Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 30, Evidence of November 23, 2005
OTTAWA, Wednesday, November 23, 2005
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:36 p.m. to study the state of preparedness for a pandemic on the part of the Canadian government and in particular, measures that Canadians and Canadian businesses can take to prepare for a pandemic.
Senator Wilbert J. Keon (Deputy Chairman) in the chair.
[English]
The Deputy Chairman: Honourable senators, could we get started, please? Unfortunately, we are running a little late. We have an hour and 25 minutes to conduct our hearing. This room is booked for 6 o'clock for another committee.
I want to thank the witnesses for coming. I particularly want to thank the senators, too, who are coming under extenuating circumstances, for providing me with a quorum to do this hearing.
We had a motion on the floor of the Senate that directed us to hold this hearing, which is the reason we are here. I will read it to you,
That the Standing Senate Committee on Social Affairs, Science and Technology be authorized to examine and report upon the state of preparedness for a pandemic on the part of the Canadian Government and in particular on measures that Canadians and Canadian businesses and organizations can take to prepare for the pandemic.
We are then to submit a report.
We will report to the chamber of the Senate at some point in time. Things are a little uncertain in our lives right now. As senators, we enjoy much more certainty than some of our colleagues in the other place. Eventually, we will report to the Senate on this.
I thank you all for coming. There are six presenters here. I ask you to keep your presentations to about eight minutes which would give us a half hour for discussion. If some of you are satisfied with a little more or a little less that is all right, too.
The order on your agenda has been modified slightly. Dr. Judith Bossé, vice-president, Science, will go first, and then the other presenters will go in order from the top.
Dr. Judith Bossé, Vice-President, Science, Canadian Food Inspection Agency: Thank you for allowing me to come on behalf of the CFIA and present the readiness situation for the CFIA.
Before I talk about the various aspects of our readiness plan, I would like to talk about the disease that has been talked about a lot these days, avian influenza. I will explain how complex this agent is so that people understand that one size does not fit all. It is a contagious viral infection which affects birds primarily. Under certain circumstances, it may affect other species.
There are multiple strains of avian influenza. They are characterized by two letters and many numbers. There is a possibility of 1 to 16 Hs that can be found and 1 to 9 Ns. The different strains reassert themselves constantly between the different Hs and Ns. So far, it has been reported that about 144 strains or subtypes are reported in the birds. That is the number of viruses.
Normally these viruses are found in wild birds. The viruses are usually not harmful to those types of birds. They carry the virus in an enteric form, which is in their gut. The virus does not usually give clinical signs with the exception of the Asian strain, H5N1, which is the strain everybody hears a lot about these days.
There is a way to classify how virulent those viruses are in birds. We call them either low pathogenic or high pathogenic, and this classification reflects the severity of the clinical illnesses it causes in birds. A low pathogenic virus normally gives mild signs or none at all and a high pathogenic virus gives much more severe clinical signs up to death. The condition of low to high pathogenic classification is more specific to two particular subtypes, which is the H5 and the H7. Therefore, the CFIA and the international veterinary community pay much attention to those two subtypes.
Only two subtypes have been shown to switch from low pathogenic to high pathogenic classification. I remind people of the B.C. incident a year ago where we had an H7N3 virus that on the first farm was low pathogenic and was not demonstrating much clinical illness in the birds. As it passed from the second barn on the first farm, it became virulent and ultimately spread to other farms.
Over the past year, the H5N1strain has been talked about a lot in the media. It is a highly contagious and fatal infection in poultry but is also fatal in wild ducks. That is news because we were not aware of strains that could be highly pathogenic in that type of bird population.
The virus has also demonstrated an ability under certain conditions to transmit to some people upon direct contact. These conditions are not yet known: the public health people can probably shed more light on this situation.
This H5N1 strain from Asia for the time-being is mainly in Asia and it is progressing toward Europe and the western part of Europe. As it moves around the world, as it will reach the Middle East or Africa. We do not perceive that the risk is very high that it will get in Canada. As the virus moves and progresses around the world, there is no doubt the risk will change and increase.
The virus is currently endemic in multiple Asian countries. Lately, we have heard some reports from European countries, and Middle Eastern countries have reported cases in wild birds.
What are the ways that this strain can get to Canada? There is no doubt that the focus right now seems to be on migratory birds, and, yes, it is a possibility. However, it is remote at this time. There is focus on illegal poultry imports. There is also a concern that the virus could be carried by people who have visited farms or come from infected regions.
An outbreak of H5N1 would have a significant impact on public health. It would have economic, societal, and international trade consequences. As with bovine spongiform encephalopathy, BSE, or severe acute respiratory syndrome, SARS, the impact would be out of proportion with the number of cases of animals or human illnesses.
The international capacity to deal with this influenza virus is at the present time uneven at best. Therefore, Canada sees that it can play a role in assisting other countries in finding ways to mitigate the risk in the birds. We believe that if the risk can be mitigated in the birds, it prevents potential transfer to humans of becoming a greater risk.
The Canadian Food Inspection Agency, following the B.C. incident in 2004, has reviewed their plans. As they develop and improve based on the lessons learned, many aspects need improvement.
In terms of prevention, the measure we took was to increase the work we are doing with the provincial partner and industry partners to maintain, but mainly to enhance, biosecurity on the farm. We believe that if it does not get to the farm and does not get into the domestic birds, the exposure to humans will be much less.
We are working with the Canadian Border Services Agency to strengthen our border control. Currently, we are initiating poultry surveillance in slaughter plants to monitor the possibility of H5 and H7 subtypes that could circulate in Canada in the domestic area.
We are working with our provincial partners to monitor all on-farm poultry disease records for any abnormal trends. We are also working with the wild bird community in Canada to monitor the strains currently circulating in the wild bird population through the country. We are monitoring these strains to establish a baseline understanding of what avian influenza strains are out there. This information will allow us to put in place the right risk mitigation processes to prevent subtypes H5 and H7 from infecting domestic birds and also to have an early detection if the avian strain from Asia was to occur in North America.
