Health Committee on Nov. 25th, 2009

[The Chair, Conservative, Joy Smith]

You have one minute.

[Nicolas Dufour, Bloc, Repentigny, QC]

Mr. Butler-Jones, at our November 18 meeting, you said that, across the country, some translations were not always useful. In some cases, that even involved translations into French. Complaints were received and the PHAC had to accommodate dialects and local variants.

I would like to know if that situation has been rectified and if you know the nature of the complaints that were made about it.

[Dr. David Butler-Jones]

It is up to each region to do any necessary translations. When I was chief medical officer for a region, it was the same; we had to adapt brochures and other documents. It is impossible to translate everything.

En anglais, if we did it, I wouldn't want it if I were a local medical officer because the chances of our getting the local dialect are not very great. We have to be generic for the country and that then allows l'adaptation locale.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much, Mr. Butler-Jones.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we'll go to Ms. Wasylycia-Leis.

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

Thank you.

My thanks again to all of you for being here.

I want to go back to a topic we discussed at a previous session. It has to do with health and safety concerns of nurses and other health care workers on the front lines, particularly with respect to their feeling that to be consistent with the precautionary principle, the N95 masks should have been considered as a national standard across this country.

Dr. Butler-Jones, whenever we've raised this in the past, you've said it's not necessary because we're talking about something spread through droplets. Some of us were recently at a session here put on by the Canadian Federation of Nurses Unions. There was a fairly prominent speaker by the name of Mario Possamai, who was a senior adviser with the SARS Commission. He gave us an in-depth presentation on the importance of lessons from SARS, the need to rely on the precautionary principle, and the need for us not to get caught up in splitting hairs.

He thought that, rather than arguing about droplets, we ought to ensure that the strongest precautionary mechanism was being used. Have you had any change of thought on this issue?

[Dr. David Butler-Jones]

That would be true only if it were effective. We have studies showing that the N95 masks do not reduce the risk of infection to health care workers working with influenza. Whether they use a surgical mask or an N95 mask, the risk is exactly the same. The precautionary principle would apply only if it actually made a difference, but in this case, it doesn't.

You can always find disagreement among experts. But the vast majority of experts, those dealing with infectious diseases on a regular basis, would say that (a) it makes no sense, (b) it's difficult, and (c) it may actually increase the risk if it gives a false sense of security.

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

I'm wondering if your study of the issue took into account the SARS example that was given to us. They contrasted Vancouver General Hospital's response, which employed the precautionary principle, with that of another city in another region. Vancouver demonstrated a minimal spread of the disease while Ontario showed a more significant spread because the precautionary principle wasn't adopted.

[Dr. David Butler-Jones]

There are many other variations when you look at a situation like that. I'll let Dr. Gully, who was actually around at the time AND working on those issues, speak to it.

What is very clear is that when you look at the protection of health care workers, you start with a whole range of things: everything from sanitation to access to handwashing to gels that supplement handwashing. Personal protective equipment is only one piece of that. Much of the spread of SARS had nothing to do with the use of masks. It had to do with how we recognized or dealt with basic infection control procedures. They should be in place in all hospitals at all times, particularly for people who have potentially infectious diseases but even for those who don't, because you can't predict or tell who has the infectious disease.

We have abundant evidence now that when you focus on just those who you think are sick, as opposed to exercising good infection control procedures all the time, you may actually increase the risk to health care workers. That does not necessarily mean N95 masks. There are certain conditions for which they are recommended. At the same time, there is an appropriate responsibility in the local situation to assess that situation and take the precautions necessary. However, the evidence suggests that in the vast majority of those cases N95 masks do not offer any more protection than surgical masks.

Go ahead, Paul.

[Dr. Paul Gully]

If I could just add to that, in our understanding, what happened in Vancouver as opposed to Toronto was what happened right at the beginning. In fact, it was a mask that was put on a suspected case of SARS, on an individual, a patient, as opposed to the utilization of masks by health care workers, that in fact then I think, perhaps to a great extent, led to the difference. At least, that was our assessment at the time. In fact, if I--

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

A thorough presentation by Mario Possamai, who I think was heavily involved in the entire SARS assessment afterwards, clearly presented the fact that in the case of Vancouver General Hospital, a patient who presented at the hospital was isolated within five minutes. Within 15 minutes, the staff had N95s, the respirator on, and so on. He contrasted that with Ontario.

I don't want to split hairs on this. I don't want to get into a debate. I think the issue here is that you have a strong message from a national association of nurses representing people right across this country who are very concerned about the way they are being treated. There is a feeling that the precautionary principle is not being respected and that their health and safety are at risk. I think somebody needs to take this into account and deal with it.

