Health Committee on May 30th, 2007

[The Chair, Conservative, Rob Merrifield]

We'll call the meeting to order.

We are here pursuant to our order of reference of Thursday, March 29, 2007, concerning Bill C-42, An Act to amend the Quarantine Act.

We have with us, through video conference from British Columbia, Minister of Health Perry Kendall.

Mr. Kendall, can you hear us all right and see us okay? Or Dr. Kendall, is it?

[Dr. Perry Kendall, Provincial Health Officer, Public Health, British Columbia Ministry of Health]

Yes, thank you.

And yes, it's Dr. Kendall.

[The Chair, Conservative, Rob Merrifield]

Okay. I didn't have that in front of me, but I'm glad you corrected me.

We have one other witness who is going to be joining us in a few minutes, but we'll start with you, Dr. Kendall.

There is a problem with some of our microphones, with an echo in the room. Dr. Kendall, could you say a few words to see whether you're coming through all right?

[Dr. Perry Kendall]

Sure.

I'm Dr. Perry Kendall and I'm the provincial health officer for the province of British Columbia.

[The Chair, Conservative, Rob Merrifield]

Okay, Dr. Kendall, we will give you the floor and we look forward to your presentation.

[Dr. Perry Kendall]

Thank you very much, Mr. Chair and honourable members of the committee.

I thank you for the opportunity to appear on the matter of amending section 34 through Bill C-42. I am the provincial health officer, so I'm the chief medical officer of health for the province of British Columbia. I'm here on behalf of not only myself but the three chief medical officers of health of the public health system for the health regions in British Columbia that have contiguous border crossings with the United States. They are Dr. John Blatherwick of Vancouver, Dr. Paul Hasselback of the Interior Health Authority, and Dr. Roland Guasparini of Fraser.

We want to speak on the matter of amending Bill C-42. I've read the transcripts from your last meeting and I understand the desire to increase security and provide security to Canadians from threats of communicable diseases being imported across the border. But I do not believe that a requirement to mandate an advance notice for land conveyances will actually add any modicum of additional security to the system we have. It will perhaps give the appearance of increased diligence, but it has the potential to divert public health resources away from other tasks they would be doing.

What I think is needed to enhance the general security for public health for importing public diseases is a better and increased public health surge capacity within provinces and territories, and the completion of the build of electronic health records and the communicable disease surveillance system that is currently being developed. I say this because, in all honesty, looking at SARS and our experience with imported diseases, we're most likely to recognize or need to recognize imported illnesses or new illnesses in emergency rooms or hospitals. The chance of picking something up at the border is infinitesimally small.

So our effective public health response is going to require rapid recognition and diagnosis, and then response and referral to an active public health system that can do the necessary contact tracing for persons who have been exposed, so they can be isolated or cases can be quarantined. Despite intensive surveillance for SARS during the period we had SARS, no SARS cases were effectively detected via airport or port surveillance.

I think the historical rationale for quarantine on ships worked because the trip travel time was much longer than the incubation period of any of the diseases we were concerned about. I think this is more dubious for air transport travel time because it is often shorter than most of the incubation periods of the diseases we are concerned about. The chances of somebody actually developing an illness and being clinically diagnosable while on an airplane is relatively small. That is why we pick people up before they get on the plane and stop them from getting on, or pick them up several days after they've landed when they've presented at hospitals.

I worry about the requirement for adverse notification of people who might be symptomatic, particularly in wintertime. I'm concerned that reports of influenza-like illnesses, bronchitis, coughs, fevers, etc., would put so much noise into the system that we'd divert resources away to look for this and wouldn't pick up any of the signals of real illness.

That's essentially a summary of the position or advice I might give or ask this committee to consider. I believe you may have received a couple of letters to that same effect from my colleagues who are medical officers of health.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Now we'll hear from our second witness today. From the Institut national de santé publique du Québec, we have Monique Douville-Fradet.

Thank you for presenting before the committee. The floor is yours.

[Dr. Monique Douville-Fradet, Medical Consultant, Biological, Environmental and Occupational Hazards Directorate, Institut national de santé publique du Québec]

If you don't mind, I will be speaking in French, but I may answer questions in English afterwards.

I have prepared some notes and they are available to you. Maybe you have them already or will have them.

[The Chair, Conservative, Rob Merrifield]

Just for the committee, they're only in French. We don't have them translated so they're not in front of us, but that's okay. We'll follow along.

