Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 12 - Evidence - September 29, 2010
OTTAWA, Wednesday, September 29, 2010
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:16 p.m. to study Canada's pandemic readiness.
Senator Art Eggleton (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
We are starting a new study on pandemic preparedness in this first session as a result of a letter received from the Minister of Health, the Honourable Leona Aglukkaq, which came to us in June. The researchers and staff have prepared a work plan, which has been approved by the steering committee. We will conduct this study over the next nine hearings, some meetings will be two hours and some will be three hours in length. Toward the end of these hearings we will hold a round table meeting for three to four hours to wrap us up in early November. The Library of Parliament researchers will then draft a report and submit it for translation. Toward the middle of December, before the Senate adjourns for Christmas, the committee will table the report in the Senate.
You might have noted that yesterday in the Senate I put a motion to extend the reporting time from the end of October, which was in the original request from the minister, to the end of December. We consulted with the minister's office, and they agreed to that extension.
The first session will deal with background and overview of the H1N1 situation in Canada. Before I introduce today's witnesses, I welcome Senator Patterson, who is sitting in as a substitute today; and a new regular member Senator David Braley, from Ontario. I also welcome all others who have been here before.
Our first witness today is Dr. David Butler-Jones, Chief Public Health Officer of the Public Health Agency of Canada. Mr. Butler-Jones is Canada's first Chief Public Health Officer and leads the agency that provides leadership on government efforts to protect and promote the health and safety of Canadians. He has worked in many areas of Canada in both public health and clinical medicine and has consulted in a number of other countries.
Our second witness is Dr. Danuta Skowronski, Epidemiology Lead for Influenza and Emerging Respiratory Pathogens with the BC Centre for Disease Control. Dr. Skowronski is a clinical Assistant Professor at the School of Population and Public Health at UBC. She has been a communicable disease consultant with the South Fraser Health Region in Lower Mainland B.C. She is also a member of the American Board of Preventive Medicine. Dr. Skowronski is one of a team responsible for surveillance, research and policy issues related to vaccine preventable diseases, most notably influenza and pertussis.
Our third witness is Dr. Donald Low, whom I remember from Toronto during the SARS outbreak. Dr. Low is Medical Director of the Ontario Agency for Health Protection and Promotion public health laboratories. He is head of the Department of Microbiology at the University Health Network and Mount Sinai Hospital in Toronto. His primary research interests are in the study of epidemiology and the mechanisms of antimicrobial resistance in community and their clinical relevance. Dr. Low is a recognized authority on microbiology and infectious diseases. He has published more than 300 papers in peer-reviewed journals.
Dr. Susan Tamblyn is a consultant for pandemic planning and past chair of the National Advisory Committee on Immunization. She is a former medical officer of health. Dr. Tamblyn has been involved in influenza pandemic planning for over two decades. Since 2004 she has consulted on pandemic planning for all levels of government, and during the SARS outbreak she served on the Ontario SARS Expert Advisory Committee. During the H1N1 2009 pandemic, Dr. Tamblyn supported the pandemic response for the Public Health Agency of Canada as a member of the vaccine team.
Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada: I would like to thank the Senate committee members for this opportunity and for this contribution to the ongoing pandemic planning process. Several agency representatives will appear over the coming weeks, and myself more than one time to discuss pandemic planning and more details on the lessons learned from H1N1.
[Translation]
To help set the context today, I think it will be appropriate to start with the H1N1 experience.
[English]
Mr. Chair, what we saw in 2009 with the H1N1 pandemic could have been much worse. If the world and our approach to pandemics had not changed, it could have looked very much like 1918 all over again. Keep in mind that in 1918, a young healthy person would have died. In 2009 that same young healthy person was on a respirator, thanks in part to major improvements in technology, antibiotics and treatment.
However, H1N1 was not a Robin Cook novel, and there is a good reason for that. It is because Canadians, together with their communities, institutions and governments, responded effectively, as did those around the world. Our collective response could not have happened had it not been for years of planning and the Government of Canada's investment in this planning effort.
Without the plan, Canada may not have benefited from one of the world's highest H1N1 vaccination rates. A structure would not have existed to share ever-changing information and surveillance between jurisdictions, laboratories and hospitals. Canada would not have had a vaccine contract so unique in the world, tailored to our specific needs and focused on maximizing the safety of the vaccine and the vaccination process. We would not have been able to go from decoding the virus to the largest mass mobilization in Canadian history all in a matter of a few months.
[Translation]
We would not have been able to effectively address risks in vulnerable populations.
[English]
We would not have been able to launch national advertising and public education campaigns to provide Canadians with the information they needed to protect themselves and their families. Nor would Canadians have benefited from the access to early antiviral treatment thanks to national stockpiles and to relatively seamless, effective care, all of which helped ensure an 85 per cent survival rate in institutional cases, in those in the most severe cases in ICUs. The plan worked.
Governments invested in years of planning and it paid off. The plan built on lessons from the SARS outbreak in 2003, which included setting up the Public Health Agency of Canada, agreeing to protocols, tools and improving lab capacity, research and communication. It was centered on a unique 10-year pandemic vaccine contract, and it linked and maintained national groups of expertise, international networks, global and domestic surveillance, media and communications, following the leadership of the World Health Organization.
It is nearly impossible to count with any certainty the amount of illness and death that the actions of all Canadians prevented. International comparisons are difficult, especially given major differences in how other countries collect data.
[Translation]
But the outcomes of our shared interventions speak volumes.
