. What direction have you now received from the federal government in terms of very specific things--for instance, for an ambulance driver? Are you instructed to wear a mask if you're carrying a patient who has H1N1? Or if you are a police officer and asked to enforce a quarantine, have the police been given specific directions from the federal government through this process for how to handle that?

[Alain Normand]

Thank you, Madam Chair.

Yes, we have received some communication. We received, actually last week, a communication from the federal government directed at the front-line responders—police, fire, paramedics. However, it was a very short communication. It was very succinct and had only very basic information. We would like to see more, and we're willing to come to the table and work with the federal government to come up with some more extensive guidelines.

The guidelines really talk about how to wash your hands, how to wear the mask. I have to say that in the city of Brampton we're fortunate. We're a larger community, and we've taken the time way back to actually fit-test the masks for every single one of our emergency workers. I can't say it would be the same for all smaller communities. They do not necessarily have the same level of resources as we have, and that's my concern. Even though I may come from Brampton, as a representative from the FCM, I am concerned about the capacity in other communities as well.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Did that kind of directive come down after your fairly substantive letter on July 27 to the minister?

[Alain Normand]

Actually, I think it came very close.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Obviously, your speaking out caused a reaction. Maybe today we'll get another reaction.

[Alain Normand]

We're hoping that we can engage in this form of dialogue. That's our reason for being here today.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Let me ask you this, Dr. Maxted. You made a comment in your remarks about the need to act now, the time for study is over, and if we know enough information now about first nations communities and Inuit people being affected more severely by H1N1 than others, why aren't we taking measures to deal with that?

Just to respond to Mr. Clarke's comments from earlier, I don't think that's being “un-Canadian”. I think that's recognizing that there might be a disproportionate impact on certain populations, and that if it was, for example, the case that more women were affected than men, we'd be asking the same questions.

So I'd like to know from you, what should we start doing immediately on that front? If we're lucky enough to get another meeting with the minister soon on this issue, what should we be asking her that wasn't addressed today?

[Dr. John Maxted]

I've noticed a lot of your questions today have to do with questions around planning: where's the plan for this, and where's the plan for that, and the other thing? I'd suggest to you that a plan is only as good as its implementation, and in fact we have plans out there, or at least there are plans out there. I could refer you to the 600- to 800-page pandemic national plan, which probably very few of us have actually read, although I, for one, have. And I could refer you to other plans that different municipalities, hospitals, and other health regions, and so on, have created, all of which have substance, have value to them. But the plan is only as good as the implementation.

It's in the implementation that we have begun to realize, through H1N1, that there are problems, and some of the problems that I have identified are the problems around communication. Somebody used the word “patchwork”. I think that in fact across this great country we've seen a patchwork. We've seen a patchwork of communicating with front-line providers, who, by the way, are some of the most important providers in this whole network. It's not the community medicine specialists necessarily, and not the intensive care experts, who in fact are looking after those who are dying. It's the vast majority of the population walking into the primary care centres who we should be paying attention to, because those are the people who are not walking in with labels on their foreheads that say they have H1N1, but need to be diagnosed and need to be treated and managed accordingly in order to deal with this situation before they get to intensive care units.

So I think it's the implementation that really needs to be focused on, the availability of resources. My comments ended simply with the fact that we're willing to work with both the public health agencies as well as local public health authorities. We haven't seen the same response back sometimes from some of those same places.

[The Chair, Conservative, Joy Smith]

Thank you so much, Dr. Maxted, for your insightful comments and for all of your comments here on committee.

We're now going to go to Dr. Perry Kendall, who is with the Pan-Canadian Public Health Network.

Good afternoon, Dr. Kendall. Welcome to our committee today. Can you hear me? There's no audio, I'm sorry. Do you hear anything?

[Dr. Perry Kendall, Provincial/Territorial Co-Chair, Special Advisory Committee on H1N1, Pan-Canadian Public Health Network]

Good afternoon. Can you hear me?

[The Chair, Conservative, Joy Smith]

Dr. Kendall, I think we can hear you now.

