Health Committee on Oct. 2nd, 2012

[The Chair, Conservative, Joy Smith]

Welcome to committee today. It's great to have you all back here, and great to start on our pandemic vaccine lists dialogue that we're going to have over the next couple of weeks.

Today we have video conferences.

From Yellowknife we have Dr. André Corriveau. Welcome, Dr. Corriveau. We're glad to have you with us.

Dr. Corriveau, can you hear me?

[Dr. André Corriveau, Provincial/Territorial Co-Chair, Public Health Network Council]

Yes, I can hear you fine. Thank you.

[The Chair, Conservative, Joy Smith]

Wonderful.

We also have from the Government of Nova Scotia, Dr. Robert Strang.

Dr. Strang, welcome.

Can you hear me, Dr. Strang?

[Dr. Robert Strang, Chief Medical Officer of Health, Department of Health and Wellness, Government of Nova Scotia]

I certainly can. Thank you very much.

[The Chair, Conservative, Joy Smith]

We have Dr. Plummer.

How are you? You're back in Winnipeg.

[Dr. Frank Plummer, Chief Science Officer, Scientific Director General, National Microbiology Laboratory, Public Health Agency of Canada]

I am. It's good to be here again.

[The Chair, Conservative, Joy Smith]

Great. Thank you for joining us, Dr. Plummer.

In person we have Dr. John Spika from the Public Health Agency of Canada.

We will begin with you, Dr. Spika, for a 10-minute presentation.

Welcome, and thank you for joining us.

[Dr. John Spika, Director General, Centre For Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada]

Good morning, everyone.

I am the director general of the Centre for Immunization and Respiratory Infectious Diseases at the Public Health Agency of Canada.

I played many roles during the time of the pandemic, as did the person who is accompanying me, Dr. Frank Plummer, who is the chief science adviser at the agency and also the director general of the National Microbiology Laboratory in Winnipeg.

We're here today to talk to you about the epidemiology of pandemic influenza and the role the agency plays in planning and preparing for a pandemic.

We will speak also about the way decisions were made about who was to be prioritized for vaccination and the moment and time that actually occurred. We'll talk at the end about some of the lessons we learned following the last pandemic and the go-forward in terms of our planning activities.

The federal government plays a leadership role in providing guidance to decision-makers to help inform response efforts. We work very closely with provinces and territories through the Pan-Canadian Public Health Network and the Council of Chief Medical Officers of Health. As has already been identified, Dr. Corriveau and Dr. Strang will be providing some information from their perspective as well.

I'll begin by explaining the importance of epidemiology in a pandemic.

People are exposed to different strains of influenza virus throughout their lives. The influenza viruses usually change, if only a little bit every year, and our immune systems adapt to these small changes, either as a result of vaccination or because we have what are generally mild infections. However, three to four times a century, the influenza virus undergoes a major change, causing a new strain to emerge for which humans may have no immunity. This is what leads to a pandemic, which generally causes a more severe disease than seasonal flu.

There were three influenza pandemics in the 20th century, one in 1918, one in 1957, and one in 1968. We've already had the first one in this century, in 2009. Each of these pandemics has differed markedly in severity, duration, and the populations most affected.

In 1918, for example, the Spanish flu was one of the deadliest, if not the deadliest, natural disasters in human history, in that it caused upwards of 50 million deaths. Some people have estimated that it may have actually caused 100 million deaths. Most of the victims were healthy young adults, in contrast to influenza outbreaks, which predominantly affect the young, the elderly, and persons with underlying chronic health conditions that put them at greater risk of severe disease.

The Hong Kong pandemic in 1968 caused an estimated one million deaths worldwide. In this case, it mostly affected the elderly, those 65 and older.

The virus responsible for the 2009 H1N1 pandemic was again different. This time, approximately 300,000 people globally died from the disease. Interestingly, many were younger people who were otherwise healthy.

You may recall that Canada played a leadership role in understanding and responding to the virus. Our laboratory and scientific expertise allowed the agency to decode the genetic makeup of the Mexican strain of the H1N1 flu virus.