[English]
The use of antivirals in children leapt from 48 per cent to 89 per cent between both waves of H1N1 and 60 per cent to 65 per cent of Canadians said they increased how they often practiced basic, personal infection control like hand washing and coughing into their sleeves. An Ontario study highlights that our shared interventions helped prevent $20 million in potential health care costs, not to mention preventing death and illness on a large scale.
This does not mean any plan can stop a virus in its tracks. Pandemics are notoriously unpredictable in terms of pattern and severity. By the end of the second wave, Canada experienced 428 deaths and thousands of hospitalizations. While the majority had underlying risk factors, about one-third had been perfectly healthy, and many of the others had mild, controllable diabetes, asthma and other conditions.
Intensive care doctors in Canada had never seen anything like the severity of respiratory distress and difficulty in ventilating adults. Young people not hospitalized described it as the sickest they had ever been. Others tell the story of heart and other problems that have persisted long after being ill.
Not everything about our response, though, was perfect. Managing the flow of urgent demands for information in real time meant we sometimes had to adjust our advice. The technical uncertainties associated with vaccine production sometimes translated into public uncertainties as to when vaccines might be available. Discordant voices tended to confuse rather than help Canadians.
All of this shows, as history has taught us, that the planning is just as important as the plan. For this reason, I am pleased to report the Joint Public Health Agency and Health Canada review of its response to H1N1 is nearly complete.
The review will include specific areas for action, across the spectrum of the response effort, leading to several cross- cutting recommendations. Non-government organizations engaged by PHAC and Health Canada throughout the pandemic were asked for feedback. Many of our partners, including provincial and territorial governments have their own reviews under way.
This committee's study will be an indispensable resource for all of us at the agency and for all partners involved. For the agency specifically, H1N1 was a test of our abilities on all levels in terms of preparing for public emergencies, promoting health and the practice of public health. I believe this experience will serve us very well in the future for all emergencies, not just future pandemics.
Dr. Danuta Skowronski, Epidemiology Lead for Influenza and Emerging Respiratory Pathogens, BC Centre for Disease Control: I want to start by giving committee an indication of my perspective. It did not necessarily come across in the biography, but I am a senior public health adviser and also a researcher, a scientist, and my portfolio covers rapid response activities. I have the rapid response portfolio, and I will explain what that means.
As a policy adviser, I am a member of a number of provincial and national committees, including the National Advisory Committee on Immunization, the pandemic vaccine task group, the Pandemic Vaccines Working Group, formerly the Pandemic Influenza Committee, and so on.
I advise policy-makers around influenza prevention and control annually, and during health crises due to novel respiratory pathogens — emerging pathogens. As an example, I was the lead on the response to SARS in British Columbia in 2003. We had a very different kind of SARS experience from Ontario. I also provided the human health recommendations around control of the largest poultry outbreak of avian influenza in Canadian history, the H7N3 outbreak, and I provided the guidance around the B.C. response to pandemic H1N1 this past year.
In order to do my job, in order to inform the policy-makers, is up-to-date and the best available evidence. That means that there has to be a real swiftness in the ability to generate that evidence but also to critically appraise new evidence that other people may be generating, because during a crisis that comes in very quickly. It is not necessarily done in the best form. In other words, a randomized controlled clinical trial cannot be done so sometimes the methods are not the top-notch methods that we were looking for but it is the best that we have during a quickly evolving crisis and compressed timelines.
There has to be an ability to appraise critically that evidence, and sometimes we have to generate that evidence ourselves and we have to be able to communicate that and translate that for others who need to make some public health decisions. All of that requires readily available and rehearsed expertise, infrastructure and capacity, both human and material resources.
I want to relate my main impressions from that perspective about the pandemic H1N1 response. First, from that perspective, there definitely has been improvement in rapid response and applied public health research capacity in Canada since the lessons learned from SARS in 2003. For instance, we now have three large and linked provincial public health agencies, namely the long-established BC Centre for Disease Control where I come from; also the Institut national de santé publique du Québec; and we have the newly created Ontario Agency for Health Protection and Promotion, which came about, as did the Public Health Agency of Canada, as a result of the SARS experience.
It is great that the three largest provinces are collaborating on research initiatives — that is, on evidence-based decision making. Obviously, it would be greater if there were others that could contribute to that.
The Public Health Agency of Canada was established as a result of the SARS outbreak. That agency is an enhancement to the national coordination efforts. In addition, Public Health Agency of Canada and CIHR-funded pandemic team grants that have helped support research networks and their development across Canada.
However, I do also think that there is still much room for improvement in the rapid response research capacity in Canada. First, we need to establish and rehearse a national process for rapidly generating, appraising, incorporating and communicating new evidence during a crisis. That is critical. If you look at the next slide, you will see a quote from a public health official indicating how he was struggling with dealing with new and evolving evidence that was accumulating real time during the pandemic. He said, "This is not my favourite way to do public health practice — in the middle of an evolving outbreak, to have to consider preliminary research as an influence on decision making."
During an evolving crisis, there is nothing but preliminary evidence. By definition, if you are dealing with a novel pathogen, everything is new. You must develop that evidence quickly and you have to be able to appraise and respond to it. This requires ready expertise, system flexibility and transparency.
Honourable senators, I believe that we have a severe lack of communicable disease epidemiologists or methodologists who can support and inform public health practitioners, policy-makers, and officials such as the public health official I just quoted.
I want to make the clear distinction between epidemiologists and academically trained methodologists — those who know how to appraise critically new evidence and studies — from the public health practitioners that use that information, from the policy-makers, and from the clinicians at the front line who are giving care. You need epidemiologists who can actually appraise the evidence as it is coming in rapidly.
