Health Committee on Oct. 2nd, 2012

[The Chair, Conservative, Joy Smith]

Okay. Thank you very much.

As I told you before, Dr. Hanley will be joining us. We'll suspend right at 12 because two of the doctors have to leave the committee and another doctor will be coming in.

We'll go into our five-minute rounds because we have time. We'll begin with Dr. Sellah.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you, Madam Chair.

I would like to thank Dr. Spika, who is here with us, and the other witnesses, who have joined us by videoconference, for their contribution to this very important discussion.

I listened attentively to what Dr. Spika was saying. He said that two leadership groups would be involved in the case of a pandemic. There is the network of public health physicians. He also mentioned the medical officers of health.

Dr. Robert Strang, from Nova Scotia, also joined us. I know what a hygienist does, but for the average citizen, I was wondering if Dr. Strang could explain what a medical officer of health does. Everyone knows what a dental hygienist does, but not the role of a medical officer of health, who would intervene in the case of a pandemic in the vaccine process?

Dr. Strang, could you please provide some clarification in this respect?

[Dr. Robert Strang]

Sure. The two groups were the Pan-Canadian Public Health Network Council and the Council of Chief Medical Officers of Health. As I indicated, those groups were pre-existing leaders in public health, and they were brought together as part of our response.

Each province and territory has a chief medical officer of health. We have the lead accountability for public health in our provinces. We all have legal authority under some type of health protection act or health act that allows us to take certain actions and to provide advice to our elected officials. When there are threats to the public's health, we have some level of independence to take action, if required. We're able to delegate those functions to our medical officers and their regional health authorities, and to delegate it down through front line staff, both public health nurses and public health inspectors.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

My next question is for everyone.

According to the appendix of annex D, the pandemic vaccine prioritization framework of the Canadian Pandemic Influenza Plan in the health sector states that "the degree to which prioritization will be necessary will be linked primarily to the rate of vaccine production, which will not be known until production is under way."

During an influenza outbreak, does the Public Health Agency of Canada usually publish an official list of priorities? If so, at what stage in a pandemic is the list communicated? Which jurisdictions receive the list? Provincial, territorial or municipal governments? I was wondering if someone could answer my question, please.

[The Chair, Conservative, Joy Smith]

Who would like to take on that question?

Go ahead, Dr. Spika.

[Dr. John Spika]

In general, it's really the jurisdictions that prioritize how vaccines are given in their particular communities and to whom they give the vaccines. Some jurisdictions, even with seasonal flu, give the vaccine to selected groups as opposed to the whole population, as is the case in Ontario and certain other selected jurisdictions where they have universal flu programs.

We would only develop a priority list for influenza vaccine in the case that there was a flu vaccine shortage. From the standpoint of a jurisdiction, it would probably be at the jurisdictional level, based on their issue. It does raise an interesting question about when we've had other vaccine shortages, not flu vaccines but other vaccine shortages. The jurisdictions have to work together, which they do, to identify how we're going to adjust to that shortage. Sometimes it can mean that we're looking for vaccine from another supplier. I have to admit, from that standpoint, there's always work to be done. That's another issue that has been identified as we think about our national immunization program: How do we plan and mitigate against vaccine shortages and adjust and work together to address them when they occur?

From a pandemic standpoint, we have a framework. We're not going to address a prioritization framework for the next pandemic until it occurs.

[The Chair, Conservative, Joy Smith]

Thank you so much. Our time is up, Dr. Sellah. I gave you a little extra.

Dr. Corriveau and Dr. Strang have to leave at 12 o'clock, and we're at one minute to 12 now.

Thank you so much for joining us today on this very important topic. I appreciate your time.

We are going to suspend the committee for a couple of minutes, because Dr. Hanley will be joining us shortly. We'll listen to Dr. Hanley and then we will go into our five-minute questions and answers.

With your indulgence, Dr. Plummer, we'll be back online very shortly.

[The Chair, Conservative, Joy Smith]

I would ask the committee to resume.

We have Dr. Hanley online.