The agency also assisted Mexico with diagnostic testing of clusters of severe respiratory disease in April 2009. Over 400 specimens from the ministry of health in Mexico were tested. Shortly thereafter, our National Microbiology Laboratory developed a test that allowed researchers to determine whether the strain of influenza involved was a common regular strain of seasonal flu or actually the new H1N1 virus.

The agency then, in collaboration with the provinces and territories, rolled out a national surveillance activity to track confirmed cases of the H1N1 virus in Canada.

At the same time, the agency was working with international partners. It sent officials, including epidemiologists and lab researchers, to Mexico to assist in the early investigation of the H1N1 outbreak. The investigations that were done there actually helped us a great deal in Canada, as well as other countries, in that we were able to better understand the transmissibility of the virus.

Our successful response to the H1N1 outbreak was, in great part, attributable to our advance planning. Canadian governments and public health organizations had been working together for many years to prepare for a pandemic. Canada was one of the first countries in the world to have a pandemic plan. Our first plan was actually developed in 1988.

The goals of pandemic preparedness and response in Canada have been, and continue to be, twofold: first, to minimize serious illness and overall deaths, and second, to minimize disruption to our daily lives.

The Canadian pandemic influenza plan for the health sector, which I will call the CPIP, maps out how the health sector can prepare for and respond to a pandemic influenza. It is a federal-provincial-territorial framework and the Public Health Agency of Canada is considered its custodian.

While the latest version was published in 2006 and consists of a main body and 16 annexes, it is important to note that a number of these annexes were updated in as late as 2009. These annexes address key aspects of the pandemic preparedness planning and response in greater detail and cover vaccines, antivirals, communications, and surveillance, among many other issues.

The 2006 CPIP was developed under the governance of the Pan-Canadian Public Health Network Council. It is the result of extensive federal-provincial-territorial dialogue and collaboration with a very wide group of stakeholders.

The CPIP is available on the Public Health Agency website. We have provided the link in the information note to committee members, as well as a copy of annex D from the pandemic plan, “Preparing for the Pandemic Vaccine Response”. That is actually dated September 2008 and was amended after the initial plan was published in 2006. This annex includes a prioritization framework that outlines the factors to be considered when developing priority access strategies, but it does not prioritize any group.

Population subgroups are identified within the vaccine annex. Under the subgroups entitled "key societal decision makers" and "pandemic societal responders", reference is made to fire chiefs and firefighters as examples of who would make up these groups.

As a pandemic is evolving, experts have to consider many factors in determining recommendations for priority access to vaccines. Factors include consideration of the severity and epidemiology of the pandemic, that is, who is most likely to be affected in terms of illness, complications, and death. Factors also include ensuring business and societal continuity and consideration of vaccine availability. In other words, during a pandemic, a risk management approach must be used to inform decisions. Guidance must allow for flexibility and latitude to enable jurisdictions to take into consideration their particular circumstances.

During the H1N1 outbreak, the epidemiology of the virus showed that some Canadians, that is, pregnant women, children less than five years of age, and people with underlying health conditions, were at higher risk of developing serious illness and death. It was those people and their caregivers who went to the top of the list when developing the pan-Canadian recommendations.

The list identified primary, secondary, and tertiary targets. Those who were at greatest risk were primary targets, along with their caregivers and health care workers. Secondary targets included firefighters; they were right behind those at most risk. That list, dated September 10, 2009, has also been provided to the committee members.

Taking into consideration the list and the rationale provided for priority access, provinces and territories then made their own decisions based on what was occurring in their particular jurisdictions.

Manitoba and Yukon chose to allow firefighters to be immunized within the first week of vaccination clinics. Others gave higher priority to vaccinating schoolchildren.

The 2009 pandemic was the first major public health event to test the CPIP and Canada's pandemic response generally. Reviews played an important role in paving the way to ensure that we are even better prepared the next time around. One of the reviews was undertaken by the Senate Standing Committee on Social Affairs, Science and Technology, at the request of the Minister of Health.

Overall, the Senate committee concluded that pandemic planning was successful. It did recommend that the agency collaborate with the provinces and territories on revisions to the CPIP that would allow for a more scalable response to address particular pandemic epidemiology. That way, the CPIP would more easily be adaptable to mild, moderate, and severe pandemics.

