Health Committee on Oct. 19th, 2009

[The Chair, Conservative, Joy Smith]

Good afternoon, everybody.

Welcome, Dr. Martin. It's nice to see you sitting on our committee. It's a pleasure to have you here.

Welcome to our witnesses today. We are so pleased you could come to committee to give us some insight into community preparedness for H1N1. We've been studying it extensively, so we're glad to have a new perspective today.

I'm going to ask each organization to have a person give a 10-minute presentation. If you want to share, that's just fine too. I tend to have a little leverage on that to make sure you get to say everything you want. Following that, we'll have two rounds. If you have two people presenting, each will have five minutes. So guard your time accordingly.

Right now we're going to start with your presentations, then we will have a seven-minute question and answer round.

We'll start with Dr. Anand Kumar. I would very much like you to present, Doctor, and welcome.

[Dr. Anand Kumar, Doctor, As an Individual]

Thank you for the invitation to be here today.

My name is Anand Kumar. By way of background, you should know that I have some unusual qualifications to speak to you on the subject of the threat of pandemic H1N1 today. I'm an academic intensive care specialist from the University of Manitoba. I'm one of about 12 physicians in Canada trained in both critical care medicine and infectious diseases.

As you all know, Canada is in the midst of a major H1N1 influenza epidemic that represents the leading edge of the first influenza pandemic in over 40 years. During the first wave during the spring outbreak in Manitoba, over 50 mostly young, relatively healthy patients with H1N1 influenza were admitted to the ICUs of Winnipeg with severe viral pneumonia complicated by an exceptional degree of lung injury, kidney failure, and occasionally shock. All were at immediate risk of death, and eight died--that's about 20%.

The strain on ICU and hospital resources during the epidemic was severe. I know this because I was there and, along with several of my colleagues, treated many of the patients stricken during the most severe portion of their illnesses. There is an appropriate concern that the Manitoba epidemic was simply a harbinger of a larger pandemic that we're beginning to see this fall.

The experience of the Manitoba spring outbreak and the subsequent smaller outbreaks across the country during the summer may provide important lessons for the Canadian response to the H1N1 threat going forward. Among the key observations is that relatively healthy adolescents and adults, particularly women, are the primary groups at risk for severe illness and death, which is a tremendously unusual pattern of illness.

In addition, first nations communities, the obese, and pregnant women are at especially high risk. Further experience to date suggests a remarkable degree of illness associated with severe H1N1 infection and an astonishing requirement for ICU resources to support such patients. These observations by me and my colleagues in the Canadian Critical Care Trials Group were published just last week in the Journal of the American Medical Association.

The price for the earliest of these lessons was paid by the citizens of Manitoba, from the severe illnesses and deaths in both Manitoba first nation and non-aboriginal populations to the exceptional strain on our health care workers during the epidemic. Their losses and sacrifices should be acknowledged. In addition, I want to make particular note of the leadership of Brian Postl and Dan Roberts of the Winnipeg Regional Health Authority; the tremendous effort and resilience of ICU and ER nursing and support staff at all of the WRHA hospitals, particularly the Health Sciences Centre and St. Boniface hospital; and the professionalism and dedication of our intensive care and emergency room physicians. I've been honoured to work alongside all of them.

The boundless efforts of my colleagues, particularly Rob Fowler in the Canadian Critical Care Trials Group, should also be noted. Dr. Fowler's foresight and the dedicated efforts of group members are responsible for the collection of tremendous amounts of critical data on the national spread of the spring/summer outbreak. The data the group collected, at their own expense and without any immediate external financial support, has been crucial in formulating our national H1N1 response strategy, from identifying groups at highest risk for early intervention to determining optimal medical therapy for the most severely ill subset of patients.

The efforts of the Public Health Agency of Canada and the scientists of the National Microbiology Laboratory of Canada, headed by Frank Plummer, should be lauded. As the magnitude of the local threat became apparent, they quickly offered their resources and support without precondition. This allowed us to collect important biological samples for analysis early in the epidemic to help determine ideal diagnostic and therapeutic management strategies. Their support has also been crucial in forging relationships between industry, academia, and government, which are leading to the improvement of standard therapies and the development of novel treatments rapidly enough to make a difference to the patients we will see in the weeks and months ahead. Further, the Public Health Agency and NML quickly arranged a national conference of ICU specialists, public health professionals, and other stakeholders to share information about the pandemic H1N1 risk.