In terms of increased preparedness, we have developed an avian influenza laboratory network that has been expanded by improving the partnership with provincial labs. Now, we have six extra labs that are part of this partnership. We have been renegotiating and renewing our foreign animal disease emergency plan and negotiating agreement with the provinces. This renewed plan is a far more inclusive and comprehensive.
We also have agreements to access international veterinary reserves for surge capacity. We now have a Canadian animal health surveillance network that exchanges information on a real-time basis on what animal diseases are circulating in this country. We are working much closer with our colleagues in the public health sector so that any animal diseases are assessed in terms of risk to public health.
If an outbreak occurs, a number of plans are in place to facilitate a rapid response. These plans were exercised in the discovery last Friday of one duck with a low pathogenic strain of avian influenza in the B.C. situation. Our operation plans are based on quarantining, testing, and humane depopulation. As well, on-farm bio-heat treatment, or composting, has been established for disposal of the poultry so that the risk is not moved around. Also, research is ongoing on various aspects following the B.C. discovery in 2004.
The last component is the recovery stage, which is essential. We have put in place a policy for movement control and restocking to permit poultry meat to move in different locations outside the area under quarantine.
If we want these diseases to be reported early, we need to have strong compensation capacity so farmers have an incentive to report diseases when they see them. We are reviewing the compensation package that we have in place.
Dr. Arlene King, Director, Immunization and Respiratory Infections Division, Centre for Infectious Disease and Control, Public Health Agency of Canada: I will try to limit my comments to eight minutes. First, I will not elaborate more on avian influenza because I think Dr. Bossé has done that.
Right now it is difficult at times to distinguish the strains of influenza because of all the different kinds that are going around. Therefore, I will define some terms.
Seasonal flu is what humans get every year. It occurs in the winter season. We are starting to get influenza in Canada right now. This virus causes human strains of influenza. Every year, there are minor changes in the virus and that is why we need to develop new vaccines to make sure we can protect people against those changes.
Pandemic flu is different because it is caused by a major change in the structure of the influenza virus. It is a new virus and the population is not familiar with the virus. It then results in the lot of transmission between people and it can lead to widespread illness in a large portion of the population.
Vaccines are substances that stimulate the immune system and provide immunity for variable periods of time against one or several diseases. Anti-viral drugs, which again you are hearing about, come in either pill form, liquid form or sometimes even as inhalers. These drugs can be used either for short-term protection or for early treatment of either influenza or pandemic influenza.
With respect to the impact of avian influenza on humans, this influenza is tough to get. It is difficult for humans to acquire avian influenza. There is widespread avian influenza bird flu right now, particularly in Asia.
We know, as Dr. Bossé has said, that it has extended westward as well. Since late 2003, there have been only 130 cases of H5N1. This avian strain that Dr. Bossé talked about resulted in 67 deaths. It is a serious illness in people and results in greater than 50 per cent death rates, but it is rare and difficult to catch.
However, the concern is that the increased spread of avian influenza in poultry populations increases opportunities for human infections. Therefore, that avian virus can convert to something that can be transmitted easily between people, or the opportunities are there for that virus to mix with human viruses. This change can occur either in pigs and the creation of a new virus. We also believe the change could occur in humans.
Right now, there is no evidence that the current H5N1 avian flu virus spreads efficiently from human to human. Human infections are rare: therefore, no pandemic is likely to occur from this type of influenza.
In terms of our state of readiness, we have a Canadian pandemic influenza plan in place. It is a national plan that outlines the roles and responsibilities of all levels of government. It was developed jointly under the guidance of the Pandemic Influenza Committee which I co-chair with the Province of Alberta.
It is a model for a national health emergency response plan with preparedness response and recovery sections in it as well as a lot of annexes, which are guidelines to help all those within the health sector prepare for a pandemic.
This plan was posted on our Public Health Agency of Canada website in February of 2004. It is currently being updated. We hope there will be a new release of the plan in December or January.
The plan is being revised to reflect new information that has come out of the World Health Organization particularly with respect to phases. I will not go into the details. If you have questions on the phases, I will answer them. We are also adding other elements to the plan, one of which is non-medical drug-vaccine-related interventions that will help to mitigate the effects of a pandemic.
Most provinces and territories have developed their own plans as well. Local health authorities are also working on those. You will hear from Dr. Huston on what is going on in Ottawa in terms of local planning. We are also working with First Nations and provinces to ensure plans are integrated.
We have a pandemic as a component of a well-rounded and balanced pandemic strategy. We have a pandemic influenza vaccine strategy. Vaccine will be the foundation of our response in the event of a pandemic. However, we cannot produce the vaccine until the pandemic strain is known.
Our goal is to immunize all Canadians when the pandemic occurs. Canada was the first country in the world in 2001 to put in place a contract with a domestic manufacturer, ID Biomedical, to produce enough vaccines for all Canadians in the event of a pandemic.
We are currently developing a "mock" or prototype pandemic vaccine using the H5N1 seed strain from Asia to produce the quantities to be able to do studies with that mock vaccine to determine the safety and ability of a vaccine to produce an immune response in humans. We are doing this to be ahead of the game when the pandemic strain actually emerges.
Anti-viral drugs are an important but temporary measure. They are a stopgap measure in the event of a pandemic. The federal Pandemic Influenza Committee advises on the use of anti-virals, and on the composition and size of the stockpile. At present, we have 35 million doses in the country with another 5 million doses on order.
Priority groups for the use of those anti-virals drugs and the use of vaccines have been published in our plan. However, I need to re-enforce the message that when the pandemic occurs, we will look closely at the epidemiology of it — who gets sick and who dies — and adjusting our priority groups based on how that pandemic emerges.
Our pandemic plan has many other elements. I would like to leave you with two things. We need to have a balanced pandemic strategy. We need to ensure that we address all elements of pandemic preparedness. We need capacity at all levels of government to be able to do this in all sectors. We need to ensure that we have adequate surveillance capacity, response capacity, research strategy and a strong communication strategy so that the public is aware of what they should do at various phases in the pandemic alert and pandemic periods.