I have observed an unwillingness to depart from prevalent viewpoints or bureaucratic processes. I say this in particular in relation to influenza vaccine. There are some strongly held opinions about influenza vaccine, almost polarized. It is almost religious in nature, the belief either in the vaccine or not in the vaccine. That can become difficult to deal with when you have to honestly and openly appraise evidence for or against the use of that product. We have to be able to let down our strongly held beliefs when we are evaluating during an evolving crisis, and we have to be able to adapt to the current context and our public health objectives.
I also observe advisory committees who are informing decision making whose conflicts of interest and debates are held as confidential. As a researcher, if I want to publish my research findings, I must declare in print what my conflicts of interest may be so that whoever is reading that evidence can know how to interpret it. However, that is not the case for advisory committees. In the U.S., the conflicts of interest are declared openly, published and posted. That is not the case here in Canada. For the sake of transparency, that needs to happen.
Finally, we have a critical appraisal and a peer review and publication process that cannot keep pace during a pandemic or an evolving crisis. If we want good peer review of science before it is translated into public policy, we need that system of experts who can participate in that process.
I will not go through these additional slides for the sake of time, but I want to draw your attention to the fact that an earlier review was done in follow up to the 1976 swine flu event. For those of you who do not know, in 1976 another H1N1 swine flu outbreak occurred, a limited outbreak, in Fort Dix military camp in the U.S. As a result of that the U.S. decided to launch a mass immunization campaign to immunize all Americans. It turned out that the 1976 emergence of a swine flu outbreak was limited. It was contained and it did not cause a pandemic. It did not spread the way they had anticipated, so it turned out that decision to immunize all Americans was not the right decision. Unfortunately, some serious adverse events happened as a result of that vaccine.
As a result of that experience, Neustadt and Fineberg — Neustadt being a political analyst and Fineberg being a policy analyst — did an in-depth review of the factors that led to that premature decision to immunize in the U.S. I would like to draw your attention to the references that I have provided because they give good insight. I have summarized the seven key lessons from that experience, which were echoed in the 2009 pandemic. They are difficult lessons to learn, obviously, but I think they are really important. I will just touch on a couple of them, if I may.
The Chair: Quickly.
Dr. Skowronski: First, overconfidence in theories spun from meagre evidence. Again, the evidence will always be meagre during an evolving crisis. What you want to avoid is overconfidence in evidence early on. You want to ensure you have a filter, a good safeguard of experts, epidemiologists, who can critically appraise that evidence.
Second, premature commitment and deciding more than had to be predetermined. For instance, the decision to use an adjuvanted vaccine in Canada was made early on. Was there a documentation of the evidence for and against that? That is, was there a detailed analysis of the benefits and risks associated with going with an adjuvanted versus a non- adjuvanted vaccine? How flexible was that decision with the evolving evidence as we progressed through the pandemic?
Third, the insufficient questioning of scientific logic and implementation prospects. At the local level, how readily were they able to administer that vaccine? We saw long line-ups. Was that taken into account in the planning process? For instance, the vaccine required mixing at the time of administration. How did that slow things down? All of these sorts of factors, for instance, and these lessons — and, I will not go through all of them — can each be applied in the modern era.
Finally, Fineberg did an update to those 1976 lessons learned in relation to avian influenza. I have summarized those for you as well. The two lessons that I would most like to emphasize are the need to invest in a balanced portfolio of research and contemporary preparedness. During a crisis, knowledge is power; information is critical. If you do not have that rapidly generated and synthesized, you are operating in a vacuum.
Second, we should refrain from the overstatement of objectives and the misrepresentation of risk if we want to ensure our long-term credibility and the trust that the public has in us.
The Chair: Thank you very much.
Before I go to our next speaker, I want to mention that Senator Dickson is also here. I am so used to seeing him at the Finance Committee, I thought he belonged here every day, but he is in as a visitor today. Thank you, welcome.
Senator Dickson: I am here for Senator Eaton.
The Chair: Senator Patterson, as I mentioned, is here for Senator Martin.
Dr. Donald E. Low, Microbiologist-in-Chief, Mount Sinai Hospital: First, I would like to thank the committee for allowing me to present before you today on some of the thoughts on the pandemic of 2001, some of the lessons learned and maybe some of the things we can do better in the future.
At the time that I was asked to make this presentation, I was also asked by the Canadian Medical Association Journal to do an analysis on the pandemic. Dr. Allison McGeer and I co-authored that analysis. It will be available in about two weeks online. Many of the thoughts that I share with you today are included in that article.
I also want to disclose that I participated in advisory boards for Roche and Novartis and that I have served on speaker bureaus for Roche and GlaxoSmithKline.
I will touch briefly on three things that continue to come up: Was the pandemic overhyped; the vaccine program; and maybe some of the lessons learned that we can look for to better ourselves in the future.
It is important to remember that, given that the flu pandemic is a global problem, it is the World Health Organization that is called upon in helping us prepare for it. Their involvement is critical. Because of SARS, subsequently because of H5N1 that was about 2005, and the fear that there may be another pandemic, it really served as encouragement to all countries to prepare for a pandemic, which was done, including Canada.
However, because of the severity of the human infection with H5N1 when it occurred, the mortality rate was over 50 per cent for individuals infected with H5N1. I think the public's expectations were that a similar pandemic or another pandemic would result in the same kind of mortality rates.
It is interesting when I speak to colleagues that it is almost as if they were disappointed that our pandemic did not live up to expectations. There is a bit of danger that people are perhaps thinking that we should not be concerned about pandemics. That is an important lesson we need to get out to the public.
One of the questions is why was it not as severe as it was or, in fact, was it really that bad? I think that we measure things in death rates. We look back to 1918, where we saw the death rate was about 1 in 100 people, 2 in 100 people. In fact, with H1N1, the mortality rate was only, fortunately, 5 in 10,000.
