Health Committee on May 3rd, 2021

[The Chair, Liberal, Ron McKinnon]

Thank you, Ms. O'Connell.

Mr. Thériault, you have 30 seconds.

[Luc Thériault, Bloc, Montcalm, QC]

Dr. Ruel, you agree that in the context of a vaccine shortage, it's still more beneficial to vaccinate as many people as possible than to follow the manufacturer's recommendation to administer the second dose of the vaccine 21 days after the first dose.

That's what you're saying about this, noting that an exception should be made for frontline health care workers, however. Is that correct?

[Dr. Marc Ruel]

That's essentially what I'm saying.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

[The Chair, Liberal, Ron McKinnon]

We go now to Mr. Davies.

Mr. Davies, finish this up, please, for 30 seconds.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thanks.

Dr. Attaran, you've written that the federal government can make national rules—specifically, minimum national standards—for COVID-19 control that the provinces must play by. They can put a standard, legally binding floor under the provinces—a backstop of disease control that kicks in only when they fail.

Can you explain that a bit, Dr. Attaran?

[Dr. Amir Attaran]

You need a safety net. There has to be a safety net. You cannot have a free-for-all of a country, where some provinces don't do the right thing—whether it's on vaccination, on shutdowns or on the size of public gatherings—and expect good outcomes.

If every province is making it up on their own, you're never going to get 10 out of 10 doing it right—never. You need minimum national standards, including for vaccination, as Ms. O'Connell averred briefly. That is something the federal government can do with its emergency powers constitutionally. There is precedent.

I'll give you the names of some federal acts that set minimum legal standards across the board. For the environment, it's the Canadian Environmental Protection Act; for medical care, it's the Canada Health Act; and for privacy, it's the Personal Information Protection and Electronic Documents Act. They're all federal legislation and they all set minimum standards.

Why can't we have minimum standards for disease control in the biggest crisis this country has faced in a century?

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Davies.

That brings our panel to a close. I would like to thank the witnesses for sharing with us their time, their expertise and their knowledge. Thank you all for being here.

With that we will suspend to bring in the next panel.

[The Chair, Liberal, Ron McKinnon]

We are resuming meeting number 34 of the House of Commons Standing Committee on Health. The committee is meeting to study the emergency situation facing Canadians in light of the COVID-19 pandemic; specifically today we are examining Canada's national emergency response landscape.

I'd like to welcome the witnesses. We have, appearing today as an individual, Dr. Gregory Marchildon. I apologize for my mispronunciation of your name. He is a professor and Ontario research chair in health policy and system design at the Dalla Lana School of Public Health at the University of Toronto. With the Canadian Public Health Association, we have Mr. Ian Culbert, executive director. With the COVID-19 Immunity Task Force, we have Dr. Timothy Evans, executive director.

With that, I will invite the witnesses to give their statements. For your information, I will display a yellow card when you're getting near the end of your time, and a red card when your time is up. When you see the red card, try to wrap up. Thank you all.

We will start with Dr. Marchildon. Please go ahead, sir, for six minutes.

[Dr. Gregory Marchildon, Professor and Ontario Research Chair in Health Policy and System Design, Dalla Lana School of Public Health, University of Toronto, As an Individual]

Thank you very much.

In addition to my academic appointment, I'm also director of the North American Observatory on Health Systems and Policies, which has a mandate for Canada, the United States and Mexico but is based out of Toronto. In the 1990s, I served as deputy minister of intergovernmental affairs, and later as deputy minister to the premier, and cabinet secretary, in the Government of Saskatchewan. After that I was executive director of the Commission on the Future of Health Care in Canada, commonly known as the Romanow commission.

I'd like to start by saying that we live in one of the most decentralized federations in the OECD. This means that our first stop in any national public health crisis will naturally lie with the provincial and territorial governments. From the beginning, provincial and territorial governments have assumed this responsibility in various ways, and they've used their emergency acts and their public health acts to declare states of emergency or of public health emergency in order to close businesses and schools, to prohibit or restrict gatherings, to restrict the movement of populations and, in Quebec, to impose a curfew.

Of course, infectious diseases like the coronavirus are something that crosses borders, and governments need to act in a coordinated way if they're to be effective. This puts a very heavy onus both on federal-provincial-territorial collaboration and on regional collaboration among the provinces and territories, such as we've seen in the creation and maintenance of the Atlantic bubble.