We must ensure that we have a strategy around international collaboration. A well-balanced pandemic strategy and preparedness at all levels of government and in all sectors of health is extremely important to ensuring that we are prepared.
We are moving well in that direction. Are we ready? We are better prepared every day. We continue to work on that, and we will be better prepared tomorrow than we are today. I want to reassure you that we are working hard at all levels of government together with our colleagues at animal health to make sure that we are prepared.
Dr. Patricia Huston, Associate Medical Officer of Health, City of Ottawa: Thank you for the opportunity to speak here today.
I am the Associate Medical Officer of Health in Ottawa for Ottawa Public Health. I chair the Ottawa Pandemic Steering Committee. My main message to you today is this: Although Canada has been an international leader in pandemic preparedness, there remains some important preparedness gaps at the local level. Despite significant advances, if a pandemic hit tomorrow, we would not be ready here in Ottawa.
In September of this year, we released Ottawa's Interagency Influenza Pandemic Plan. This plan is consistent with the Canadian plan, which we consider a landmark document. It is consistent with the Ontario Health Pandemic Influenza Plan and the World Health Organization phases of a pandemic. This achievement is huge and provides a strong foundation.
This plan was developed by the Ottawa Pandemic Steering Committee that included people from Ottawa Public Health, from the City's office of emergency management, hospitals, paramedics, physicians, long-term care providers and representatives from the provincial public health laboratory here in Ottawa.
We developed the Interagency Influenza Pandemic Plan that identified who does what. Then we requested that each agency develop their own operational plans around how they were going to do what they had committed to in the interagency plan.
Despite the advances we have made locally, there are three key gaps that I would like to describe to you today. The first gap is in early detection capability. This is critical for a swift and effective response. Right now, we simply do not have it.
The current surveillance system for Ontario is based on clinical assessment and not laboratory data. We have pre-identified sentinel positions across the province that contribute to Canada's FluWatch program. However, these physicians report only clinical cases of influenza-like illness. Unlike some other provinces, these physicians do not take viral samples. They report only the clinical data.
Some viral testing is sent to the laboratory, typically for the investigation of influenza outbreaks in long-term care institutions. It takes three to four weeks to identify the exact viral subtype because we do not have a rapid diagnostic capacity.
This time frame means that if a pandemic hit Ottawa today, we would be halfway through the first wave of the pandemic before we were able to confirm that it indeed was caused by a pandemic influenza virus.
Our second and biggest gap is the lack of a clear understanding of how we will look after all the sick people.
Before describing this gap, let me paint a picture of what pandemic influenza might look like in Ottawa. We have a population of about 850,000 people. Based on projection models developed by the U.S. Center for Disease Control and adopted by both the Canadian and Ontario plans, we could expect each week to have 30,000 people getting sick with pandemic influenza.
Over half those 30,000 people would seek health care assessments. There would be 350 hospitalizations and 80 deaths. Ten per cent of the population could be sick at any one time, and over a two-month period, over one-third of the population would get ill.
Here are the clinical challenges we face. Hospitals do not have the surge capacity to meet the increased demands. Although 350 hospitalizations per week may not seem all that much on first glance, one must remember that hospitals are already hovering at 100-per-cent capacity. This is not a one-time absorption of 350 patients. It is 350 patients each and every week, week after week.
Ottawa has less than 50 intensive-care-unit beds in the entire city. When pandemic hits, estimates suggest that 185 per cent of ICU beds will be needed in the first week alone for influenza patients.
The challenges of pandemic preparedness in the community have received less attention but are of increasing concern. If 350 people are hospitalized, that still leaves 29,650 infected people every week in the community.
Who is going to look after them? Now, here is the crunch. The Ontario plan identifies that pandemic influenza patients will be assessed by primary care providers. However, most primary care physicians are not convinced they should care for pandemic patients in their office.
They would like to redirect these patients to influenza assessment centres so they could look after the ongoing health care needs of their patients in their practice. The Ontario plan identifies that information on assessment centres are "to be developed." Locally, it is not clear who will set up and run these centres.
Hospitals already feel overwhelmed with surge capacity requirements for hospital care. Family physicians do not want to do take on the responsibility. Even if public health were to provide the physical space for an assessment centre, who would provide the care. It is far from obvious.
Physicians have indicated that if they were to be involved in the care of pandemic influenza patients, they would like Tamiflu prophylaxes; infection control supplies such as masks, gloves, face shields and sanitizers; income protection; life and disability insurance; security services; and clear guidance on what health care services can be delayed or deferred.
At the current time, only Tamiflu prophylaxes have been promised by the province, which is the anti-viral medication.
Pandemic planners believe primary care physicians are perfectly capable of looking after influenza patients and at this point in time do not think physicians should be subsidized to provide this care.
However, family physicians say that if they expose themselves and their staff to increased risk of illness and death, increased expense, potential loss of income, and increased liability with absolutely nothing in return, why should they sign up for this?
Few have forgotten that the first health care professional to die of SARS was a family physician who was exposed to SARS in his office setting. Nor have they forgotten that the family who lost their father in the line of duty received no compensation.
It seems most pandemic planning to date assumes primary care providers will be there to look after pandemic patients in the community. This huge assumption is untested. Physicians tell us they are not willing to care for pandemic patients without support. This is a critical current weakness in our current preparedness plans.
The third and final gap is the large variability in local public health capacity for preparedness activities. Locally, physicians have told us repeatedly they are looking to Ottawa Public Health for support. After all, local public health authorities have been identified as lead in planning and co-ordination in both national and provincial plans.
However, public health authorities have been given this enormous responsibility without any additional funding. This responsibility comes at a time when Public Health is already acknowledged to be underfunded. In my report, I show that if you look comparatively at funding — for hospitals, $ 800 million in 2002; for physicians, $ 400 million in 2002; and Public Health, less than $ 20 million — you have to ask yourself, "What is wrong with this picture?"