[Dr. Monique Douville-Fradet]

Okay.

Your committee is currently studying Bill C-42, an Act to amend the Quarantine Act, in order to make it consistent with the International Health Regulations which will soon come into effect. There is some question as to the government's intention in correcting the problems posed by the wording of section 34 of the Quarantine Act, which has to do with the obligation of conveyance operators to report the death or illness of a passenger when they cross the border. I will not read this section to you, but we may refer to it if necessary.

The Institut national de santé publique du Québec, whose mandate includes support to public health decision-makers, was asked to appear before you in order to give an opinion on Bill C-42, particularly on the relevance of reporting to someone as quickly as possible and whether or not to include land conveyances in this reporting requirement, in the same way as buses and trains. I will therefore give you the opinion of the Institut national de santé publique du Québec.

I would like to say that I am a medical examiner at the Institut national de santé publique du Québec. I am also a medical public health specialist and I work on the monitoring and control of infectious diseases.

We would like the reporting to be done as soon as possible through an intermediary, to quarantine officers, before the vehicle arrives at its destination. We believe it would be judicious to report any problematic situation as soon as possible, before arrival at destination, as that would perhaps allow us to advise on the measures taken onboard in order to minimize transmission, where that is possible, and to be able to properly prepare for arrival. It is particularly in this regard that we know improvements can be made.

As for the limitation on the kinds of conveyances described, I know that an amendment proposed to replace the words "all conveyances" with the words "air and watercraft... and prescribed conveyances". The intent was therefore to exclude land conveyances such as buses and trains. As a result, when we talk about buses and trains, we are only referring to cross-border traffic of conveyances coming from Canada and the United States.

We believe that the obligation to report should extend to all commercial vehicles, insofar as this is possible. I will expand somewhat on this subject—because we went a little bit further in our opinion that we submitted to you—I'm talking to you about the relevancy of having quarantine services at Canada/U.S. border crossings. If they are offered onboard aircraft and in trains, must they absolutely also be operated at border crossings?

First of all, I would reiterate what my colleague Perry Kendall said concerning the assessment of the risk of transmission of a targeted disease in Canada, coming from the United States. You must understand that the wording of the Quarantine Act is not very clear as to the kinds of problems it is targeting. It concerns the reporting on any reasonable grounds the operator may have that a person, merchandise or other things onboard a conveyance might risk spreading a communicable disease that is listed in the schedule, that a person onboard is deceased or that some other circumstance provided for in the regulations exists. In my opinion, this is not very clear.

Schedule 2 of the International Health Regulations is a bit more specific as to the kinds of issues that must be studied. I therefore included this schedule in the document, so that what we are talking about is very clear. Even if you do not have it before you, I will discuss these diseases. You will therefore be better able to follow.

In fact, these would be reportable diseases in every jurisdiction of North America. Among the diseases listed in this schedule, some, like smallpox, polio, avian flu—it says "pandemic" in my notes, but it should say "avian"—cholera, pneumonic plague, yellow fever, hemorrhagic fever, do not pose a major risk. This is because in most cases, the transmission of these diseases is extremely rare if non-existent in North America, given that the absence of causal agents or the public health measures that are already in place. We cannot imagine that this could happen in that way here at home.

Other diseases identified in the regulations are rarely seen, even though they do exist in North America and are susceptible to transmission. Public health authorities in Canada and the United States are well trained to diagnose and deal with these cases, as well with contact with meningococcemia, for example, which we discuss in the document. West Nile virus is not transmitted from human to human. It is only transmitted through contact with the blood or organs of an infected individual or through breast milk, which is not what we are discussing here.

Finally, there may be new entities with a highly contagious potential that could emerge and be added to the list. I am sure that the diseases that are of the most concern are no doubt those that are transmitted by respiratory route, and given the high level of transmission by respiratory route, these are probably the diseases that would most likely be added to the list we are discussing. We must understand that the severe acute respiratory syndrome, or SARS episode, and the efforts that are currently under way to prepare Canada for a potential influenza epidemic, have allowed for greatly improved monitoring of these entities. There are many monitoring mechanisms that have been put into place for severe acute respiratory diseases, both in the United States and in Canada. In English we call them

SRI, severe respiratory infections.

Were a patient presenting such symptoms to arrive at a hospital emergency room, the patient would be isolated and public health authorities would be contacted within minutes.