I don't think it should be left for us to hear presentations like this and then have their concerns dismissed. I think there has to be a way for this government to take the evidence and say that you'll study it, you'll talk to the nurses again, and you'll figure out what's going on. I think that would be a healthy response to the situation. It's not a trifling issue.

[Dr. David Butler-Jones]

This is the perspective of one scientist. We have consulted with the best scientists in the country, with experts in infectious disease and infection control.

These are not government guidelines. These are guidelines that have come up from committees of experts from across this country who have reviewed all the evidence from around the world. These are the recommendations based on that.

Let's look at the Vancouver General situation versus Toronto's. They knew what was coming. They knew there was a problem. They isolated it when it came. It had nothing to do with the N95 mask and everything to do with recognizing something and treating it seriously as opposed to not recognizing it and carrying on as if everything was just fine. That's when people are put at risk.

It's not about N95 masks versus surgical masks. It is about the whole comprehensive approach to infection control we need to follow all the time, whether we're talking about C. difficile, MRSA, H1N1, or anything else. It's about treating infectious diseases seriously in hospitals and following good infection control procedures. It is not about N95 masks versus surgical masks. Ninety-nine percent of it is about everything else.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Butler-Jones.

We'll now go to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

No, it will be Ms. McLeod.

[The Chair, Conservative, Joy Smith]

Oh, I'm sorry.

Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you.

I'll also be sharing my time with Mr. Brown.

I have to make a comment for the record. In British Columbia, the vaccine clinics opened to the regular population on Saturday. I decided to go up there on the first day. Parking was superb, the clinic area was superb, 30 nurses were working, and it was 15 minutes from when I arrived at that door until I received my vaccine.

Maybe there were some logistical issues at the very start, but I think they have done a superb job. I think we need to give credit to our health authorities and our workers on the ground. This was a Saturday and there they were. I don't know how many hundred injections each nurse does in a day, but they're significantly stepping up to the plate.

The thing that's interesting to me right now is my sense that within the general population we seem to have a quite quickly diminishing level of anxiety. With that, I have some worries about our getting that target level of population immunized.

I have two questions. First, do we have a communications strategy that's going to really start to work on that piece right now? Second, we're talking about massive volumes of vaccine being delivered, next week, finally, so does that keep going until we have all the doses, even though perhaps we're...? How is that staggering of vaccine going to happen as we look at diminishing as opposed to ramping up?

Those are my two questions. Thank you.

[Dr. David Butler-Jones]

Maybe I'll start.

Then you can follow up, please, Sue.

There is quite a communications plan moving forward. You've seen the earlier phases.

We'll be working closely with the manufacturer in terms of delivery in the provinces and territories. They say they're looking forward to the continued vaccine. At some point we will have enough vaccine to immunize all who need it and want it, and then it's an issue of what we do with that and how we manage that. We're in consultation both with the manufacturer and the provinces and territories about that. We're not there yet, but as we get there, we'll need to have that in hand.

On the other question, I guess people are getting more comfortable with it, but the reality is that we have 20 million people still potentially at risk, who have not either been ill or been immunized so far. Of those, if we have a 25% attack rate, eventually—not in the next few days or weeks—we'll get over the hump and then we'll see smaller numbers. But then you're looking at 4,000 to 20,000 hospitalizations just in that group, 500 to 4,000 in ICU, and 250 to 1,000 deaths somewhere. This is still to come, at some point, if we don't get more people immunized.

Nobody should be complacent about it. I know of young twentysomethings who unfortunately have died or are in ICU on ventilators. It's impossible to predict which ones will be affected in that way. This is not like seasonal flu. It's a different group, by and large, that is more severely affected and it is something that is cheap, simple, and easy to prevent through immunization.

Sue.

[Sue Ronald, Director, Marketing, Creative Services and E-Comms, Communications Directorate, Public Health Agency of Canada]

Thank you.

Yes, as you know, we do have a comprehensive citizen readiness marketing campaign that's been under way since April/May. Right now we're moving into the month of December so we'll be doing some messaging to the general population.

On what you pointed out, we have research rolling polls that are showing certain pockets of the population that don't have the pickup as much as some others. So in the first of the year, we're looking to start what we call drilling down into those target audiences to find out who the people are who aren't getting the vaccine.

Dr. Butler-Jones is right that the research is showing us right now that the 18- to 35-year-olds are the population that's a bit loosey-goosey, for lack of the technical term, about getting the vaccine.

The majority of our communications at this point has been targeted at the general population. Moving into the new year, we will be looking at which people we need to really go to now, the people who seem to have the information but don't seem to be taking the necessary action we want them to take. Of course, our goal always is to give people the information they need so they can take the right decision for themselves.