Can you hear me, Dr. Hanley?

[Dr. Brendan Hanley, Chief Medical Officer of Health, Department of Health and Social Services, Government of Yukon]

Yes, I can hear you well.

[The Chair, Conservative, Joy Smith]

Dr. Plummer, are you online as well?

[Dr. Frank Plummer]

Yes, I am.

[The Chair, Conservative, Joy Smith]

Thank you so much.

Our committee has reconvened.

Dr. Hanley and Dr. Plummer, I want to thank you so much for discussing this very important topic.

Dr. Hanley, as you know, the committee listened to some other presentations prior to your arrival. We went into the seven-minute Qs and As and started the five-minute Qs and As. We are now going to break the five-minute Qs and As to listen to your presentation.

We're so grateful that you're here. You have 10 minutes. Would you begin, please, Doctor?

[Dr. Brendan Hanley]

Thank you for this opportunity to speak. I won't take long and I won't belabour points that you likely already are familiar with from perusing the national pandemic plan and other sources.

Yukon itself has a fairly high-level pandemic plan that was revised in 2009 during the H1N1 pandemic, incorporating early lessons learned.

It's important to remind committee members that we are a small territory. We have only 35,000 people in the entire territory. One quarter of our people are first nations. As a small territory, we do not have a great capacity for research or analysis, nor for in-territory scientific expertise which the provinces may enjoy. However, we do have excellent collaborative relationships with our colleagues in the south. As a small territory, we also have the advantage of close connectivity between the public clinicians, political leaders, and public health personnel. In short, when we need to, we think we can get things done.

We were part of the national vaccine prioritization discussions held during pandemic 2009. Prioritization became a question of how best to protect a population with limited vaccine supplies and how we define protection for a population. Is it protecting societal function? Is it protecting the most vulnerable? Is it protecting children? Is it preserving the most life years possible for a population?

In the motion brought to the standing committee, there's reference to “the epidemiology” of the pandemic. What were the important aspects of the 2009 pandemic that related to prioritization? I would submit they were the following. The influenza was relatively mild but occasionally severe, especially for those with underlying medical conditions. There was some evidence of greater susceptibility among aboriginal peoples. There had already been a first wave of the pandemic, so an unknown number of people were already likely immune. The senior population had residual immunity from prior exposure to similar influenza viruses.

You can see how these features would influence prioritization. This would mean that if we were to prioritize, we would be very interested in our first nations people and those with underlying medical conditions, and perhaps we would be putting less priority on societal disruption and the senior population.

Apart from epidemiology, however, there was a key issue. The availability of the vaccine itself was in a tight race with the coming of the second wave. Therefore, for 2009, timing was everything.

In Yukon, though, as in other northern territories, at a certain point we realized we had a huge advantage that left us more or less peripheral to the detailed and angst-ridden prioritization discussions. For pandemic H1N1 2009, because of our small population, we were able to have all of our vaccine supply delivered in one shipment. In addition, we had the logistics to be able to deliver vaccine quite quickly.

Rather than having to triage people by susceptibility, age, gender, and occupation, we felt it was more efficient to offer the vaccine generally to the population. We believe our strategy worked well. Within two weeks we had covered 50% of our population, and after that, there was very little uptake in the weeks that followed.

Since firefighters are specifically mentioned in the motion, I'll offer the following.

Generally speaking and for future planning, protecting first responders and essential services people such as EMS, police, and firefighters has to be balanced with protecting the most susceptible members of the population.

Decisions about how to organize such priorities will of course depend on the epidemiology of the next pandemic and on features such as: whether certain age groups are more susceptible; the rate of transmissibility; the rate of severe disease; the expected demand on clinics and rural health centres, EMS, emergency wards, and in-patient services; and when the vaccine is actually going to be available vis-à-vis the course of the pandemic itself.

Regarding the importance of preserving societal function, we should agree to continually revise our definitions of what essential services are.