I would now like to talk about our ability to detect and deal with these problems. In order for such a health problem to be detected, one needs to have a sufficient length of time for observation—I would refer you to Dr. Kendall's comments on this issue—and the clear presence of evocative clinical symptoms. The kinds of symptoms one would look for would be fever, difficulty breathing, persistent diarrhea and others. It seems to us that these symptoms are not very specific, which means that one could not identify a potentially contagious disease of such seriousness at the outset that would justify in and of itself having quarantine officers present at every border crossing. You must understand that these are very common symptoms. Dr. Kendall talked about seasonal flu, for example, etc., and that is indeed the case.

Furthermore, it is quite unlikely that a person who is already in such a precarious state would be able to board a conveyance unnoticed. When it is obvious that the state of a passenger is rapidly declining, the vehicle would likely be stopped and transportation to the nearest hospital organized. Given the non-specificity of the symptoms and the available diagnostic abilities, the intervention of quarantine officers is therefore limited, especially since these services are located at many border points of entry. In most cases, a medical diagnosis will be necessary, which makes the transfer of the patients to specialized facilities mandatory.

We have a proven safety net. The illnesses that are of concern to us are already reportable diseases and Canadian medical authorities are well aware of the need to alert the public health authorities, as quickly as possible, of any suspicion of this kind of health problem. In fact, an on-call system covers all public health emergencies 24 hours a day. The system exists at the national level as well as in each of the provinces and territories.

You may have the impression that I was listening to yesterday's news, but I wrote my text well before that. In fact, it does sometimes happen that a person suffering from meningitis or with an acute case of tuberculosis has significant contacts, for example with passengers in an aircraft. When the case is diagnosed at emergency, it is immediately reported to public health authorities. The significant contacts are identified, found, and prophylactic medication is prescribed to them in order to stop any transmission. The cases may be referred to the interprovincial level and from Canada to the United States, or even elsewhere in the world. The Enhanced Severe Respiratory Illness Surveillance Plan represents another bulwark against the transmission of an emerging respiratory disease.

Quarantine officers are placed at border points that appear the most important to us, that is to say airports and ports that could be receiving international passengers coming directly from points of departure outside of North America. It seems a judicious choice to us, given the more obvious risk of presence of this type of communicable diseases, of the significant volume of travellers coming directly from countries at risk and the capacity for the development of an epidemic situation over the course of a long voyage, for example on a ship.

The situation does not seem comparable to us in the case of land conveyances, given the nature of the risk posed by those passengers and the shorter exposure time. These would be very costly measures that would produce very modest benefits, particularly, as is the case here, when the risk is minimal.

In conclusion, we can only support rapid reporting of health problems that arise aboard commercial conveyances, whatever the kind of vehicle, but only where this is possible. Such a measure could allow for a minimization of the spread and for the organization of case management services. The risk of the spread of disease that concerns us exists when an individual crosses an intercontinental border. This is however very rare. The risks of transmission are even smaller when we are talking about a Canada/U.S. border crossing. The quarantine services' ability to detect and manage the case is limited.

The setting up of quarantine services at all border crossings does not seem justified to us, given the rarity of significant cases, the multitude of border crossings that would have to be covered, and the ability to detect and handle these cases and the costs this would incur. There is a 24-hour public health on-call service that is available across Canada and the United States that can respond to this rare demand. The setting up of a communications mechanism between the public transportation authorities and Canadian emergency services would allow the authorities to have access to this on-call system should it be necessary.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your presentation.

We'll now open it up to questioning. We'll start with Ms. Bonnie Brown.

[Bonnie Brown, Liberal, Oakville, ON]

Thank you, Mr. Chair.

Welcome to the witnesses. Thank you for your presentations.

Dr. Kendall, you said, I think, that you were not in favour of quarantine officers for land crossings. And you said, I think, that in the case of SARS, even our efforts at airports were rather fruitless and that therefore, probably based upon the incubation period of some of these diseases, the only serious attempt could be made as people come off ships.

Is that right? Is that more or less what you said?

[Dr. Perry Kendall]

No. Let me clarify. I am in favour of quarantine officers at crossing points, because I understand that the international regulations, as proposed, would have a land-based conveyance report somebody who was sick at the border, if they still had that sick person on board—if they hadn't off-loaded them to a hospital, which I hope they would have done. I support quarantine officers at airports and at ships as well.