My name is Joy Smith. I'm the chair of this committee. We've had, as you know, witnesses here today who have discussed our topic of the H1N1 issue. What you will have is a 10-minute presentation, Doctor. Following that, we'll go into the question period.

So I would welcome you to begin your presentation.

[Dr. Perry Kendall]

Thank you, Madam Chair.

I really appreciate the committee fitting me in and arranging for me to speak to you today. I am the provincial health officer for British Columbia. Since 2005 I have been the provincial/territorial co-chair of the Pan-Canadian Public Health Network, which you will know was established by the ministers of health post SARS to knit Canada's public health systems together federally, provincially, and territorially.

The Public Health Network consists of senior federal-provincial-territorial public health officials who report to the Conference of Deputy Ministers of Health. It has six expert groups, who draw on expertise across the country, looking at emergency planning, public health laboratories, surveillance, communicable disease control, population health promotion, and chronic disease prevention. It has links to the Council of Chief Medical Officers of Health across the country, who in fact make up about half the membership of the council. It also has links to the national collaborating centres for public health.

One of our major pieces of work since our formation in 2005 has been preparing and updating the Canadian pandemic plan.

In mid-April there was the emergence of a novel H1N1 influenza virus in Mexico. The Public Health Network and the federal-provincial-territorial deputy ministers established what were virtually daily calls to coordinate the activities and responses to this H1N1 emergence.

Some time in April or May, the deputy ministers of health created a special advisory committee on H1N1, consisting of every chief medical officer of health across the country, every representative on the Public Health Network, and the Public Health Agency of Canada. I have co-chaired that since its inception, with Dr. David Butler-Jones. This committee met daily until early June, and since that time it has been meeting twice weekly and reporting weekly to the federal, provincial, and territorial deputy ministers of health.

The organization is to focus on H1N1, and part of our work was to develop an organization that could respond in a timely fashion to the cross-Canada needs from H1N1. So we have created what's called a pandemic coordinating committee, which is a smaller group of folk from the network, including our relevant expert groups and experts from across the country. It is like an executive committee that focuses on the response and forward planning over the summer for what we believe will be the re-emergence or resurgence of H1N1 in the fall, when children go back to school.

That coordinating committee has put together a number of structures that draw on provincial, territorial, and clinical and epidemiological expertise from across the country. So we have a task group that is working on surveillance, epidemiology, and laboratory preparedness. We have another task group that has been preparing guidelines on infection control and occupational health. We have a group that has been working on a communications platform and building on existing work the Public Health Network did.

Part of our pre-existing pandemic preparedness that has obviously helped this year had been building antiviral stockpiles, developing proposals for accessing vaccines and plants for delivering vaccines, and building a communications platform for influenza in general that can be easily adapted to H1N1. We have a pandemic vaccine working group, which has been working on criteria for purchasing and developing a pandemic vaccine. We also have a group of our infectious disease control people looking at other vaccines--for example, a pneumococcal vaccine--and at seasonal influenza vaccine criteria.

We have a group that has been working on public health measures, school closures, summer camp guidelines, mass or group meetings, etc.

We have a group that is working with the chief veterinarians of Canada to look at human-animal transmission, the zoonoses implications for avian or swine infections on humans, for example.

We have a group that has been looking at clinical care guidelines. They have developed clinical care guidelines for pregnant women and are also developing clinical care guidelines for emergency room physicians, etc.

We have a group as well that has been looking at the use of antivirals and prioritization of groups and the necessity for antivirals. We have a group that has been looking at the antiviral stockpile management and the refresh, and we have a group that has been applying a lens across all these products to ensure that remote, isolated, and first nations communities are taken into account.

The work that these task groups have been doing over the summer, much of which has been completed and much of which still remains to be done, has been giving us a sense of where H1N1 is going globally, in the southern and northern hemispheres, tracking the spread of the disease, tracking its severity, tracking its impact on individuals, on communities, on the health care system, and on the broader social service system, and then producing guidelines that are evidence based, that can be used in the jurisdictions across Canada or, if they're not used identically--because they're not meant to be cookie cutters--will give the evidence-based principals on which jurisdictions can formulate responses, can provide guidelines to nurses, physicians, hospitals, health care workers, ambulance attendants, and so on, schools, day camp operators, or in fact the general public, so that we will have an evidence-based response in place and ready as we move into the fall, when we expect to see the second wave of H1N1 enter the northern hemisphere.