Part of the reason for that was it was an H1N1 virus, which is not as severe as H3N2. Probably more importantly, it affected young people. In fact, 10 per cent of the population infected was over the age of 65, whereas in a typical seasonal year of influenza, 90 per cent of mortality is found in individuals over 65 years of age. Therefore, a different part of the population was affected.
If you look back at years of life that have been lost — that is, someone that dies at age five and all of those years that are lost — and compare it to our H1N1 pandemic, it probably is as severe as a seasonal flu year and probably was as severe as the pandemic of 1968. We have to take that into consideration.
Regarding the immunization program, the decision was made by the Public Health Agency of Canada to have a vaccination program. That was done in June at a time when there was very little information available about how severe the situation would be. It is very difficult, with so little information, to make that decision. Was it going to be .1 per cent, 1 per cent or .02 per cent?
A decision was made to buy vaccine to have it available for every Canadian to be vaccinated. Some of the problems that evolved after that were the implementation of the vaccine program. These are where there are many lessons to learn.
I do not think we anticipated the complexity of delivering the vaccine. It was badly underestimated. The attempts to deliver a rapid public health education message about the vaccine failed and the vaccine did not become as available as quickly as we had hoped.
Vaccine manufacturers actually did a pretty good job. They got it out in six months, but everyone was hoping it would be sooner. The virus did not grow as quickly as we had hoped it would grow. In addition, we had the complete production of the routine seasonal vaccine, so you could not start up until that was complete.
There was a brief period that was lost because it was recognized that since we were using an adjuvanted vaccine, we would have to make some non-adjuvanted vaccine for pregnant women and young children, and that slowed things down, unfortunately.
It also returned a bit quicker than we had hoped. It came back in early September with a vengeance. I think we were all hoping we would get a bit of a break and that the second wave would come sometime in October or November, once the children were back to school, we saw this surge of H1N1.
The other issue that was a bit of a problem was in the delivery of the vaccine and the communication to the frontline physicians. Frontline physicians normally distribute vaccine, at least in Ontario, during the seasonal flu. That was in the plan for a pandemic, but it was going to be public health that delivered it.
There was a bit of a problem for primary care physicians who would have to buy 500 doses of vaccine at a time. Unfortunately, the vaccine was sold in that amount. This posed a problem for a physician who would not normally need 500 doses for a private practice. The physicians would run the risk of wasting a considerable amount of vaccine. The vaccine was also available in 10-dose vials, which meant that once the physician mixed the vaccine, he or she would have to give it to 10 individuals. After 24 hours it would no longer be effective. That was a bit of a problem.
In Ontario, there was a prequalification requirement for family physicians in order to be eligible to administer the vaccine. The physician had to have a proper refrigerator and the common bar fridge was not adequate. This meant that the physician would have to buy a new fridge and this in turn slowed down the process.
The message from the Public Health Agency of Canada was a little bit unclear — vaccine available for everyone but we have priority groups. Early on in September, from the polls that were being taken, it looked like no one was keen about being vaccinated. Only about 30 per cent of people were going to be vaccinated.
There was not a lot of interest, so some of the provinces said now we have this vaccine coming in October, let us use it and roll it out to everyone; they kind of fell from the guidelines. Then on October 26, we had the death of the young boy in the Greater Toronto Area and all of a sudden everyone started to take this quite seriously and people started to line up. Pretty soon, clinics were out of vaccine. In fact, I remember my son was in Calgary and he waited five hours to get vaccinated. The public became discouraged.
Then we came into a situation where people started to think, is this vaccine safe and do we really need it? We are not seeing the number of deaths that we have been told would happen and we are hearing about this adjuvant vaccine. Is it safe for my family?
What have we learned and what can we look for in the future that we have to do better? Will we be able to deliver a vaccine before the second wave of the next influenza pandemic or will we have to look for a new way to manufacture vaccines? How can we provide effective public education in the setting of a new disease? Can we better understand the emotional epidemiology of pandemic influenza? What is the optimal way to measure rapidly the virulence of a new pandemic influenza virus? That is, how quickly can we establish the narrow confidence limits for case fatality that range between .1 per cent and 1 per cent? When non-pharmaceutical interventions are effective, which ones are effective in reducing the spread of influenza and how effective are they? How can they be best implemented?
Dr. Susan Tamblyn, Public Health Consultant, as an individual: Good afternoon, senators. My presentation will be on a little bit different aspect than what you have just heard. I am probably the only person here who has been involved in Canadian pandemic planning since the beginning in 1983. That is when the National Advisory Committee on Immunization was asked to develop a pandemic plan for Canada, a project that I was subsequently asked to lead.
The impetus was the 1976 swine flu incident that Dr. Skowronski mentioned, in which a novel influenza virus caused severe illness on a U.S. military base and people feared the 1918 deadly pandemic would come back.
There were lessons learned, but a major lesson for Canada was finding that our usual U.S. vaccine supply was cut off. We had to scramble to find vaccine somewhere else. That experience taught us the importance of having a pandemic vaccine source within Canada.
Canadians were pioneers in pandemic planning and we developed solutions on our own, using our knowledge of past pandemics and of seasonal flu, the influenza that comes around every winter, as a guide.
The first plan completed in 1988 was much simpler than the current version, but it already identified the major issues and the response components that we have today. It recognized the link between strong seasonal or every year influenza programs and pandemic preparedness.
Throughout the 1990s, a small group including myself developed successive versions of the pandemic plan, adding operational details, and we consulted internationally. The 1997 bird flu incident in Hong Kong, which is when the H5N1 first came on the scene, added additional lessons.