There is huge variability in the funding of pandemic preparedness activities in local public health units. Why is this? Currently, funding for local public health is determined by local boards of health, which in Ottawa is our city council.
Some boards of health are much more sensitized to the need for pandemic preparedness than others. Ottawa Public Health has requested one-time funding for pandemic preparedness. Due to the vagaries of our budget process, this does not even appear for councillors in the 2006 budget documents. Thus, we do not know at this time whether we will have funding for pandemic preparedness activities as of June 2006. At this time, contrary to our own advice given at the pandemic steering committee, we do not have an operational pandemic plan for Ottawa Public Health. Thus, we find ourselves much like the shoemaker who does not own his own pair of shoes.
Ottawa Public Health constitutes only 2 per cent of the municipal budget. Thus, like many other health units, it is easy to be overshadowed by larger municipal demands such as police services, public transportation and maintenance of roads, et cetera. The bottom line is the weakest link in public preparedness at the local level where preparedness is entirely dependent on the vagaries of municipal bureaucratic and political process.
In conclusion, these local gaps are not widely known, but they are not secrets either. People involved in pandemic planning are aware of them and are working toward solutions. With ingenuity, time and increased funding, they could be largely addressed. The first gap, early detection capability, and the final gap, funding, could easy be addressed. However, the second gap — having a clear understanding of how we will care for tens of thousands of additional sick people every week — will need more work, because it is based on different perspectives held at the current time by public health authorities and primary care providers.
In summation, are we ready for an influenza pandemic? We have a good foundation, we even have a draft blueprint but the building is not complete. There are huge issues remaining, and ultimately it is a race against time.
The Deputy Chairman: Thank you very much. Frankly, that is a worrisome presentation.
Dr. Roy West, Epidemiologist, Memorial University, as an individual: Thank you for inviting me to present today. I am a public health professional who has been in public health in Canada since 1969. In addition, I was part of the team at Health Canada in 1976 during the swine flu episode. I was in charge of the national influenza surveillance program at that time.
I have prepared a brief, which I believe you have, in which I have talked about important areas of preparedness, activities that may be harmful to public health, and then lessons from history.
With regard to important areas of preparedness, we have heard from Dr. King that Canada has a relatively well developed influenza pandemic plan, but I agree with Dr. Huston that the challenge will be in the response, should a pandemic occur, especially at the grassroots operational level where, in many parts of the country, the public health system lacks the necessary capacity to mount a response.
Being a scientist, I want to bring some scientific issues to the fore. The major scientific issues are the efficacy and cost effectiveness of the strategies used in response to a pandemic. Those strategies most discussed are preventing the spread of the disease through the use of a vaccine, and modifying the course of the disease using a pharmaceutical agent or an antibiotic.
In the case of influenza A, there is no clear evidence of either the efficacy or cost effectiveness of such strategies, especially in the face of a pandemic. Most of the scientific evidence we have for these strategies comes from studies done in the inter-pandemic endemic years, and there may be conditions in a pandemic that would modify the efficacy. Frankly, at the real-world level of effectiveness, we have little measure of how good that will be.
I have provided you with some notes on vaccine production. You have heard from Dr. King on that. The Canadian government should be congratulated for investing in a model of vaccine production, which goes beyond the investment in improving vaccine production. The model includes every step of the process until that vaccine has been approved by Health Canada and distributed across the country.
With regard to stockpiling therapeutic agents, once again, the real-world effectiveness of Tamiflu has not been shown in the face of a pandemic. In fact, some strategies we are discussing to modify the impact of the disease could be overwhelmed in an actual pandemic.
Surveillance is vital, and there are ongoing surveillance programs. I am somewhat biased in this area. I believe that we must continue to make our surveillance programs both sensitive and specific. You heard from Dr. Huston on both issues. I believe that initially we may have to use strategies that are not specific to a specific virus. They pick up acute febrile respiratory disease, but those need to be backed up with laboratory studies, et cetera, all of which takes time.
There are ongoing surveillance activities, and the Public Health Agency of Canada is an important focal point for surveillance.
With regard to program delivery, the Naylor report spoke to the lack of capacity in public health in Canada, which I believe is the issue, rather than putting extra personnel in place to deal with a pandemic that may never come. We all believe that a pandemic will come at some time but, if we are not careful, governments will put resources in place for a specific potential eventuality when it would be much better to strengthen public health capacity all across the country at the grassroots level. This strengthening involves the provincial and territorial governments, to which Dr. Kettner will probably speak. We risk unbalancing the public health system if we dwell too much on pandemic preparedness without dealing with the other issues in public health at the same time.
My brief includes a section on activities that are harmful to public health. I personally believe that some of the concern which is being provoked at the moment in the general population is harmful to public health. Some activities that do not help include predictions of when the next pandemic will occur, what the viral strain will be and the number of deaths. We do not know these things. The catastrophic language that is being used does not help either. We rarely hear reports of avian flu without the inclusion of the word "deadly." There are currently many other public health hazards that are far more deadly to Canadians than avian flu, so that language is not helping.
We have lessons learned from history. There have been two important episodes in Canada. One was the Asian flu pandemic of 1957. We had another pandemic in 1968-69, but the Asian flu pandemic was the last time that both the H antigen and the N antigen in the flu virus changed at the same time. Some people believe that if that occurs again, it can increase the virulence of the organism.
I worked at McGill with Corbett McDonald, who did much work in the 1960s on measuring the impact of flu. I have included some data that he retrospectively researched from the 1957 pandemic. According to this data, the numbers of excess mortality decline somewhat when one considers that there are endemic numbers that always exist. When we say that there could be a certain number of hospitalizations or deaths, we tend to use the total number, ignoring the fact that some will occur regardless.
The only outbreak of the Asian flu was in 1957, and it started at the beginning of September. We have traditionally mounted our influenza vaccination programs for October. If the virus emerges in Asia in the spring, which it tends to do, we do not necessarily have as much time to produce that vaccine as we think we will, based on the Asian experience of 1957, in that early September is the earliest that an outbreak of a pandemic has ever started in Canada.