I could go into more detail on the work plans that have been approved by this group and presented to and approved by the deputy ministers of health, who would be ultimately reporting to ministers of health; or I could stop there and give you more time for questions rather than go through a list of the outcomes that we're going to deliver by the end of the summer.

[The Chair, Conservative, Joy Smith]

Then perhaps I'll ask the will of the committee. Would you like to continue with the questions?

Monsieur Malo, as I promised—you have to remember this—I'll give you the two and a half minutes now.

Thank you.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you, Madam Chair.

Dr. Kendall, thank you for being with us this afternoon.

When the Minister left earlier, she made an announcement in the hallway that she did not make in front of the members of this Committee. She announced that she would be presenting a plan for the schools next week. We all know full well that schools are not managed by the federal government; rather, they fall within the purview of the competent authorities in the different provinces.

As the provincial-territorial co-chair of the Special Advisory Committee on H1N1, can you tell me whether the various provinces are intimately involved in developing this plan for the schools?

[Dr. Perry Kendall]

Thank you. That's a good question.

We know that schools act as a culture ground for the spread of influenza viruses. When these viruses enter a community, they first affect younger people, because younger people are naive and have little resistance. In Australian day cares and schools, because of the close contact, we see the level of replication of the virus multiply in those communities before they move to families, before they then move into the adult population, and before they move into the community at large.

One of our criteria has been, what should we do when we get outbreaks in schools? Should we be closing schools? There is evidence that, because viruses will spread in the schools, should we close the schools and should we keep all children at home, we slow down the spread of the virus and delay its entry into the general population. In fact, that's what's happening over the summer holidays. We had the virus in the broader community, the schools broke for holidays, and the levels of influenza activity have continued but at lower levels. When the kids come back, they're going to ramp up.

Our initial response in British Columbia and south of the border in the United States, when we identified H1N1 in schools, was to close those schools down. Other provinces didn't. We've looked at the evidence as to whether school closures can be effective in mitigating or ramping down the spread of influenza. If this influenza were really severe, were really making many children very, very sick, had serious implications for the health structure or health of the broader population, it might be worth incurring the social costs of closing schools down—because that has impacts on the broader economy, impacts on parents who have to stay home. It only works if children actually stay home in relative isolation. If we close the schools down and the kids mingle in the malls, we've accomplished nothing but disrupting their educational process in civil society.

We've looked at the evidence, and the documents that the minister was talking about are in fact evidence-based guidelines for what public health officials and school officials can do or should do in response to outbreaks of H1N1 influenza in schools, which is essentially focused on prevention by keeping sick children home, focused on hygiene, focused on identifying kids who are ill and isolating them until they can be sent home, and basically keeping the schools going as long as there is a sufficiency of adult staff to keep the school safely open.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Kendall.

We'll now go to Dr. Colin Carrie for his questions.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair, and I want to thank Dr. Kendall for joining us today.

I realize, Dr. Kendall, your job is quite sensitive at times. You're doing quite the juggling act ,and I want to commend you for the good work you're doing in regard to all these federal-provincial-territorial jurisdictional issues. My colleague from the Bloc brought up a very important point with schools, to make sure that we have an evidence-based response to these different scenarios that we're going to be presented with.

Our colleagues from the municipalities brought up some good points too. I think everyone's aware that PHAC is responsible for the H1N1, but for critical infrastructure, what the municipalities are dealing with at the grassroots is public safety. So I see there such a huge coordination.

One of the points brought up was that it doesn't appear that we have a federal plan. That's exactly what we do have. We do have a federal plan and we're working through that plan, and you are a very key player for that.

I was wondering, number one, with the concerns of the municipalities here...they said that there really isn't a plan for those front-line workers. Could you elaborate on a plan that you have been working on?