Although much has been learned and substantial progress has been made, significant risks remain. Prime among those risks is the persistent skepticism among the public about the utility and safety of vaccination. The potential benefit of influenza vaccination will never be greater than it is this year. Normally the very old and debilitated are the major victims of influenza. This year its victims will look much like the people in this room and like our children. It is imperative that we find a way to transmit to the public the importance of vaccination, which is the single most effective way of limiting potential damage from pandemic influenza. In addition, although ICU resources have been supplemented, we need to remain vigilant in certain areas, particularly in nurse staffing, where systems stresses may be acute in the months ahead.

There is also an immediate need for increased applied research funding on this epidemic. Funds were recently allocated for influenza research. That's a good thing, but a casual perusal of funded projects suggests that most will yield dividends years in the future. The gun is at our collective heads right now, and we should consider additional funds to answer key questions that will inform our management of patients immediately.

l'd be happy to take any questions.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Kumar.

You and I are both from Winnipeg, and I'm very aware of the excellent work the doctors, the nurses, and the staff at St. Boniface hospital and the Health Sciences Centre did on that issue of the pandemic. We're following it very closely and are very happy you could make it here today.

We'll continue now with the Canadian Healthcare Association and Denise Desautels, their director of policy and communications; and Pamela Fralick, president and chief executive officer.

Please go ahead, Pamela. Thank you.

[Pamela Fralick, President and Chief Executive Officer, Canadian Healthcare Association]

Thank you, Madam Chair.

Thank you very much to all of the committee members for the opportunity to speak with you.

Frankly, I'm not sure I can say anything today you haven't already heard. That being said, given the opportunity, I'll certainly underline some of the key issues. My presentation will be moving very much from the front lines to the systems issues, so it will likely be a different perspective for you.

I am going to assume that most around this table do know that the Canadian Healthcare Association is a federation of provincial and territorial hospital and health organizations. We really do represent a very broad continuum of health in this country.

I have to tell you that the members of CHA are, in general, very satisfied with the treatment of the issue thus far and are certainly in agreement with the Public Health Agency of Canada's management of this file. We know there have been glitches along the way and that there are still issues to be dealt with, but I did want to pass on that message from our members.

That being said, there are seven points that I think you should hear about today, which I'll make fairly quickly to leave lots of time for questions.

One goes without saying, and that is the importance of an evidence-based approach in everything we do. It does speak to an issue just raised about getting the public's confidence. We recognize that we cannot truly predict the full severity and impact of a potential outbreak, but it's very important that all of us, including our media stakeholders, are sensitive to the negative effect of fear on both the general public and the professional health system community. Therefore, it's critical that we make sure the decisions reached and strategies implemented are evidence-based as much as we can and that we accept scientific guidelines as credible and legitimate.

Perhaps one of our most important points has been addressed by Dr. Kumar, and that is the role of prevention. We know that current data suggest that only about 35% of Canadians at large will take advantage of immunization. We also know that many health care workers haven't been taking advantage of the seasonal flu vaccination; there's only about a 40% to 60% compliance rate among them. So programs and approaches must be put in place to promote or encourage all Canadians, including health care staff, to be vaccinated against H1N1. We have to convey with great confidence that evidence supports mass inoculation and collectively encourage Canadians to subscribe to this approach.

While Dr. Kumar was speaking, I found myself wondering whether having this entire committee receive their vaccinations on national TV might be a good way of instilling confidence, showing all-party support for an initiative. But I'll leave that with you for in camera discussion.

[The Chair, Conservative, Joy Smith]

Well, I would have to consult with Monsieur Dufour to see if he likes needles, before we could agree.

[Pamela Fralick]

I will leave that to your in camera discussions.

A third point I wanted to mention--again, I'm sure this is not new to you--is the communication issue and the need for consistency of messages. We feel strongly that there does need to be a sole source of communications. Messaging has been coming from federal, provincial, and local levels. They need to come more quickly and they do need to be consistent.