[The Chair, Conservative, Joy Smith]

Mr. Brown, perhaps you'd like to ask your question.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair.

I, too, got my H1N1 shot last week, as Cathy mentioned, and I was surprised that there were no lineups. It took from five to ten minutes, so clearly the process is going along very smoothly.

I want to get a sense of whether we have any idea of how much has been spent on advertising. I remember that at one point there were some concerns from the opposition that there wasn't enough spent on advertising compared to other things.

I play hockey every Sunday with the person who does advertising for a local paper and he says your advertising is helping keep them in business. I notice when I read any paper that there are ads. If I turn the TV on, it's very difficult not to see your face.

I think there's been a very effective advertising campaign, so maybe if we have a sense of the numbers it might allay some of the fears of a month ago that there wasn't enough emphasis put on getting the word out.

[Sue Ronald]

Thank you.

Right now we've spent about $20 million on advertising. We've tried to put our money where it's best used. You have seen Dr. Butler-Jones out there a lot and that's thanks to the media, which are covering him wherever he goes.

As we're coming into December, we're getting ready to launch a print ad that will be in daily newspapers on Saturday, November 28, and then for two weeks nationally you will hear some radio ads, starting on November 30. Right before Christmas, you will see a couple of full-page print ads. You will also hear more radio ads prior to Christmas, but the message is going to change slightly. It's going to be about Christmas as a time when people have social gatherings and are around a lot of people, so we don't want people to forget to cough into their arm, wash their hands, and do all of those kinds of things.

Yes, a significant amount of money has been spent.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Ronald.

We'll now go to Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

I think that on all sides of this table everyone appreciates the job that the front line people have been doing. In fact, great people sometimes can overcome poor processes. That's a truism in quality improvement.

I want to go further into the question that my colleague asked on jurisdictional changes. I spoke with someone who was a former chief medical officer of a large population. This person's view was that Dr. Butler-Jones' role should really be one of reporting to Parliament. We know that coordination has been a challenge and that there has been some concern about coordination. When we had the public service briefing, it turned out that nobody was in charge of preparedness in the ministries, really, except for the ministries themselves. There was no one in charge overall.

We did have poor early communication and we saw that the budget spent on H1N1 communication was one-tenth of what was spent on advertising to persuade Canadians that the economy was doing well. We've had confusion and province-to-province differences over whether you should get the seasonal shot or the H1N1 shot. We heard from a lot of front line people that the clarity never got to their level, especially in the early weeks.

My very direct question is this: if we had a system in which the Public Health Agency of Canada and the Chief Public Health Officer reported directly to Parliament, would we have had fewer incidents of confusion, mixed messages, and early ineffectiveness?

[Dr. David Butler-Jones]

The short answer is no.

When the agency was established, I was part of the grand debate on what the role of the Chief Public Health Officer should be, who that person should report to, whether the agency should be inside government or outside of government, and so on, but I was not expecting that I would have to live with those recommendations. As I look at it, I don't really think there would be much advantage in that idea. I've been able to speak to the issues that I need to speak to.

Public health ultimately is a local jurisdiction. It is a local activity. It's important that local medical officers have it. If you look at what I said six months ago and what I'm saying now, other than where things themselves have changed, what I'm saying hasn't really fundamentally changed.

However, there has been a seeking out of different views, predictions, and recommendations, and that has confused the picture, because it gets play in the media as one scientist versus another, as opposed to 99 to 1, or all the chief medical officers in the country versus somebody who happens to work somewhere and has the title of doctor. That's part of the system. Whether you have a unitized system or a federation, as we do, I think that would still occur.

It is important to adapt things locally. It will vary a little bit. You don't see this level of scrutiny, interest, and comparing and searching for differences anywhere else in the world, even though those differences exist and even in unitary states. How it's carried out in one county in the U.K. is not exactly the same as the way it's carried out in another county, but here it's an issue, a media issue and a controversy, as opposed to being seen as just the way public health does business.

The short answer was the first one; I'm not sure it would ultimately make much difference to this situation.

What has made the biggest difference in terms of the positive things and the speed with which we've been able to come to ground on these issues is our public health network system. There's collaboration around the country. There is joint decision-making and planning with the provinces and territories, which then work with their local health authorities and bring together the expertise to address the issues. Very quickly you see people learn from the experience, and they apply it and share it across the country. That, in a federation, is a huge challenge.

Getting to those answers quickly is to the credit of the people at the local level and in the provinces and territories. I'm not sure it's so much a credit to us.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

I have another quick question. We have heard that the level of activity of infection is well above what was the expected level for this time period and that hospitalizations and deaths are still increasing. Do you see any connection between that and the fact that we began our vaccination programs weeks later than other countries because of certain decisions that were made in the planning?