My point was that, given the length of incubation periods of many of these diseases, you'll probably only get the disease manifesting itself on board a ship, because of the time the ship is in transit. The chances of somebody developing an illness in the 12 hours that they might be on a airplane, and developing symptoms to the point where they become symptomatic and obvious, is somewhat limited.

Our efforts at detecting people with increased temperatures at airports in Vancouver during SARS, where we had thermal scanners at every airport, didn't pick up a single case of serious illness. They may have picked up a number of people with slightly elevated temperatures, but not a single case of SARS was prevented from entering the country by means of that screening mechanism.

[Bonnie Brown, Liberal, Oakville, ON]

So now I'm hearing you say you are in favour of quarantine officers in all three ways of conveyance bringing people into the country?

[Dr. Perry Kendall]

Yes, my understanding is that what we were actually discussing was the requirement for land conveyances crossing the borders to report in advance people who were being transported who may have symptomology of illness, and this is the proposed amendment. My understanding was to remove that to bring the Quarantine Act into consistency with the international regulations, where the advance requirement is just for marine or air transport, which I think makes a lot more sense.

[Bonnie Brown, Liberal, Oakville, ON]

But in saying that, you just said a minute ago that you thought it was a good idea to have a quarantine officer at these border crossings. You just don't think the bus driver should have to phone ahead.

[Dr. Perry Kendall]

That's right.

I'm not sure how many quarantine officers we're talking about here. I was more concerned with the issue of the prior notification of potential illness, which I saw as being of little functional utility in terms of actually identifying serious illness or keeping serious illness out of the country--

[Bonnie Brown, Liberal, Oakville, ON]

Dr. Kendall, I'm sorry, if we didn't have a quarantine officer at each land crossing...and some of these land crossings are grouped, if you think in terms of Fort Erie, Niagara Falls, Detroit, etc.; some of them are fairly close together. But with an advance call, we might be able to get a quarantine officer to that crossing prior to the vehicle that is carrying the sick person coming in.

I think that's more what we had in mind. We didn't have in mind an officer at each crossing. That obviously would be tremendously expensive. It seems to me that the advance warning actually saves the need for that.

[Dr. Perry Kendall]

It might. You would have to weigh the probability of actually picking up a serious illness and keeping it out of Canada against the inconvenience to passengers in buses and trains who were forced to wait periods of time while the quarantine officers were brought in, and then the cost of moving quarantine officers to the border crossing where somebody was coming in. So it's the feasibility of this.

It's feasible, but I'm not sure you're going to get any benefit from it. That is the point I was trying to make.

[Bonnie Brown, Liberal, Oakville, ON]

One of the suggestions we were given by the officials who were suggesting that this was the way to go--that is, to take land conveyances out of the bill--was that Americans, people from the United States, for the most part have similar health status to Canadians, and that the real threat comes from third world countries; for example, the SARS infection.

But we've just had a case in the news in the last 24 hours where the person who was putting others at risk was actually an American who was carrying a disease that was not normally thought of as something you would expect to come from the United States. He in fact was told by his doctor not to travel. He travelled anyway, got the results of his earlier tests while he was abroad, knew he would not be accepted into the United States because he was immediately put on the no-fly list, and flew to Canada instead in order to rent a car and drive home.

So it seems to me that this serendipitous--in my view--case, for our purposes, has proven that you can't name which country these germs are going to come from. They could come from anywhere.

[Dr. Perry Kendall]

Yes, indeed they could, and I think it makes the point that was being made by the doctor from the INSPQ: that our system can track people even if they're asymptomatic. This gentlemen was not coughing. He was presenting a relatively low risk, even though he had a very serious organism. In fact, he was sputum negative on the culture. He wasn't symptomatic, so no symptom watch on an airplane or a boat or a land conveyance would have picked him up in any case. He was picked up because of a good diagnostic surveillance system and good communications, and the keeping of records.

[Bonnie Brown, Liberal, Oakville, ON]

Both of our witnesses, Mr. Chair, have said that it's better to detect these illnesses before someone is allowed to embark, and indeed, this particular man who's been in the news in the last 24 hours had been to the doctor, had been tested, and had been told not to fly. What do you think we can do about those kinds of situations?

[The Chair, Conservative, Rob Merrifield]

Mr. Kendall.

[Dr. Perry Kendall]

Sorry. Were you asking me that question?

[Bonnie Brown, Liberal, Oakville, ON]

Maybe Dr. Douville-Fradet might answer.