We do respect the right of every jurisdiction to shape their own communications in every health delivery issue, but right now we feel that the right of Canadians to receive clear, consistent messaging should override any other needs. We do feel that there's a situation where many players feel the need to say something about this, and say it in their own language. For the average Canadian, that's simply not acceptable at this point in time.

There also are communication gaps at the community level. I'll combine two points: a great deal of the focus has been on the acute care setting, and for obvious reasons, but we know from all of the information provided from the specialists that this is a community-based issue. The information is not being conveyed appropriately to health professionals in that particular setting.

Another area of consideration, because we do try to bring forward information on solutions and not just problems, is that the health professional associations are a tremendous source of information sharing. They have not been utilized. We've been trying for years to have greater utilization of the health professions.

For example, many of you know about the Health Action Lobby, HEAL, which has been around for many years, a coalition of 38 national health associations. It's a naturally built community, if you will, to get information directly in the hands of every health provider, which can only consolidate and strengthen the information being received from other sources. So I would put that forward.

Clearly the need for sufficient staff to care for the anticipated ill patients is a great concern. We're concerned about the coordinating piece of it. I would put a few words on the table, such as labour mobility, AIT, and licensing issues, which I know we've tried to address since SARS hit, but I'm not quite sure how well they have been addressed, even with all provinces signing on to AIT. Are there implementation processes in place so that if the crisis situations are not in the entire country at one time, but are at different times in different parts of the country, we can share human resources to help and address the staff shortage that we absolutely anticipate?

The education of health professionals is perhaps the final point that I'll bring forward. These are folks who will be administering the vaccine. They do require specific information on the safety and the risk of the vaccine.

I might also highlight what might seem a minor issue: expiry dates on the various drugs and the vaccinations. We know that the dates provided are the best possible dates, but we also know that many medications are valid beyond that day. So if supplies are in short supply and great demand, how do we find out which ones can in fact be used safely and effectively beyond the expiry date that is given? It's perhaps a minor problem, but it could be a big part of a solution if we find ourselves in a great shortage.

There are a number of other issues that we won't go into detail on at the moment. Perhaps they will come out in conversation. These include the psychological and ethical sides that arise in situations of resource allocation, and the tough decisions that need to be made. We feel that these have not yet been addressed in the face of just the basic logistics of getting vaccination out.

We do recognize that dealing with this unfolding situation is no easy task for all of us. We do welcome this opportunity to further the dialogue and work on solutions with everyone who's part of this committee, and we look forward to taking part in the discussion after the presentations.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Ms. Debra Lynkowski.

[Debra Lynkowski, Chief Executive Officer, Canadian Public Health Association]

Thank you so much for this opportunity to appear before you. We had hoped to have Dr. Cordell Neudorf, who is our chair, and he's also a medical officer of health from Saskatoon region, but he wasn't able to be here today. I solicited some feedback from people who are on the ground who are dealing with this, as Dr. Kumar is as well.

In general from CPHA's perspective, we feel that much has been learned from previous public health emergencies. Thanks to the leadership of the Public Health Agency of Canada and our chief public health officer, we feel there have been dramatic improvements this time around. The level of coordination and communication and cooperation between the federal agencies and the provinces and territories has been quite exemplary when you compare it to something like SARS. We're seeing similar leadership at the provincial-territorial levels and at the local levels as well.

All that said, we do know we are dealing with a unique situation, and we're trying to respond to the spread of the virus in real time. I think that is what makes this so challenging. It's a bit like the canary in the mine shaft with SARS, and now with H1N1. It points to the vulnerabilities in our public health system and in our acute care system as well. I wanted to talk to you a little bit today about the observations from the ground from a public health perspective in terms of what we feel is working and where we anticipate challenges.

In general, I think the sense is that there is an overall plan, and people feel that plan is working well and is evolving. I think everyone understands it has to evolve because of the fact that this is complex and that, really, within a six-month period we have gone from identification of a virus to a vaccine, to full immunization campaigns, so it's quite remarkable.

The public health surveillance systems are working well and they're tracking the disease. Public health laboratories, as mentioned by Dr. Kumar, are doing exceptionally well. The development of provincial networks, and in particular new public health agencies.... B.C. isn't so new, but B.C., Quebec, and Ontario have made a real difference in terms of how we're able to respond this time around. The new pan-Canadian public health network has really given us an opportunity to have that ongoing dialogue and coordination, and it has allowed for more standardized responses, which has been very important.