From the point of view of the swine flu episode, an important factor is the political response. I think the idea of universal vaccination is a noble goal, but I get a little nervous because I do not believe we will be able to produce enough vaccine for universal vaccination in the first year of the outbreak. For the second and third years, yes, it can be there. If public expectation is too high for universal vaccination and we have to fall back to a high-risk strategy, which is laid out in the pandemic plan — the order in which we would make the vaccine available — we may have created problems for our front-line workers. I have said their front-line lack capacity, but if we have people trying to run immunization clinics and they have to deliver that vaccine to specific groups of people, and yet the public believes there should be a universal vaccine program, the front-line worker has the job of telling people they cannot have the vaccine because they are not a high risk group. Therefore I would like to tone down the talk with regard to universal vaccination.
The other issue that I would like speak to is whatever strategies we evoke, whether it be vaccine or the drug Tamiflu, these agents have downsides. We do not hear much talk about the downside from the point of view that in the swine flu episode in 1976 there was a clear link between the vaccine and Guillain-Barré syndrome in people in the United States, a neurological disorder. The risk is low. It is about one in 100,000 doses of vaccine but it is definitely there.
Equally, from the point of view of a drug used on a mass scale, we pick up in clinical trials the frequent, perhaps less severe adverse reactions, but the rare event we do not pick up. There have been questions recently out of Japan, which may have been resolved, over Tamiflu and potential adverse events, but we have to bear in mind that anything we use may have a downside. I am not saying that is a reason not to use vaccines, but we need to be able to cope with them.
When Guillain-Barré cropped up in the vaccination program in the States in 1976, they had to put a hold on their vaccination program until they were able to sort it out.
Those are my comments. I hope it is a little better laid out in my brief. At the end of my brief, I have tried to provide conclusions for the committee.
Dr. Joel Kettner, Chief Medical Officer of Health, Manitoba Health: Thank you for the opportunity to speak at this meeting. As the last speaker, I have the advantage of having heard everyone's perspective, but rather than respond to what others have said, I will try to stick to my knitting and deliver the presentation that I had planned, although I will shorten it in the interests of time. Perhaps we can engage in some discussion of the important issues that have been raised.
I want to start off by saying what I do in Manitoba. I am the chief medical officer of health there. I also want to make it clear that I am not here representing my provincial government, nor am I representing other provincial chief medical officers of health. I am giving my own views and my own perspective on the question of our state of readiness and preparedness for pandemic influenza.
If I wanted to have one take-home message from my presentation I will say it now in case it does not come out in the abridged version you will receive. I would like us to take a balanced view of this problem and keep it in perspective as best we can in considering all the issues.
I am not a specialist in infectious disease and my work in public health is at the most general level. My task is to put all public health challenges into perspective, weigh them and to try to influence our health system and our social system to address all issues in a perspective that hopefully improves the health of all people in my province and reduces inequalities of health between them.
Pandemic influenza is an important issue and in its fullest and most complex analysis raises all the issues that we need to address in disease prevention and health promotion. In that sense, I am pleased that it is being looked at in the way you are looking at it, and that we have the opportunity here to discuss it.
If we took an ideal perspective and asked the question how could we most be prepared for a pandemic influenza, and took it out of perspective of all the other things we are doing in public health, there is no question that we would fall short of the ideal in many ways. We will not have an anti-viral medication for everyone either for treatment or on a prevention basis. We will not have a vaccine that is perfectly effective for everyone soon enough before a pandemic influenza could be circulating here in Canada. We will not have a primary care system or a hospital system that can fully and perfectly treat every person.
Of course, in the complex analysis of all the factors there, we really need to make sure, as we go forward, that we continue to achieve progress towards not just planning and preparedness for pandemic influenza specifically, but for all public health and human health threats that we face. Most of them are here today. We know what they are and we know their morbidity and mortality. In many cases we know how to prevent them, or how to treat them, whether that is cancer, heart disease or other infectious diseases such as tuberculosis, AIDS and injuries, et cetera. We cannot lose sight of the fact that our system has to be robust to address all those issues.
On the other hand, unlike most emergencies we face, such as floods and forest fires, or other extreme conditions of weather that are local and brief, a pandemic influenza has the potential impact of affecting us across the country and for a longer period of time. One aspect that is different is that although we want to reduce injury and death from all emergencies, in this case disease and death is not only the cause of the problem, but the outcome. That is why, when we talk about our pandemic plan, we talk about not only reducing our morbidity and mortality, but also minimizing societal disruption. Of course, they are related. If we create a panic around pandemic influenza that interferes with our ability to provide the basic functions and needs in society, whether it is at the health care level or providing food, heating and all of the other essential services, then we may end up — and Dr. West referred to the potential harm that we could do — creating even more of a disruption than would otherwise be necessary.
I will sum up by saying that we should look at our preparedness on four levels: There is preparedness of the population itself, and that is in the work we do all the time in improving the health of our population; our resilience, but also the knowledge and attitude of all people and citizens towards health in it fullest capacity. There is the second level of preparing all those sectors outside the health system that impact on health, so all government sectors and non-government organizations, as well as the general emergency preparedness system.
There is a level of preparing and building the capacity of our health system, and we could break that down into the public health system. It has already been stated that strengthening the capacity of our public health system is the most important general function that we need to pay attention to in preparing for a pandemic.
There is still much progress needed in the health care system at the primary care level and all levels within the system to be able to cope with the kinds of challenges a pandemic would bring, aside from the everyday challenges of today.
There have been great accomplishments in all these areas, but there are also ongoing needs and opportunities to strengthen these things.
In the first level of preparedness of the population, we now understand the importance of a healthy living strategy. It is not just a superficial aspect of educating persons on how to eat healthier or be more physically active, but addressing the underlying determinants of health and the environmental conditions that enable it. As well, there is an understanding of people and their mental health promotion and motivation to take care of themselves and their families.