In this regard, the agency has been working with provinces and territories to review the CPIP and to revise it as required. This work is being conducted over a three-year period and will include consultations with all key stakeholders, including firefighters.

The revised CPIP will be tested on an ongoing basis to ensure that Canada maintains its ability to prepare for and respond to any emergencies that might threaten the health and safety of Canadians.

We continue to dialogue with the provinces, territories, and principal stakeholders, notably, the organizations that represent first responders, to enable us to prepare for a pandemic and to develop our activities in general that allow for a pandemic response.

I thank you for the opportunity to speak on the issue.

[The Chair, Conservative, Joy Smith]

Thank you.

We'll now go to Dr. André Corriveau of the Public Health Network Council.

[Dr. André Corriveau]

Thank you very much for inviting me to take part in this meeting. I will speak mainly in English.

Still, I want to emphasis that I am currently the co-chair of the Public Health Network Council of Canada. It is a mechanism we have to work together with the federal government, the provinces and territories on public health issues.

I should also mention that at the time of the pandemic, I was not the co-president; I was basically the chief medical officer for Alberta. I played a role in some of the working groups as part of the PHN Council and as one of the members.

I was involved in all aspects of the process. For example, I co-chaired one of the working groups, or expert groups, dealing with isolated and remote communities and how to modulate the response in those kinds of settings. That was one of the working groups that fed information to the pandemic coordination committee, which then advised the Public Health Network members, and ultimately, the Conference of Deputy Ministers of Health on the decisions that had to be made.

I don't really have a lot to add to what Dr. Spika said. Basically, even though the pandemic plan is designed to deal with pandemics in a generic way, we really rely on the epidemiology of each pandemic to ascertain what the response will have to look like in its fine details, including prioritization for immunization.

It was in the lessons learned during the first wave of the pandemic that the evidence started to emerge, as was mentioned by Dr. Spika, with regard to some particular groups that were at higher risk of severe illness. These included pregnant women, people with chronic medical conditions, some people living in aboriginal communities, and very young children. That provided the evidence for the expert group, which had been put in place to advise us on prioritization, to do its work over the summer and come up with the recommendations that Dr. Spika outlined.

I'm not going to add anything else at this point. I'll wait for questions that come up. I know that you have two other speakers who will provide additional details.

[The Chair, Conservative, Joy Smith]

We'll go to Dr. Robert Strang, chief medical officer at Nova Scotia's Department of Health and Wellness.

[Dr. Robert Strang]

Good morning, everybody. Thank you for this opportunity. I'll be brief.

As I think you've heard from others, if our primary goal of pandemic response is to minimize severe illness, then clearly determining the priority groups for who gets immunization needs to be based on the available epidemiologic evidence in that regard: who is at greatest risk of becoming severely ill.

It's also based on the understanding that an influenza pandemic and how we respond to it is an evolving event. At any given time during a response, our information will be incomplete, but we have to make decisions based on the best information available at the time and be able to review and adjust our decisions as more information on the pandemic unfolds.

This was the process that was used in developing priority groups during our response to H1N1, to facilitate a coordinated response when H1N1 first appeared in the spring of 2009. There were two existing FPT groups, which you've heard about: the Public Health Network Council and the Council of Chief Medical Officers of Health. They were combined to form the special advisory committee, or SAC. The two groups were brought together to allow us to be a bit more nimble in our response. We established some technical working groups reporting to us, and then we in turn reported to the Conference of Deputy Ministers of Health.

We did identify, as Dr. Spika has already noted, that as part of our pandemic response plan which we had in place, developing a prioritization list was one of the issues. That was referred to a working group. They did their work during the summer of 2009. They brought forward recommendations, based on existing epidemiological evidence, that were approved at the special advisory committee and then went up to the deputy ministers for further approval.

We had that prioritization list. When a vaccine shortage did occur at the end of October 2009, all the provincial and territorial jurisdictions and the federal government used that established prioritization list to phase in our immunization programs. The extent of the vaccine shortage required that we subdivide the first priority group. While we strove to have consistency through discussions at the SAC table, there were, as Dr. Corriveau has noted, some interjurisdictional differences in how we did that first subdivision.