Finally, most of you have probably seen the recent release of the preparedness guide. We're very pleased that the information to the public that is available now is very accurate and accessible.

We anticipate there will be challenges, and one of them probably isn't new to this committee. Public health in Canada continues to be chronically underfunded and under-resourced. There are many different figures, but what I do know for a fact is that it's between 4% to 6% of all health spending. When you look at that in terms of being able to mount a response, there are limitations. Most public health units today don't even have the resources to implement best practices in general, so it's very difficult to then add a pandemic into the mix. We're less than two weeks away from beginning the largest immunization campaign in decades, and what we're looking at is two to three times more doses than we would in a normal campaign. All of this is happening in a system that is, quite frankly, stretched to capacity, and all of it without any additional resources.

There's an implication and a cost to this. At a local level, public health is having to defer, cancel, or scale back on most other services for a one- to two-month period to mount this campaign. What does that mean to Canadians? Past experience shows us there may be a cohort of children who never catch up on their regular immunizations, mothers who don't get visited, and quite frankly, inspections that won't get done. Surge capacity simply doesn't exist in public health. As I've been told by my colleagues on the ground, we can't have two public health crises at a time; we couldn't deal with them.

We anticipate there will be information challenges for general practitioners, primarily physicians and acute care practitioners, because while there are public health networks that are well connected, acute care networks that are well connected, they aren't necessarily well connected to one another.

Another challenge would be to make sure we have the best information on the vaccine, because what you're dealing with are practitioners who then have to translate that science into clear accessible advice for their patients.

Most importantly, I think, given what Ms. Fralick just said as well, public health can't be reduced to sound bites, and that's what we've been trying to do lately, catch these sound bites and put them in the media, and it just doesn't work. It's far too complex. As someone told me, public health is just as much of an art as it is a science.

So while we do know that there will be differences in approach among provinces and territories, it is becoming increasingly confusing for the public, and we all have a responsibility to ensure that the best evidence-based recommendations are out there and are consistently promoted.

In closing, I just want to say I realize that this committee wants to know what's happening today and wants to know what we can do today, but we also need to look to the future. We need to have a long-term vision for public health. I urge you, in the context of your deliberations about the present, to look to the future.

Both CPHA and the Canadian Coalition for Public Health in the 21st Century--and Pamela Fralick and I co-chair that group--have made a series of recommendations, most recently in a backgrounder that was sent to all members of Parliament, but also in pre-budget consultation briefs. I won't go into that now. We have those documents available, and Christine, we can get them to you as soon as possible.

I think what's important to remember is that public health always operates under the radar. My famous line is that I want my family to understand what I do, because no one understands what public health is. It tends to operate under the radar, and we take all of our public health successes for granted. We have clean, safe drinking water and we don't wonder how that is. We prevent injuries by seat belt and workplace legislation, and we don't think about that. We think about it only when there's a crisis, and Walkerton, SARS, and H1N1 are perfect examples. So we need to use this current experience to inform the future. If we deal only with this issue at hand, we will invite another crisis in the future.

To bring us back to today, I actually want to reiterate what Ms. Fralick said. The two most important things that you can do as committee members today to support this national response to H1N1 is get your H1N1 immunization, do it publicly, and encourage your friends, families, and colleagues to do the same.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you very much for your presentation.

I just want to say, before we go into the rounds, that we will be going into committee business at five o'clock. So we will have questions and answers for the next hour and ten minutes, and then we'll do our committee business.

We will start with Dr. Duncan.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you, Madam Chair.

You've all raised such important issues. I think I'm going to start with surge capacity, though.

Dr. Kumar, I know you treated many people from the aboriginal community in the spring and summer. What was the average time for treatment in Winnipeg, and what was done prior to treatment?

[Dr. Anand Kumar]

Do you mean time presenting to the hospital or getting medical care?

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Yes.

[Dr. Anand Kumar]

I was going to say I have data only on ICU patients, but I actually have data on everybody who presented to either the emergency room, the hospital, or the ICU. One of the things we found was that the speed with which you go from symptom onset to therapy--which is the time that you present to the physician or the emergency room--actually has a direct bearing on how severe your disease gets.