At the level, other sectors must work with the health system. I think we have an increased understanding of the importance of that with our population health strategies and understanding that determinants of health are much more than just the health care system and the ability to deliver medications or hospital care.
There has been much talk already about emergency preparedness and the need for business continuity planning, and I will not speak more about that. As well, there is the importance of strengthening the public health system and preparedness of the health care system. Maybe we can address those details in the discussion period.
I want to emphasize points around the need for more public health research, a stronger surveillance system, better public health human resources, strengthening our communication systems to the public and our partners and to carry this work out collaboratively at all levels. We need to ensure that what is happening at the local level fits with what is happening at the provincial, federal and international levels. Canada must and can play a role in being a part of an international system to protect the health of all peoples, despite varying capacities around the world.
In the interest of time, I will wind up by saying that we need to balance a few things with respect to readiness for pandemic influenza. On the one hand, we do not want to be too complacent. On the other hand, we do not want to fear-monger or exaggerate an anticipated problem through predictions and losing sight of the real problems we have everyday.
We need to balance, therefore, planning for the future with addressing today's issues. We need to balance our public health priorities within the public system as well as the requirements of looking after our own parts of the system while collaborating with others. I will come back to that question if it needs to be answered more clearly later.
The Deputy Chairman: It is extremely interesting at my old age to look back at some of the developments. I remember when AIDS first surfaced. It really was not a problem; it was just a fact.
In the hearing between the Medical Research Council and the royal society I was involved in at the time, there were several speakers that thought AIDS would not be a problem. They thought the virus was not a virulent one and that one would have to work hard to become infected. Look where we are now. You never know where things are going to end.
Dr. King stated something similar, and that is why I brought it up. I am not at all suggesting that you are not making a scientifically accurate statement; I know you are. It is interesting that the analogy popped into my mind.
Secondly, I think we all acknowledge that one of the greatest things that has happened in our country is the creation of the Public Health Agency of Canada. We can look forward to tremendous progress as a result of that.
However, of all the hearings that we have been holding over the past five years relating to our two reports, the general report of 2002 and the report on mental health today, one topic continues to surface over and over again: the lack of resources on the ground. The lack involves the disconnect between primary care and public health, the disconnect between primary care and our institutional sector, and the lack of development of primary care facilities to handle almost any health problem that we look at. Yet, we do not give the primary care physicians, nurses and other health care workers the attention they deserve.
Having worked as a specialist, it was easy to get attention. However, primary care physicians have great difficulty getting attention, as do public health officials.
Before we go further, I would like you to either confirm or deny that this, from what I see and listen to, this is the major problem we have if we are confronted with a real health crisis. We will proceed in the order of speakers. Could you comment first, Dr. Bossé? Then we will hear from Dr. King and the others.
Dr. Bossé: I defer to my public health colleague because my specialty is animal health. I have the privilege of working closely with public health, but I cannot address the question from a public health perspective.
Dr. King: Yes, I think the issue is with respect to public health capacity. It is public health capacity right across the system — locally, provincially and federally — to be able to mount the kind of activities we need to engage in. We recognize this as a priority as well within the Public Health Agency of Canada.
I did not talk about the priorities, in our view, from the perspective of the Public Health Agency of Canada. Surveillance and capacity development would be at the top of our list in terms of issues.
We need to have a robust public health system there everyday to deal with the day-to-day challenges and all emergencies and issues that come forward such as pandemic influenza.
A robust public health system will enable us to do things such as surveillance, which we will need during a pandemic. Dr. Huston has pointed that out. It would enable us to do outbreak investigation required at the initial stages of a pandemic so we can define characteristics and how the pandemic virus is behaving initially. We will need that public health capacity to deliver anti-viral vaccines and to monitor the use of those drugs, as Dr. West correctly pointed out.
These skills we need on a day-to-day basis, and we will need more of them in the event of a pandemic. We recognize that it is a challenge across the system, and our belief is that building and strengthening the public health system is our number one priority.
The Deputy Chairman: Can I ask you to go a bit further? For example, I am aware that in Ottawa, where I have lived most of my life, public health is under City Hall. The resources they need lie in the primary care community, and there is no link between City Hall and the primary care community. I do not know what mechanism could be put in place to improve the ability of the public health officer to make that link.
Do you have any ideas on that?
Dr. King: Ensuring opportunities for communication and collaboration at the local level is important. One area where collaboration has happened generally in non-regionalized public health systems is infection control committees, where public health and primary care try to get together regularly at the local level.
In regionalized health systems, all health service sectors are under one regional sector, and one regional authority in some provinces and territories. There are different models that enable collaboration, some of which may be more natural than others. In health systems where the sectors are all separate, the opportunities have to be created to do that.
We are looking at providing those opportunities where we can get people together more readily. We realize better communication between primary care and building those kinds of linkages are important, and those were clear lessons learned by SARS.
Dr. Huston: I agree with everything Dr. King has said, and I would say there is a growing desire for more public health and primary care collaboration.
I know that the College of Family Physicians of Canada and the Canadian Public Health Association, for example, have been talking about how they could help to provide leadership in this direction.
The mechanisms right now are not there. It is a huge and difficult gap.
Dr. West: Once again, I empathize with the person at the grassroots level. I agree with the chair that the public health agency is a marvellous step forward, but there is a danger. As more planning is done at the 10,000-foot level, the poor workers on the ground see all these instructions coming down and throw up their hands in horror.
We must get beyond putting such a big proportion of our resources into treatment. There is a spectrum from prevention at one end to palliative care on the other, and other the years, the two ends of that spectrum have been starved. We are talking about the prevention end and the public health end today, but it must be looked at with a view to balancing it across the spectrum.
The Deputy Chairman: Dr. Kettner, you could probably make some useful comments here because you are looking at this from the perspective of an organizable province.
Dr. Kettner: I am sure there is variation across the country in terms of this opportunity for the type of collaboration we are discussing.