We had some comments from the Canadian College of Physicians, but also Dr. Butler-Jones, about improving the communications. I think this is what this is all about. We have certain stakeholders who don't feel that we have a plan. Apparently we do have a plan, but it's not being communicated.

Would you be able to comment on what we can do, perhaps what the federal government can do, to work with the provinces? Municipalities are creations of the provinces, so how can we work with the provinces to better communicate and get those lines of communication out to the municipalities that have very valid concerns with the overall plan that we have with the government?

I know that's a long question, but please do the best you can.

[Dr. Perry Kendall]

Thank you. It's another good question.

Our Canadian pandemic plan has two primary goals. One is to reduce mortality and morbidity, particularly in the most vulnerable, and the other is to, if you like, maintain the infrastructures that go to creating a civic society and the critical infrastructure pieces. The two are linked in that if we keep people as healthy as possible and minimize the rates of infection and illness and absenteeism, we have a larger workforce in place to manage the health care system, or to maintain bridges, ferries, transportation, municipal infrastructure services, fire, police, ambulance, etc. So part of our focus is on keeping those front-line workers healthy by focusing on, in this case, early intervention through access to antiviral drugs, particularly for people who have become ill or are at particular risk for serious illness.

The other piece of the pandemic planning goes back a number of years and has to happen, as I think you pointed out, at the provincial or the territorial or the local level, where local regional health authorities or local public health agencies have to engage with their municipal counterparts. Certainly in B.C., and I believe across the rest of the country, the fundamental primary responsibility for disaster and emergency response lies with municipalities. They are the foundational piece of that.

We and, I think, most provinces have put up annexes of their pandemic plans, which do include guidelines for municipalities and in fact businesses in general, on how to prepare for predictable things like pandemics in terms of looking at mission critical structures and ensuring that you have plans in place for a reduced workforce through increased absenteeism, that your critical infrastructure pieces are duplicative so that at least you have somebody who knows where the critical switch is that manages the water treatment plant or electricity or power grid. That has to be done at the local level, and it really has to be done in intense cooperation with the local public health folk who can know the details.

I think that prior to the arrival of H1N1, across the country we lapsed a bit into pandemic planning fatigue. There was so much going on that it was hard to maintain the focus on that; it should have been kept up year after year after year. I think it has taken H1N1 to give us a wake-up call, particularly for some people, perhaps, to realize that they didn't keep their planning up to date, that they weren't up to date with their websites or that we didn't develop the linkages that we need to develop at that very local level.

[Colin Carrie, Conservative, Oshawa, ON]

Are you saying to the members of the committee that we actually now are making those linkages? I know the minister brought up the point that she was working on an MOU with the provinces. What I found very interesting is that our municipal colleagues brought up some interesting things about prioritization of the antivirals and the vaccine. You said that you are actually doing that right now, but it appears they're not aware of it.

We've worked very hard on this plan. It has been there since 2006, and we've put $1 billion into it. But what can the federal government do to improve things in working with the provinces so that these communications get out a little bit better, so that our front-line workers...? We recognize they are the responsibility of the municipalities, but we need to have this coordinated response. How can the federal government help to get the messages out? It appears you're doing what has been asked, but the message isn't quite getting out there.

So do you have some advice?

[Dr. Perry Kendall]

Yes, I do. Thank you again.

I think we've been focused very much on the health care sector with our local planning. What the communication strategies need to do, with leadership from the Public Health Agency and the federal government, is to liaise with organizations such as the Federation of Canadian Municipalities to tell them what is going on, to engage with them to determine what they think their critical communication leads are, and then to have your provincial and territorial counterparts liaise with.... We have the Union of B.C. Municipalities, for example, which will be meeting in September, and I anticipate that H1N1 preparedness will be a key focus of what we'll do in British Columbia.

So I think we need a template of broad messaging and to get people to build into a social marketing or informational database or campaign and pick out what those key messages are and then drive them down into the provinces and territories, and then further down, in B.C. for example, into our regional health authorities—or in Ontario it would be through, I guess, their 38 public health units, which were often creatures of the municipality, or were co-funded by them.