You may have heard that Yukon had a total communications blackout only two weeks ago. What use is a 911 system without working phone lines or a cellular network or Internet? That is just one example of the complexities of assigning values to societal importance. In this case, we just might want the cable guys who are out there fixing the lines to be the most healthy.

In summary, I can offer a few lessons from what I have learned.

One, rather than being a purely value-based system, it's crucial that prioritization be based on an ethical framework that is accountable and is free of bias, as should be the best of democratic processes.

Two, technology can change everything. Canada needs to be a leader in investing in immunization technologies for the next pandemic, whenever that may occur. I hope we're not still waiting for chickens to lay enough eggs in which to produce viral strains for vaccine.

Three, even when supplies may be limited, consideration should be given to the inefficiencies and societal distress inherent in assigning values and priorities. There may be lessons to be learned from what happened in the north: wide open access and rapid immunization of the population as a whole, an efficient, democratic, and equitable practice that we were lucky to have.

That's all I have to say. Thank you very much.

[The Chair, Conservative, Joy Smith]

Dr. Hanley, I think you've said quite a bit and said it most colourfully and adequately. Thank you very much.

We'll go back to our five-minute questions and answers. Mr. Strahl.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Thank you, Dr. Hanley, and the others who are still with us from the first panel.

I remember the 2009 event mainly because I was the father of a five year old, who turned eight today, actually. I remember at the time the worry that was in the population for those groups that were identified as being vulnerable. I certainly was thankful that young children were in the top priority, or certainly in the second tier in British Columbia.

My question, as we are considering this motion in the context of firefighters, is that if we mandate that vaccinations must be given to those who may not necessarily be vulnerable based on the epidemiology, does that not necessarily put those who are vulnerable at additional risk?

Again, based on the epidemiology and the availability of a vaccine, if there is a limited supply, would you not agree that we must maintain as much flexibility as possible to ensure that we are treating those who need it the most and that we don't politically tie the hands of our public health officials by mandating that they vaccinate those who may not need it in the future?

[The Chair, Conservative, Joy Smith]

That's to Dr. Hanley, I would presume.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Dr. Hanley or Dr. Spika.

[The Chair, Conservative, Joy Smith]

Dr. Hanley, would you like to take a shot at that, please?

[Dr. Brendan Hanley]

Yes, sure.

I think the key word is “politically”. I'll go back to what I said, that there is going to be a balance between preserving societal function and protecting the most vulnerable. I don't think there is one answer. Both are critical functions, and which becomes more important depends on what we're watching from the course of that pandemic.

Again, this is where we need an ethical framework. We need to keep politics at arm's length and let the public health officials.... There will be debate, but let that debate occur based on public health values and a public health ethical framework.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Hanley.

Dr. Spika, with your vast knowledge, did you have something that you would like to contribute as well?

[Dr. John Spika]

The only other thing I would add to that is that maybe 10 years from now we'll have the first vaccine available in 12 weeks instead of 22 weeks, as we had during 2009, just because technology is changing.

In effect, our whole approach needs to be flexible to address it based on what we have at that time.

I agree with you, given the changes in technology, given that we don't know what the virus is going to do, the comment about flu pandemics is to expect the unexpected, not that it is unique to flu pandemics, but what occurred in 2009 wasn't what we expected.

Anyway, I support your comments.

[The Chair, Conservative, Joy Smith]

You have a minute more.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

In that same vein, if we're talking about prescribing who must be included in the first batch if there is a limited vaccine, at the federal level I think we need to be careful that we don't impose that requirement on the jurisdictions of the provinces and territories.

Were there any provinces after the 2009 review that came forward and said that they would have preferred if the federal government had mandated the priority for the vaccines, or did they say they needed that flexibility in their own jurisdiction?

[Dr. John Spika]

We heard no comments to the effect that they wanted more direction. I think the process during the time of H1N1 was really remarkable in that we got all jurisdictions working together, and we at least agreed on the framework and allowed them some flexibility to adapt to their local situation. In reality, even if we have enough vaccine, we may not have enough vaccine givers.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we'll have to go to Dr. Morin, please.