In Manitoba, with a regionalized health system, the regional health authorities have public health within them, as well as, of course, the other continuum of the health care system. In that sense the opportunity, perhaps, is a little bit easier for collaboration and integration.
Having said that, there are still challenges. For example, most primary care physicians in Manitoba are paid fee-for-service directly from the provincial government and are not employed by or accountable to the regional health authorities. That is not true for all of them, but is still true for the majority of them.
With the exception of the community health centres where we have primary care physicians on salary and working more as part of an integrated team of service providers, we still function in many ways under the longstanding models of health delivery, which have been challenged for many decades now.
Aside from supporting what has been said about the increasing recognition that we need to integrate public health and primary care and to rebalance the system towards prevention rather than treatment, while not implying that treatment is not important, I believe the planets are now lining up a little better to make progress. We are seeing signs of that, and I am more optimistic now.
Even with pandemic planning, if we play it smart, we will use this issue to bring that integration into play more quickly, which will benefit us in every way, even if we do not have a pandemic for a long time or if it turns out, when it does come, to be milder than what some of us fear. It is a critical part of our pandemic planning to do this.
The Deputy Chairman: Following the SARS epidemic, there were three significant committees that I am aware of, and I sat on two of them. It struck me that the medical resources that were involved were all hospital resources, when, as Dr. Huston has just pointed out, probably not one patient in a hundred will need the hospital resources. The patients will need the community resources, and we ignore that as we go along.
Dr. Kettner: There is a pyramid from prevention up to care that is still the same as it has always been, which is that the majority of daily activity around prevention and primary care is at the base of that pyramid. It involves much more than physicians and public health practitioners in terms of community supports and all the other factors, whether it is education, workplace health and safety and many other things that impact on our daily health.
I want to be careful not to suggest that the primary care physicians are the obstacle to better integration. I will share the responsibility for failing to have built those connections and those links. It is a shared responsibility, and strengthening the capacity at the community level not just in the health care system but also in the general community capacity is still, for me, from a public health perspective, the first priority of our work.
The Deputy Chairman: There is no question about that from the testimony has come before us. Primary care physicians are doing a marvellous job. They are not getting the support they should get.
Senator Callbeck: Continuing on with public health capacity, within the city of Ottawa, Dr. Huston, you mentioned many things that are on hold because you do not know where the funding is. Is there still preparation going on or is it fair to say that most things are on hold until you know where the money is coming from?
Dr. Huston: Several things are going on. We have phase one, phase two and phase three. We are doing phase one. We are preparing phase two. Phase three is on hold. We have a phased-in approach.
Senator Callbeck: I know time is a factor here, but I have several questions for Dr. King. With regard to the antiviral, you mentioned that we have 35 million doses now. Did you say we have 35 million on order or five million?
Dr. King: There are 35 million doses in the country and five million are on order by provinces and territories.
Senator Callbeck: Who determines how many we should have?
Dr. King: That is an important question. The Pandemic Influenza Committee provides advice on three things: the potential size of an antiviral stockpile, the composition of the antiviral, and how it should be used — the priority groups for the use of it.
There was an initial target set, in March of 2004, for a 16 million dose stockpile, which the federal government cost-shared 60-40 with provinces and territories. Since that time, provinces and territories have purchased more, above and beyond that. The Pandemic Influenza Committee is currently having deliberations on what the optimal size of the stockpile should be — this decision has not yet been made — and what the composition should be. For instance, because of concerns related to pills potentially being useful for everyone, for instance, we are looking at diversifying with liquid Oseltamivir. We are also examining the use of an disk inhaler drug called Zanamivir, which is another antiviral drug. We are looking at the potential for diversifying our stockpile with that as well.
However, the final decision in terms of what an optimal stockpile size should be has not been made and is still under discussion with all levels of government.
Senator Callbeck: How long does it take to get it after the order is placed?
Dr. King: It depends how much you are looking for. Right now, the wait lists are in the order of about a year for most antivirals, if you want a significant quantity. There is a global shortage of antivirals. They are all being purchased right now. Countries are in a queue for antivirals. We know from the experience of Hong Kong in 1997, when the avian flu scare first emerged, that they were all bought up and used. That is why it is important that we stockpile in advance and plan our antiviral strategy.
I want to emphasize that antivirals, for many reasons that have not been mentioned, are not a panacea. Antivirals are one element of an overall, well-rounded pandemic response. We need to think of what our priorities are for investment in pandemic preparedness. The challenge with antivirals is that they are specific to a pandemic response. In terms of building public health capacity, building our public health system, they will not achieve that. We must think strategically about how much money we need to invest in antivirals versus how much we invest in these other elements in the system.
Senator Callbeck: For how long are they good? Is there a time frame?
Dr. King: Yes. They have a shelf life. Oseltamivir, also known as Tamiflu, which is the drug of choice at present, has a shelf life of about five years, but we have discussed the possibility of looking at an extension of the shelf life to make it last as long as possible. However, five years is the stated shelf life.
Senator Cordy: I want to go back to the idea of communication and whether people on the ground are actually getting information. I served on the Standing Senate Committee on National Security and Defence when it looked at emergency preparedness and the Office of Critical Infrastructure Protection and Emergency Preparedness.
When we talked to the people in Ottawa, they all said that everything was wonderful. We then travelled to the provinces and asked, "Do you know where your supplies are?" Most said they did not. In one case, members of our committee went to where the supplies were, and the supplies were outdated and mouldy. Sometimes at the national level we think everything is wonderful, but it does not really get down to local levels. Is the information, the plan, getting down as far as the regional health boards in the provinces?
Dr. West: I had a conversation with a medical health officer for St. John's Health Region on this very issue before I came away. It is not only the health board level, it is the communication from the health board itself to the front-line worker. He said to me that he believes that is where the biggest challenge is. The managers at the health board level are starting to get it, but the problem is getting down that extra step to the front-line worker.
Senator Cordy: That is the most important step.