The major lessons included the challenge of communications in a pandemic because it truly was a media frenzy, and the advisability of stockpiling antiviral drugs for influenza treatment because the world's supply was snapped up within days of that incident first being announced.
The following years witnessed the birth of the comprehensive current Canadian Pandemic Influenza Plan for the Health Sector — CPIP. In the early 2000s, the provinces and territories were encouraged to develop their own pandemic plans under the umbrella of the national goals and approaches. The recognition that pandemic plans could serve us well in other outbreaks or serious health events was a strong impetus for this planning, and everyone took it up seriously. A pandemic vaccine contract was signed with the domestic manufacturer, an extremely innovative approach, as you have heard, that has been subsequently copied by other countries. A national stockpile of the new antiviral drugs, Tamiflu and Relenza, was put into place. The intent of all of these measures was to protect Canadians when the next pandemic arrived. We knew its arrival was certain, but its timing and severity could not be predicted. We had to be ready for whatever came. The SARS experience led to further improvements. Influenza surveillance was enhanced, coordination was improved and operational details were added as annexes to the plan.
Was the pandemic plan complete when H1N1 struck in 2009? The plan was officially published in 2004, and it had been through one full update. It did not cover everything. It is always a work-in-progress, but it served us well. We were able to mount a fast and organized response in Canada, despite the huge difficulties of coordinating a health emergency that involves so many jurisdictions and sectors, as well as sectors beyond health. Influenza is not simple. There is not a cookie cutter approach. Most critical decisions have to be taken very early, when there is still little information, but they are built on the best scientific evidence we have at the time. As anticipated, the response to H1N1 was adjusted over time to match the evolving picture and the emerging scientific knowledge.
I want to make special mention of the critical role of surveillance because it underpins every aspect of controlling influenza. For example, we need surveillance data to predict how full our hospitals and our intensive care units will be; to choose appropriate public health measures so we do not overreact or under react; and to decide who to vaccinate first to prevent the greatest amount of severe illness and death. Our Canadian surveillance systems have improved a lot since SARS, but they still need work.
Let me conclude with a few observations about pandemic vaccine and antiviral drugs because those are the two primary areas where my own planning efforts have been focused in recent years and in the case of vaccine where I assisted with the H1N1 response. The pandemic contract and preparation by our regulators helped to ensure that we had a pandemic vaccine. There is accumulating evidence that shows that the H1N1 vaccine was safe and that it worked very well. Even though the second wave of illness was well under way last fall when the vaccination campaigns began, a recent Ontario study has found that the vaccine prevented hundreds of thousands of H1N1 cases, along with many hospitalizations and deaths; and that it was cost effective. Certainly, it would have been better to get vaccine sooner. I look forward to the scientific advances that will allow this to happen.
If I could mention, I am just back from a recent international meeting where there was a lot of discussion at WHO and at very senior levels around the world about how we can shave weeks off the delivery schedule or even move to completely new approaches to get us vaccine sooner.
Antiviral drugs used to treat influenza are especially valuable before we have vaccine to prevent the disease. Again, accumulating international evidence — I have a stack of some of the papers right here — show that the use of antiviral drugs in the H1N1 pandemic did reduce the risk of complications, hospitalizations and death due to influenza. They did what we hoped and expected they would do.
I began by recounting how past outbreaks and events including SARS have fed into our pandemic planning and improvements. To me preparedness was critical for the H1N1 response. While Canada did well, every experience makes us better prepared for the next time, and there will be a next time.
The Chair: That is why we are here looking at this; there will be a next time. Dr. Butler-Jones, you mentioned in your comments that you were doing a review at this time of the lessons of H1N1. When do you anticipate that report will be complete and when can we look at it?
Dr. Butler-Jones: Every time there is an event, we do a review. Obviously for H1N1 it was much more extensive since the involvement was much more extensive. The review is coming in the next few weeks and will be in parallel with your investigation.
The Chair: That is what I wanted to know. We will get it before we go too far down the path.
Dr. Butler-Jones: I anticipate that.
The Chair: That is great. I will ask my two-part general question to all witnesses.
You have given us your experiences, your thoughts about the different epidemics and pandemics we have had in past. I am trying to determine a suitable direction for us in terms of those experiences.
Could you give us two or three key improvement areas based on what happened with H1N1 and SARS that this committee should deem high priority in this study? What path should we follow so that during the upcoming hearings we are able to deal with those key issues?
We could have a mild pandemic or a severe pandemic. What do you think we should plan for — mild, moderate, severe — or is it a layered approach to planning? How do we come to grips with that?
Dr. Butler-Jones: the planning, while focused on influenza, is for all hazards. If we have another SARS outbreak or other event that we need to respond to, do we have the systems and processes in place to address it, whether mild, moderate, or severe?
Back in the spring, we had a virus from Mexico, as did the Americans, which was of a different strain. In studying influenza viruses, ferrets are the best animal model. These viruses from Mexico killed the ferrets faster and nastier than our 1918 virus. The virus is very variable, which has been seen in the past. Even in 1918, different communities had very different experiences with the virus. As people learned the lessons from the East Coast experience, the mortality rate improved moving west across the country.
At the end of the day, although 1918 was probably the worst pandemic in human history, as far as we know, of influenza, 99.5 per cent of Canadians survived it. Of the 25 per cent that became ill, mortality was 1 per cent to 2 per cent, but that is still a lot of people. As Dr. Low made reference, the 2009 pandemic in terms of premature mortality and potential years of life lost was only second to that of the 1918 pandemic, and ahead of the 1950s, and 1960s pandemics because of its effect on younger people. We need to plan for all possibilities.