We had a very evidence-based, epidemiologically driven process. That's the process we'll need to have in place for future pandemics. In Nova Scotia we did have firefighters on our list, and we went through three steps of phasing in different groups. We always considered firefighters, along with police, as to when we could offer them vaccine, knowing that there were other groups who were at greater risk from their work and at greater risk for severe disease. We were about to implement firefighters in our last phase-in when the shortage was relieved in late October and we were able to offer vaccine to all Nova Scotians.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Members of the committee, we will be having Dr. Brendan Hanley join us via video at around noon. He was unable to make it until then.

We'll be going into questions and answers shortly. I want to remind you that at 12:45 today, we will suspend to go in camera for a 15-minute business meeting at the end of the committee. Having said that, let's go into questions and answers, being mindful of the fact that at noon we'll interrupt that session to listen to Dr. Hanley.

We'll begin our seven-minute round with the NDP, starting with Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

It's good to be back at committee and getting back to our business.

Thank you to all of the witnesses for being here today, either by video conference or in person.

I know that previous standing committees on health had a lot of information on pandemics and what the government's response was. My former colleague, Judy Wasylycia-Leis, was the NDP health critic. There was very intense information given.

However, I think you should be aware that most of us are new to this committee, so we're a bit green on this issue. If some of my questions seem a bit naive or not very substantive, it's because I just don't have the background that some of our colleagues gained as a result of the events in 2009.

It sounds as though there's a good process in place. We have the Pan-Canadian Public Health Network Council and the Public Health Agency of Canada. It sounds as though things are very well established.

Who actually decides that there is a pandemic? At what point does it move from an epidemic—and I don't know if that's the right term—to a pandemic? What is the qualitative difference? Is it something that we ascribe to under the World Health Organization? Is there a definite line when it moves from one to the other? I'm curious to know what kickstarts that. When we reach that point, how quickly can decisions be made? You have a plan, but I assume you're getting information from local health authorities about cases. Again, what's that line that kicks it into something else?

Also, this committee is going to be looking at electronic health records during the coming months. I would imagine that a lot of what you are dealing with relies on recorded information and a database. I'm curious to know how well developed that is. Are you able to quickly assess that we've moved from one scenario to another scenario?

Those are the questions I have, and I'd invite all of the witnesses to respond.

[The Chair, Conservative, Joy Smith]

We will begin with Dr. Plummer. You were with us during the pandemic, Dr. Plummer. We worked very closely together during that time. Perhaps you could start off with how you know it's a pandemic.

[Dr. Frank Plummer]

Sure, I'd be glad to do that. Thanks for the question.

I think Dr. Spika is probably in a better position to speak to some of these questions.

An epidemic is an increase in the number of cases of a given illness in a particular location. We call it a pandemic when it's pretty much global in nature, when the epidemic is occurring everywhere. That's the basic difference in terms of epidemiologic definitions.

The connotation of the word “pandemic” has come to mean a very severe influenza outbreak, as in 1918, but that is not really the definition of what a pandemic is. It doesn't necessarily have to be severe. To my mind, that's the origin of some of the criticisms of the WHO and others as to making the call about a pandemic, because it wasn't as severe as it might have been and it certainly wasn't as severe as the one in 1918.

I would refer the rest of the question to Dr. Spika or the other witnesses.

[The Chair, Conservative, Joy Smith]

Perhaps, Dr. Spika, you could continue with that.

[Dr. John Spika]

It's a good question. It's a point about which questions have been raised in a number of settings.

There are two aspects. A pandemic influenza is caused by a novel virus. It's not the seasonal viruses, but there's been a dramatic change in the virus itself, so that the regular susceptibility we have on a seasonal basis is greater, because many of us haven't seen the strain before. It's also an international event from the standpoint that not only has this virus emerged, but it's demonstrated that it can be transmitted very efficiently from person to person, just like seasonal flu, and it's spreading globally.

The WHO definition from the past is that, before they would declare a pandemic, it actually had to affect a number of the WHO regions. There are six of them. I think in terms of our pandemic planning, the situation we found ourselves in is that we thought it was going to be emerging from Southeast Asia, where a lot of the new viruses emerge, and that we didn't need to have a plan in place, or that it would be declared a pandemic before we actually saw it here in Canada.