Do we know who will be in charge? It is great to have a plan, but do we know who is driving the bus and who will be in charge? Is it at the local level, the provincial level, or does it depend on the situation? Has that been decided?
Dr. King: In the event of a national emergency such as a pandemic, the whole of the government approach will be coordinated by Public Safety and Emergency Preparedness Canada and by the Deputy Prime Minister. That will be the coordination. The lead on the health issues will be with the Minister of Health and with the Chief Public Health Officer. The Chief Public Health Office and his staff, including me, will provide the technical advice to the Minister of Health and then across government on health matters.
Dr. Kettner: An important principle of our planning in Manitoba, and I could say that this is probably true throughout the country, is that a good emergency plan builds on everyday business of doing things as much as possible, so that the last thing we want in facing a pandemic is to stop doing business the way we did altogether, and all of a sudden different people are in charge of different parts of the system. It is a balance question, in my view, involving all the usual duties, responsibilities and accountabilities in our health system, which is complex today without a pandemic. What is the regional responsibility? What is the responsibility of the physician? What is the provincial responsibility? How do we work together, vertically and across? We must balance keeping that system working as best it can with the overlay of the kind of coordination that is needed so that there is consistency and efficiency in our work.
When I say the planets are lining up better for progress, some good examples of that have already mentioned by Senator Keon about the Public Health Agency of Canada. We also have a Pan-Canadian Public Health Network now, which has federal, provincial and territorial representation at a council to oversee many functions in public health at a national level. Therefore, the ability to achieve consistency and efficiency is improving, so that someone in a province does not have to invent every wheel that could be the same across the country. It is my job at the provincial level to make sure that integration happens at the regional and local level. We have a role to play in this. If we plan well and respond well, we will build on the systems we have but not change them more than we have to.
The Deputy Chairman: I caution you that Dr. Trenholme Counsell is a family physician. Beware; she knows her stuff.
Senator Trenholme Counsell: This was both an interesting and an important, valuable presentation.
My first question is about how this spreads. Is it respiratory-spread?
Dr. Bossé: It is spread by droplets.
Senator Trenholme Counsell: It is droplets.
Second, based on the situation now of a few deaths reported from the Far East, are you making any predictions, wild or sane, on the rate of spread? We know that the spread pattern would be from east to west. Are there any educated predictions? If there are any predictions, it will be from this group of people.
Dr. Bossé: If we talk about the animal side of things, because at this stage it is mostly an animal issue with some catastrophic but limited incidents in human health, it is going westward through Europe. As it goes through the south and the African countries, if we could predict how it actually moves, there is a lot of importance given to the wildlife as a way to move the virus around. However, one is currently overstating the role of wildlife. I am not saying it is not playing a role, but currently, we are not aware of any type of wild birds to survive that virus. Potentially, there are a few. For a bird to migrate, it needs to be infected and stay infected and healthy to migrate and come to North America — or through South America or North America, depending on the migratory routes of those birds. At this stage it is a hypothetical question, namely, how long would that bird be able to carry that deadly virus, remain alive and continue the migration. There is no doubt there is a the risk of non-intentional entry through illegal importation of animals or through people carrying it in their belongings that have visited an infected site. It is a potential threat to animal health. From the public health side, I could let my colleagues answer that, but if it was to become a pandemic, it depends where in the world it starts.
Senator Trenholme Counsell: Apart from a pandemic, we have had three deaths in the Far East due to avian flu.
Dr. King: There have been over 60 deaths.
Senator Trenholme Counsell: Recently, there have been 60?
Dr. King: Yes; over the last two years now.
Senator Trenholme Counsell: Are those being spread from person to person?
Dr. King: No, they are not.
Senator Trenholme Counsell: There is no evidence of spread from person to person yet. As far as you know, they are isolated cases?
Dr. King: Yes: I want to reinforce that it is difficult to acquire avian influenza. The cases that have occurred in humans — and, we are talking about bird flu — have resulted from close, sustained contact either with poultry or with the environment the poultry are in. Some have been the result of consumption of raw poultry products such as duck blood, for instance, or intimate contact with saliva from fighting roosters — so really, sustained intimate contact. That is why, in terms of the prevention of avian flu in humans, for instance for Canadians, we have a travel advisory page on our public health website and we tell people to avoid contact, where possible, with domestic poultry and with live animal markets and places like that, where there might be a higher risk of acquiring avian flu.
Senator Trenholme Counsell: You said raw duck products?
Dr. King: Yes.
Senator Trenholme Counsell: Is that the transmission medium to humans? That is why I asked the original question.
Dr. King: Right: It is an important question. Influenza is generally transferred through the respiratory route, through droplets. Perhaps there is an element of inhalation. When people drink duck blood, it is not thought to be transferred through the enteric route. It is probably still as a result of inhalation that these cases have occurred.
I use these examples to reinforce the issue that avian flu, bird flu, requires intimate and sustained contact with infected birds.
Senator Trenholme Counsell: The experts are not saying it could be next year or likely to be five years. That is not stated by anyone at the expert level.
Dr. King: We do not know. Not only do we not know when a pandemic strain will emerge, we do not know what the cause of the pandemic will be, either. We do not know if it will be either an H5N1-related strain or something completely different.
The Deputy Chairman: Unfortunately, we must leave this room. The other committee is banging at the door. We are five minutes over our time. I want to thank everyone. I must caution the witnesses that, in a way, you are fortunate. The two people who did not have a chance to ask questions are both from Newfoundland: Senator Cochrane and Senator Cook.
Senator Cook: I have a quick question. Is there a reasonable solution to the national news, where, every night, I see dozens of chickens and ducks being crammed into bags, frightening the general public? Is there something we can do about this so that we do not kill people through fear rather than the flu?
Dr. Bossé: For every occasion, the federal government or the expert must tell the media that this is not a human health issue. We are trying hard, but you know the media.
Senator Cochrane: You do not see that, though; you only see the chickens getting crammed into the bags. Thank you.
The committee adjourned.