Reality for a virus is that it does not want to kill a lot of people because it wants to spread. People who die do not spread it easily. You will likely not have a 30 per cent mortality rate in an influenza that spreads easily from person to person. However, even 0.5 per cent, to 2 per cent mortality is an awful lot of people in a short period of time. In this pandemic, 90 per cent of the deaths were younger people, and 90 per cent of deaths in seasonal flu outbreaks are the very elderly. The median age, that is half-younger, half-older in terms of death for this pandemic was 51 years. That age was very close to the median age of the pandemic of 1918. In seasonal flu, the median age is in the mid-80s. Again, it is a very different pattern of disease with a very different impact.
Our desire is really to look at the different aspects. We have learned a number of lessons. We have applied them through it. For example, while we had a number of deaths in pregnancy in the spring, we had zero deaths in the fall because of, again, recognizing the high risk, applying antivirals. We changed the picture in Northern Canada to basically eliminate or reduce the mortality significantly.
I would like to start where we ended, plus the lessons learned. The lessons learned that you can glean around are there models of better, more rapid immunization? Again, some communities were able to do it better than others. In terms of validating, we think the pre-positioning of antivirals in remote communities really made a huge difference.
There are a number of things like that that in your review, in your questioning of witnesses, to validate the positive things that we have learned, if that is in fact true, as well as how we can address things better in terms of either decision making or communications. We can always do more communications, but again, it is fortunate the antivirals worked. If we had had resistance to antivirals, we would probably have had thousands of deaths.
It is also fortunate that for most of the world that used unadjuvanted vaccine, that in fact it was effective because the clinical trials that led up to the decision to use an adjuvanted vaccine found that, with H5N1, unadjuvanted vaccines did not work. They were not effective in producing immunity, even after two doses, much less than an adjuvanted vaccine. In the spring we had no idea of how effective the vaccine was, so an adjuvanted vaccine, as it turned out, gave virtually 100 per cent protection to children with one half dose.
Again, the validation and the challenge as we move forward will be very helpful to all of us.
The Chair: Again, the question is the two or three priority areas we should be looking at, and mild, moderate or severe.
Dr. Skowronski: Rapid response needs a system that is nimble, well rehearsed, for which the infrastructure is already present. By definition, a crisis requires rapid response. As I said earlier, I think we need to beef up the rapid response, in terms of controlling the crisis and in terms of evaluating the crisis; the rapid response research capacity. It is not just the research but the ability to then interpret that research. I will say it again: We lack academically trained epidemiologists, methodologists who are highly skilled in critically appraising the meagre evidence or the weaker levels of evidence that are generated real time during a crisis. That takes high-level skill, and you do not get that on a dime. You do not get that when a crisis is starting if it is not well established.
The nice thing about influenza is that it recurs every year and each year it adds a new twist or turn. Maybe it is antiviral resistance of a seasonal strain one year. Every year I am asked by the media: Is this the worst year that it has ever been? Is this the mildest year that it has ever been? It is always something different. Therefore the nice thing about influenza is it needs to be evaluated on an ongoing basis.
Think about how much money we spend on influenza prevention and control every year. In fact, more people die from seasonal influenza between pandemics than die during a pandemic, so there are many things that we need to evaluate with influenza.
That is a nice platform, then, for establishing infrastructure and for rehearsing it. We are not there yet. If we were to invest in more epidemiologists, more methodologists, they could become critical to the policy-makers who are having to make the tough decisions during a crisis and do not have the support of the information. Nobody wants to have to make a tough decision without information to support that decision, so if we had those epidemiologists and that research network and that process for generating and evaluating critically appraising evidence real-time, I think it would really set us far ahead. It would serve not only Canadians but actually others who would depend on that evidence as well.
Then in terms of should we prepare for a mild, moderate or severe pandemic, frankly, again, you want your system to be flexible. If you have the infrastructure in place, it should not be too much of a stretch to go further or to use that system for events that may be slightly outside of the margins for which you are already accustomed. If you do not have those baseline systems and that infrastructure in place already, you cannot even respond to a mild or moderate pandemic.
Ideally, of course, you want to be able to address across the spectrum; prepare, as they say, for the worst and hope for the best, but at least have that infrastructure in place, rehearsed and well-experienced so when it is needed you are ready to serve.
Dr. Low: We have come a long way since SARS 2003. There have been incredible improvements and we all know we can do better in the future. One of the topics at the top of the list of things that maybe did not work well and can work better in the future is communication — communications federally among the provinces so that the messages are synchronized. That is what the public wants to hear. They want to hear the same message.
Generally we need to know how we can deliver the right message to the public when we are dealing with something that is mild to a moderate risk. How can we do that? If we focus on influenza — and there is quite a large effort being made to look at this south of the border — we need to look at vaccine production. We need to either look at a different way of making vaccines or getting vaccines available to us sooner.
We also need to understand influenza. As Dr. Skowronski said, this is something that comes back every year, and the same questions keep coming up. Personal protection; do I have to wear an N95; when do I have to wear an N95? We just do not understand a lot about this virus, despite the fact that it has caused us such grief over the years. We need to continue to do research in that area. We need to continue to support the epidemiologists in the surveillance that is so critical, and I think we did quite well during H1N1.
Preparing for the next event, whatever it is, whether mild, moderate or severe, I would agree with Dr. Skowronski's remarks. We need to prepare for the worst and hope for the best.