This means intergovernmental agreement and action are essential to make this decentralized federation effective in a time of crisis. There has been some discussion already this morning about the federal Emergencies Act, and some believe that the federal cabinet can bypass this kind of intergovernmental agreement in action by invoking a public welfare emergency under section 5 of the Emergencies Act. However, I think we need to recognize that there are serious limitations to this approach, in part, as already mentioned by Dr. Attaran, with the limitations and protections that are built in to the current act.

In particular, section 5 can be invoked only if the emergency is “of such proportions or nature as to exceed the capacity or authority of a province to deal with it”—in other words, if the spread of COVID-19 or the administration of vaccines has exceeded the response capacities of the provinces.

The second limitation is that there needs to be proof that the emergency cannot be dealt with in any other way, through any other law in Canada. We've seen how the Quarantine Act has already allowed the federal government to quarantine and isolate individuals at national borders, and we've seen the use of the Emergency Management Act, which is the framework for helping provinces in an emergency. We heard from Dr. Attaran earlier about the Department of Health Act and about how it could potentially be used rather than the Emergencies Act.

These existing laws allow the federal government to do what is necessary, at least so far, in terms of the supports it's provided to individuals and businesses during the pandemic, as well as directly controlling our national border, including quarantine measures for those entering the country.

Now, even if you think—and Dr. Attaran again has referred to this—that things are bad in terms of contagion in some provinces, or you feel that the vaccination rollout is extremely poor, there's no reason to believe that the federal government could do better by acting unilaterally, in practical terms. In fact, recognizing that the administration of public health care, work sites, long-term care homes, etc., is actually in the hands of provincial and territorial governments, it would be almost impossible for the federal government to implement unilateral solutions to this crisis.

However, the question of emergency powers is a different question from the one of whether the federal government could do more. As a national government, it can and should do more.

We've talked briefly about the setting of national standards, perhaps through existing federal legislation other than the Emergency Act. I am going to focus, however, on the one task that remains, and that's achieving immunity through vaccination.

For the first time that I know of, the government of Canada has assumed the full responsibility and cost of securing vaccines. It should have used this leverage to require provinces and territories to provide additional information and data to track vaccinated Canadians and help determine the efficacy of vaccination. It should provide each fully vaccinated Canadian with an official Public Health Agency of Canada vaccination passport.

In general, it should have been involved and can still be more involved with provincial and territorial governments in the co-crafting and co-implementation of a national vaccination campaign.

We've learned that we can't depend on supply contracts with pharmaceutical companies whose own source of production and supply is outside Canada. We need a domestic production capacity and domestic vaccine research and development capable of anticipating and responding to epidemics and pandemics in the future. We had Connaught Laboratories at the University of Toronto until it was privatized and sold in the 1970s and 1980s. We need the federal government to work with our university-based scientists and academic hospitals to build this capacity for the next pandemic, to ensure this capacity is sustainable for decades to come.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, doctor.

We'll go now to the Canadian Public Health Association and Mr. Culbert, executive director.

Please go ahead, Mr. Culbert. You have six minutes, please.

[Ian Culbert, Executive Director, Canadian Public Health Association]

Thank you.

Good afternoon, honourable members, and thank you for the invitation to appear before you today.

The COVID-19 pandemic has highlighted the limits of our health care and public health systems and resulted in governments considering the implementation of the Emergencies Act. We agree that the conditions to implement the Emergencies Act have not been met, for the reasons your previous witness has indicated.

From a public health perspective, the use of the Emergencies Act should be considered only as a last resort. Its use in response to an infectious disease outbreak can be forestalled by the appropriate funding and governance of Canada's public health systems.

The fact that the federal government has discussed with the provinces and territories the use of the Emergencies Act underscores the need to modernize the funding and governance of these systems. While the delivery of health services is the responsibility of the provinces and territories, the federal government has a responsibility for leadership, collaboration and international relations. The challenge is that the federal responsibilities are not well defined.

A further challenge is that the key components of a public health response, such as data sharing, are based on voluntary agreements that are not legally enforceable and do not result in the timely collection of the information necessary for an informed response. This situation must change if our country is to respond efficiently and effectively to future outbreaks.

In May 2019, CPHA published a background document and position statement on “Public Health in the Context of Health System Renewal in Canada”. That report includes a series of legislative, regulatory and policy-related recommendations to strengthen the capacity of Canada's public health systems to protect and promote the health of Canadians.

In February of this year, we published our “Review of Canada's Initial Response to the COVID-19 Pandemic”. In this review, we noted that the health portfolio operations centre was activated, and a special advisory committee was implemented as a means for developing guidance, facilitating communication, providing governance and coordinating FPT public health activities and responses. However, the challenge with implementing the work of these groups is the current delegation of authority for managing health services. This division results in barriers to achieving an effective, consistent national public health response.