So what we found was that among those who died, the median time delay was approximately eight or nine days. Among those who were admitted to the ICU but didn't die, it was approximately seven days. Among those who were hospitalized, it was about five days, and among those who came to the emergency room but were never hospitalized, it was just three days. So there's a fairly strong correlation between the severity of the disease you have and how quickly you present for medical care.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

If people travelled from aboriginal communities, did they get antivirals in their community? What was the time from presentation of symptoms to getting the antiviral drug, and did that impact outcome?

[Dr. Anand Kumar]

I have no doubt that impacted outcome. You know, you never expect a pandemic to occur in your backyard, so there was a lot of uncertainty and a lot of confusion, let's say, early on in terms of exactly what was happening. Quite frankly, the advice we were getting from various sources was predicated on ambulatory patients, patients who were not that critically ill. Initially, the advice we got was that for people who were presenting like this, first, we should wait for confirmation of the H1N1 test, or influenza at least, and that took three days because we were testing only twice a week. There are all sorts of reasons that there were delays. Because our aboriginal communities were first hit, they bore the brunt of the lack of knowledge, basically, so the delays in their community were quite long, in the order of, I think, seven or eight days.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Does the chance of recovery really drop after 48 hours in terms of the antivirals?

[Dr. Anand Kumar]

No. I think there has been some misinterpretation of what the 48-hour rule should be. We always talk about evidence-based medicine, but what we don't recognize is that if the group you studied isn't the group you're treating, there is no evidence, basically.

What we found, and what we know, is that if you have mild disease and you get antiviral therapy within 48 hours of the onset of symptoms, you have about one day less of symptoms before you get better.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

What about severe disease?

[Dr. Anand Kumar]

Exactly. Initially they said to us, quite frankly, that if they've had symptoms for more 48 hours, don't bother treating. Unfortunately, some of our physicians took that to apply even to ICU cases. The fact of the matter is that if you are severely ill, getting treated at any point is better than not being treated at all.

There have been many other fallacies we were told in terms of the accepted wisdom. We've had to kind of reinvent things and re-examine them as time has gone on. I think part of the reason we're doing better nationally is that we have re-examined all the accepted wisdom, basically.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

One of the things going forward, even with severe disease, is to get the antiviral.

[Dr. Anand Kumar]

Oh, without question, if you have severe disease that requires ICU care, even if you're four, five, or six days out, you want to have antivirals administered.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

That's what I wanted to hear. Thank you.

I'd like to know at what capacity you were operating during the spring and summer and what the impact of flu was on your staff, supplies, ICUs, and ventilators. Are we still looking at 25% to 35% of the population impacted, with about 1% of people suffering severe disease? And if 1% suffers severe disease, what does that mean in numbers in Manitoba? Can you meet the ICU and ventilator demand? If there's difficulty, how do you make those tough decisions?

[Dr. Anand Kumar]

Well, there are a lot of questions there.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Yes, there are.

[Dr. Anand Kumar]

The current projections for potential attack rate, quite frankly, have varied quite a bit. We've done some mathematical modelling. We think that the ultimate attack rate in this wave of the epidemic, population-wise, would be somewhere between 25% and 30%; that is, 25% to 30% of the population will get hit, basically, this fall, assuming that the vaccine isn't out there. That's on the low end of pandemic attack rates, basically. Pandemic attack rates historically have been between 25% and 40%. So you can figure that a good portion of the population is going to be hit.

Now, I think the key question is this: what percentage of those people will become critically ill or ill enough to be in hospital? The numbers and the projections on that, quite frankly, are all over the place. I don't think anybody is really certain. Initially we were talking about one in 250, which is a number that has been used in seasonal influenza. My estimate is that the number has gone down fairly substantially. I suspect that it's on the order of one in 1,000, or less.

Again, we have some data we've recently submitted to the CMAJ. By the way, the data I gave you just a moment ago on the time to antivirals was developed by Ryan Zarychanski, one of my colleagues.

We've developed some data that looked at a dynamic model of the number of cases we might see, assuming that the vaccine was not aggressively deployed. We thought we might see as many as somewhere in the ballpark of 1,500 to 2,500 cases simultaneously across the country. That's more or less a worst-case scenario, because we only have about 3,000 ICU beds--that's a ballpark figure--across the country.