Dr. Tamblyn: I will start with your second question. I really agree with the previous two. Our current plan focuses mainly on a moderate scenario but emphasizes the flexibility. I think it was always the intent that the next step in planning was to develop a broader range of scenarios. I would say that moderate focus served us well because it is easier to go up or down. One of the H1N1 observations is that some countries that had been planning for something that was very drastic had a very hard time adjusting to something that was not quite as drastic and used a lot of public health measures that were really problematic until they were able to finally sort that out.
I have already mentioned the importance of surveillance and the need to invest in improving our surveillance systems in the country, and I would add to that and echo what others have said about pandemic research. In terms of surveillance, the capacity for analysis has been brought to your attention; that is the need for special studies, particularly very early on in a pandemic where you want to know what the disease is like and how fast it is spreading through a population. We do not have a lot of those special studies in place, organized or capacity to organize them on a national basis. That needs to be part of the preparedness.
There is the capacity to monitor who is being vaccinated where through systems like Panorama. It is intended to be a national system of electronic record keeping, and that stalled along the way and would be tremendously helpful for another time. Then finally there is the record sharing agreement. There has been quite a lot of work in this, and I am not quite sure what their status is, but things like that need to be finalized.
My second area that I wanted to mention is I think we can do a lot to improve capacity to deliver vaccines and antivirals all through the system, but that is something that happens particularly at local level under provincial or territorial directions. There is a lot to learn in this area, and there is a lot of experience. We saw many good solutions. Most areas got their feet under them within a week or two and developed some smooth ways of moving forward. I encourage the sharing of best practices by provinces and territories for ways to target people. We began with a targeted program to people who were high risk or in the first priority group. I encourage the sharing of how to reach people effectively and how to do it smoothly. That is to say, how to move large numbers of people efficiently through clinics. I think there is a lot to learn there from sharing our best practices.
Finally, I wish to mention the whole issue of surge capacity in our health care system. That is an ongoing challenge in our country. Many aspects of the system, for example, family doctors' offices, hospitals and intensive care units, were right at capacity. They were using their pandemic plans. They were right at capacity. If it had been any worse — and you have heard this was not on the severe end of pandemics — we would have been in large trouble. That is an area that is not easy to solve. It is not even easy to know how to address the planning, but it is an area where future work will pay off.
Senator Merchant: The federal government was criticized because we had only one supplier of vaccine. The government kept saying that the supplier would be able to deliver the vaccine within a certain time, but the supplier was not always able to do so.
Do you feel that for future planning we ought to have a backup plan? How would you handle this differently? How would the government handle this differently? I look to all of you for a response if you could, please.
Dr. Butler-Jones: Since I am here as a federal representative I will begin the answer.
Canada, with a domestic supplier, had a more secure and complete supply than countries with multiple suppliers. Many countries without domestic supply — and Dr. Tamblyn referred to this earlier, namely that part of the reason for having domestic supply was the access-to-vaccine issue — were still waiting for vaccine in January. I said in the spring that we hoped to have vaccine by November. We started immunizing in October. I said that we hoped to be able to immunize anyone who wanted to do so before Christmas, and we did so. We met what we expected to do, and one supplier provided us with sufficient vaccine so that all Canadians who wished to be immunized could have been done so by Christmas. We are the only country that I am aware of that was able to do that, except for maybe Sweden with a much smaller population.
Are there best methods? For example Nunavut, with very disparate communities scattered over the size of Europe, within two weeks provided immunization in every community for those who needed it and wished it and had a high rate of immunization. There are many lessons to learn in the planning as we move forward and from best practices as well. I am sure you will be identifying those as you move forward in your deliberations.
Dr. Tamblyn: I will add to that. I think the real values of having a second supplier as a backup is in case something goes wrong. Also, it is a way to get an alternate formulation if you need a small amount of another vaccine that someone else is producing without having to disrupt your major way of moving forward. As Dr. Butler-Jones has said, your domestic source is really important.
Dr. Butler-Jones: With the existing manufacturer, the government and the manufacturer have committed to a new fill facility which essentially has the capacity of 30 million doses a month, which will be a different issue should we face a new pandemic.
Dr. Skowronski: I think there was good, solid rationale for wanting to have a domestic manufacturer. I think that was a wise investment. It was like buying insurance to ensure that we had some supply in Canada. Whether it should be a single manufacturer versus some diversification, I think some diversification as a backup would be a good idea.
Where I have some additional concern is, again, related to process. Having one manufacturer means that you are dependent on that manufacturer. If there are difficulties in negotiation at the time of a crisis, that is not a good situation to be in.
For instance, the decision on the process of selecting an adjuvanted formulation over a non-adjuvanted formulation was made at the federal level. I was on the Pandemic Vaccine Task Group that was advising on those sorts of decisions, but the benefit-risk analysis — that is, the pros and cons, the strengths and limitations of one over the other — was not documented, to my knowledge.
How those decisions are made when you have a single manufacturer opens up some questions about process. It would be good to have some diversification because that does force some of the process issues to be followed.
Dr. Butler-Jones: For clarification, the discussion of adjuvanted versus non-adjuvanted had gone on for some time in advance of the pandemic, and clinical trials were funded to look at adjuvanted vaccine or mock vaccine with the H5N1. That is where it was identified that if we faced a virus like that, un-adjuvanted vaccine would not be effective versus the adjuvanted vaccine.
While at the time of that decision there was not a specific consultation with that particular committee, those discussions had gone on for some time in advance. This is a communications question. I think more communications are important, and that is certainly a lesson that we have learned. By and large, it had left the barn. There is an RFP out currently for looking at potential alternate suppliers.
Senator Merchant: Did part of the difficulty in delivery also have something to do with jurisdictional powers between the provinces, the federal government and the municipalities? At times, there seemed to be a lack of communication among them.