While we need to respect provincial and territorial authorities, the varying approaches among neighbouring provinces demonstrate that steps are required to improve the consistency of the national response.

CPHA recommends the development of a more unified structure that provides a national approach to public health while respecting provincial and territorial responsibilities. This goal could be achieved through the development of federal legislation for public health, a Canada public health act with clear roles and responsibilities defined for all governments and stakeholders. Such legislation would require a national funding accord that incorporates performance measures for the delivery of public health services according to national standards.

The COVID-19 pandemic has demonstrated the strengths, resilience and weaknesses that exist within governments' collective abilities to protect those who live in Canada from a global pandemic, and the vital role of public health organizations in achieving that goal.

These organizations have a history of responding to infectious disease outbreaks with the skills, competencies and professionalism that are the hallmarks of public health. Following every outbreak response, efforts are made to look back at their actions and to learn from them so that the response can be improved for the next event.

In the time between outbreaks, however, political commitment to implementing the recommended changes and to funding public health systems appropriately wanes. The defunding of public health systems is an easy target, because they operate in the background, protecting and improving the health of Canadians and reducing health inequities. Unlike wait-lists for surgical procedures or MRIs, there isn't a public backlash when public health services are cut.

Emergency preparedness is only one of six core functions of public health, so the necessary investments in public health governance, infrastructure and human resources will be fully utilized across the remaining functions in between infectious disease outbreaks.

The COVID-19 pandemic has clearly demonstrated that we cannot afford to allow the status quo to continue with respect to the governance and funding of public health systems in this country. If a jurisdiction spends only 5% of its overall health budget on protecting and promoting the health of its citizens, it can come as no surprise that we have unsustainable growth in our acute care systems during normal times and they teeter on the brink of being overwhelmed during this third wave of this pandemic.

We did not learn the lessons from SARS. We failed to properly and fully implement the recommendations of the Naylor and Campbell reports.

Our proverbial chickens have come home to roost with COVID-19. The political will at all levels of government must be marshalled to reform public health governance and to ensure its appropriate funding if we are to be better prepared to address the next outbreak, and there most definitely will be a next outbreak.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Culbert.

We'll now go to the COVID-19 Immunity Task Force, with Dr. Evans, executive director.

Please go ahead, Dr. Evans, for six minutes.

[Dr. Timothy Evans, Executive Director, COVID-19 Immunity Task Force]

Good afternoon, honourable members, and thank you for the opportunity to address this standing committee.

The COVID-19 Immunity Task Force was established by the Government of Canada in April 2020 with a two-year mandate. We work virtually and have a leadership group that's co-chaired by Dr. Catherine Hankins and Dr. David Naylor. The leadership group is a set of volunteer experts from across the country who work closely with governments, public health agencies, health organizations, research teams, other task forces, communities and stakeholders.

The task force is focused on understanding the nature of immunity arising from the novel coronavirus that causes COVID-19, and establishing the prevalence of that infection in the general population and in specific communities with priority populations. In January 2021 the task force was asked to take a major role in supporting vaccine surveillance, to monitor both effectiveness and safety.

There are approximately five areas of focus for the task force, and we've supported to date about 80 to 85 studies. The primary focus is to undertake zero-prevalence studies. Those test for the presence of antibodies arising in individuals from either previous infection or vaccination with a COVID vaccine. These studies shed light on the level of immunity in the general population and in priority populations such as long-term care residents. They were initiated in May 2020, shortly after we were established, and are ongoing as we navigate the third wave.

Initial studies from the blood banks across Canada revealed that at the tail of the first wave in May and June 2020, the level of population immunity in Canada was extremely low, at less than 1%. While this was a strong indicator of the success of public efforts to limit the spread of infection, these low levels of immunity made it abundantly clear that across the country we remained extremely vulnerable to a second wave.

Updated results in January 2021, in the midst of the second wave, suggest that levels of immunity are higher in all regions beyond the Atlantic provinces, yet remain extremely low. Of particular concern in the latest results is the growth in inequalities in infection among people living in poor neighbourhoods and among racialized groups. In neighbourhoods with the greatest material deprivation, risk of infection is five times greater than in the least materially deprived neighbourhoods, and that risk of infection is growing nearly three times as fast in neighbourhoods of greatest material deprivation. Among racialized groups, infection risk is more than three times greater compared with the white population and is growing at about twice the speed.