Actually, the reverse was true. Here we were actually having illness before it was even recognized as a new novel strain, because of Canadian tourists going to Mexico. Nova Scotia was a good example, where they had some school kids who, I believe, were down in Mexico on vacation. British Columbia had tourists who were down there. All of a sudden, when we recognized that this new strain had emerged, it was already spreading around Canada, but it was still not called a pandemic from a WHO perspective, because it was just in North America. It wasn't until after it spread into Europe and some of the other WHO regions that the WHO officially declared it a pandemic.

In a way, that underscores the fact that our plan needs to be flexible, and not just totally dependent on the WHO declaring it to be a pandemic before we activate our plan and get going.

[Libby Davies, NDP, Vancouver East, BC]

Do I have a little more time?

[The Chair, Conservative, Joy Smith]

You're right on the button. Sorry.

We'll now go to Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

I just noticed, Dr. Corriveau, that you're only going to be here until noon, and I do want to ask you a question.

I understand you were the chief public health officer of Alberta at the time. I was wondering if you could comment on why you think it's important that provinces and territories have the flexibility to determine their own priority list for vaccines during a pandemic.

[Dr. André Corriveau]

First of all, I just want to expand on what Dr. Spika said. Even though it's called a pandemic plan, we also react to what's happening on the ground.

As was mentioned with Nova Scotia and B.C., we also had a lot of tourists coming back from Mexico. We had already activated, to some extent, the alert among ourselves. As soon as we heard there was an unusual illness going on in Mexico, we had weekly and then daily phone conferences to keep track of what was going on.

Through our provincial labs, Alberta in my case, we had reports of people being diagnosed with a novel strain of influenza. Way before it was declared a pandemic, we had already started to take action. Of course, we didn't have vaccine available in the first wave, but we knew something unusual was evolving and we needed to act. I think we did that as a nation. We developed our guidance documents together.

Your question is around the flexibility we need at the provincial level. First of all, I think we are hit differently. For example, Alberta was the first place that had first nations people who were affected. We had the first death. We had the first disease emerge in pig farmers, for example. In our case, we had a lot of firsts going on. We had to adapt the plan to fit the circumstances we were dealing with.

Those circumstances were localized, but they were also related to the way our health care system is structured. For example, in Alberta at the time, we had just abolished all the regional heath authorities and had created a single one. Therefore, the structure of response had to be different from that in Ontario, which has a very different type of health care system.

Even though we all endorsed a similar plan and signed on to the prioritization list, it played out a little differently in terms of implementation. For example, in Alberta, where they had chosen to use mass clinics for the immunization program, although in our communications to the public we highlighted who should come first based on the national plan that had been developed jointly, initially they didn't have the structure to screen people at the door. Basically whoever came to the clinic was accepted and was immunized.

That was a difference in what might have been done in another jurisdiction. Although we were still providing the same guidelines to our front line people, in our public communications we were using the same list as everybody else.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Dr. Corriveau.

Dr. Spika, we're talking about the framework. How is the pandemic vaccine prioritization framework set up, and how are the groups prioritized?

[Dr. John Spika]

The framework is interesting in that it doesn't prioritize per se. It actually identifies factors, both ethical and epidemiological, that one would want to consider at the time of a pandemic as to whether or not certain groups would be included in the priority list. From that standpoint we've talked about the epidemiology, those who are most affected by the disease, but also those who are taking care of people. Clearly, health care workers, people with direct contact with patients who are providing patient care, would be high on the list. You want to maintain at least that care component. You don't want to be turning people away at the emergency rooms.

The interesting thing from the firefighter perspective is whether you consider them first responders or part of the basic societal infrastructure. Depending on the jurisdiction and their responsibilities, they could be considered both.

Again, it's a matter of balancing, in this case what the Public Health Network was doing. Where was most of the burden of disease occurring as compared to who was perhaps most likely to get ill? That was an important distinction, and it's why all jurisdictions then identified pregnant women, people in remote and isolated communities, young children, who we were seeing had a lot of serious diseases. Then there was that flexibility to adapt to some of the other groups as they saw them on the ground in the jurisdiction.

[Colin Carrie, Conservative, Oshawa, ON]

Are these frameworks used every time a pandemic comes up? Can you comment on that? I know that these things are rare.