The abundantly clear messages that are emerging from our CR prevalence data are that, one, we're a long way from herd immunity; two, vaccines are the only route to herd immunity; three, vaccine rollout must be directed as a priority to materially deprived neighbourhoods and racialized communities; and four, adherence to recommended public health behaviours remains critical until vaccine coverage reaches thresholds for herd immunity.

The task force is also working to advance our understanding of immunity against SARS-CoV-2 infection, and some of the results we have to date give us an indication, for example, that immunity following infection remains strong and protective for at least eight months, and also that older populations living in long-term care may have a less robust immune response following a first dose vaccine. As we follow cohorts of infected persons and now vaccinated persons, we're going to gain more insights into how long immunity from infection and/or vaccination lasts in different age and sex groups, and when booster doses of vaccines may be needed.

The task force is also supporting immune testing work across Canada to validate and improve access to immune tests. We've validated a dried blood spot specimen, which is a made-in-Canada antibody test that helps distinguish vaccine-induced immunity from postinfection immunity. This is permitting home-based testing, and it is being deployed in studies across the country to gather information about how population immunity is evolving as vaccines are rolled out.

In terms of vaccine surveillance, we're working with a consortium of Canadian organizations: the Public Health Agency of Canada, the Canadian Immunization Research Network and the National Advisory Committee on Immunization. Together, through something called the vaccine surveillance reference group, we've identified studies that monitor the safety and effectiveness of COVID-19 vaccines across Canada. Some of the topics we're monitoring include the effectiveness of alternative dosing schedules, the safety and effectiveness of vaccines in children, the safety and effectiveness of people with chronic illness, and a trial that's looking at mix-and-match vaccines. For example, if you get a Moderna vaccine as your first dose, how effective will it be if you get a Pfizer vaccine as your second dose?

Finally, we're also modelling herd immunity. With the rollout of vaccines, the task force is looking at the trajectories to herd immunity across Canada as a whole and in each of the provinces and territories, drawing on national and international sources of data.

Thank you very much.

[The Chair, Liberal, Ron McKinnon]

Thank you, Doctor.

We'll start our rounds of questions at this point, with Ms. Rempel Garner.

Please go ahead, Ms. Rempel Garner, for six minutes.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Thank you, Chair.

My questions will be for Dr. Evans. Thank you so much for being here today.

It's really serendipitous that you are here today. There's a story in The New York Times, which I'm sure you read this morning, that is getting a lot of attention. The headline reads, “Reaching ‘Herd Immunity’ Is Unlikely in the U.S., Experts Now Believe”. In it, there's a quote from an evolutionary biologist at Emory University in Atlanta. He said, “The virus is unlikely to go away...but we want to do all we can to check that it’s likely to become a mild infection.”

Based on your work to date, would this statement be accurate in the Canadian context?

[Dr. Timothy Evans]

I think it's a function of assumptions related to the evolution of the virus and the extent to which new variants affect vaccine effectiveness or escape the immune protection that's generated by the existing vaccines. This is definitely something we have to look at and follow very closely. I think it's too early to state definitively that indeed this will be the case. However, I think there's enough evidence that we need to continue to follow it very closely into the future.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Do you believe that COVID-zero is possible in Canada?

[Dr. Timothy Evans]

I think that depends on what you mean by COVID-zero. If it means—

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

I guess what I'm trying to ask is, are we likely to be moving into an endemic situation, and should we be looking at responses to manage this accordingly?

[Dr. Timothy Evans]

I think we're moving to a situation where, as with a lot of coronaviruses, we could manage this through vaccinations such that it affects people at worst like a cold, and limits severe illness, hospitalization and death to a very large degree.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

What work is being done by your group to translate some of this research and knowledge into policy on public health restrictions or benchmarks for lifting public health restrictions?

[Dr. Timothy Evans]

We have a number of studies that are looking at what the duration of protection is, not only from natural infection, as I stated earlier, but also from vaccines, and in different types of populations. We just supported a number of studies that are looking at, for example, immunocompromised populations and populations with chronic illnesses. We're looking to see the extent to which vaccine protection differs in those at-risk communities.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Do you have any sense of a timeline on when that research would be translated into public health advice for guidelines or lifting restrictions?

[Dr. Timothy Evans]

These studies are now enrolling patients as the vaccines roll out, and I think the important issue is the extent to which you can generate valid findings over time. When duration is one of the variables, then it's hard to accelerate or diminish that time interval.

To give you an example—