Dr. Butler-Jones: That may be variable depending on where you are in the country. One of the challenges was that we were watching the vaccine being produced as we were about to use it. Normally those things happen months in advance of actually moving it out. No one ever knew about this, but literally, every time there was a series of cracked vials, the manufacturer learned it as we learned it, as we told the provinces, as they advised people and had to adjust their plans. It was challenging and made it difficult for the public because we were thinking that we were going to get three million doses this week. Suddenly, a whole bunch of vials were cloudy. Safety is paramount. You pull a bunch of boxes away and you only have one million that week. It is difficult for planning, but, in the midst of a crisis, you are building the plane as you are trying to fly it through the storm.
Dr. Low: Part of the problem, too, is the logistics. You do not like to promise something that is not going to be there. The promise was in November that the vaccine would be delivered, but we were lucky to have it earlier. You then had local public health having to ramp up quickly. That was difficult, because they had to rent a facility and they had to stock that facility. They had to hire people and train those people how to give the vaccine. They had to hire refrigerator trucks in order to store the vaccine. These are huge things to carry out. You want to do it as fast as possible, because we were on this part of the curve. There was no waiting around a few weeks. We had to do it. You saw this in the media. People were lining up because they were concerned, especially after the death of that young boy. These are logistical problems that are difficult to deal with in such a situation.
Dr. Skowronski: You raise an important point. As Neustadt and Fineberg pointed out in the lessons learned in the swine flu of 1976, local implementation plans and prospects for delivering have to be taken into account. As part of pandemic planning, in some areas, that was a weakness. That was a "had-not-got-to-yet" part of the plan.
To be fair, certain nuances of this vaccine were unexpected. For instance, the packaging and the repackaging was not made known in a timely way at the provincial or local level. There was also a need for the actual deliverer of the vaccine to have to mix it; it was almost like a partially produced vaccine. They had to finish the production process, to mix it. That added time and delay.
We can learn from that. I hope that at the local level, they are paying attention to that and building some buffers, some capacity to enable them to move more swiftly the next time.
Senator Cordy: Thank you all for being here because I think it is important that we evaluate what happens and do a lessons learned exercise.
We all know that after the SARS crisis, there were great improvements in the way things were done, and hopefully, we can improve on the way things will be done in the future. As Dr. Skowronski said, we know there will be more flu epidemics in the future.
Dr. Low, you asked was H1N1 overhyped and Dr. Skowronski talked about decision making on a slippery slope. Senator Merchant asked about the single source provider.
We know from radio, television and newspaper reports that many people waited to be vaccinated. We know that the provinces were not sure how much vaccine they were going to get or when they were going to get it. We know the end story, that 50.4 million doses of the vaccine were purchased and that 25.143 million doses were distributed. I believe five million went to Mexico and they were going to be sent back to Canada by March 2010; five million were donated to the WHO relief efforts through CIDA — another great idea. That would leave 15 million doses. Did we buy more vaccine than we needed? If we did, are those 15 million doses storable? What is the best-before date for that vaccine?
It seemed to me that we waited too long to get the vaccine. Then suddenly in December-January, we were still getting all of these dosages. While 45 per cent of the population received the vaccination, 55 per cent did not. What happened to the 15 million doses, or 20 million if you count in the five million returned from Mexico?
Dr. Butler-Jones: We can provide all of that information to the committee. Essentially, at the request of the provinces, we ordered 50.4 million doses. The order was placed eight years ago when the contract was first let, and then it was just how many we actually wanted because we had first priority on the vaccine.
As we got closer to it, that order was placed. It was recognized that the efficiency of this particular vaccine was good — that one dose should be sufficient. With the manufacturer, it was actually mixed, so there were packaged doses, bulk vaccine not actually packaged, et cetera. There was a range of preparations to add to the flexibility.
As you say, five million doses went to Mexico. WHO had sufficient vaccine given where they were, so we did not do that, but the bulk was purchased back at a cost. There were a number of things so that we were able to reduce the total cost. We did not actually buy 50.4 million doses, but we can provide you with the details. We will send that to the committee clerk.
Senator Cordy: The next thing I would like to talk about is communication and how we can improve it. After SARS, we certainly had plans in place with all levels of governments for communication. I am not sure that it filtered down. I think people at the top might have known the communication plans, but I am not sure it got to the front line providers in the provinces.
In Nova Scotia, we saw full-page ads, paid for by the federal government, telling us that all citizens had to be vaccinated. The article on the next page said that the clinics would only be open on Monday and Tuesday because they did not have enough vaccine for the week. People got a little bit nervous and understandably so.
Another thing was the priority groups. Who determines the priority groups? I got something from the International Firefighters — I am sure other people on the committee did as well — saying that health care providers certainly were at the front of the line, as they should be since they are dealing with it, but what about other emergency workers? Firefighters felt that they should be considered for the priority list. The firefighters in one province, in fact, received a scathing letter from a health administrator asking how they could dare to be so outrageous as to ask to be on a priority list.
Who determines the priority lists? Does the federal government make that determination? The letter we received — and I am not sure whether that is something that this person experienced or whether this was all over — said that local people, not even ministers, were making those decisions. Did that decision come from the federal or local level? On communications overall, how can we ensure that it will filter down?
Dr. Skowronski: Communications is key. I totally agree with you; and I agree with Dr. Low that harmonized messaging is critical. As credible experts, we must be able to express uncertainty about timelines for vaccine availability, uncertainty about risk and so on. The way to improve upon that is through proper processes, ensuring you get the input of experts before declaring to the public about certain risks or certain timelines. It is important to build that capacity, because communications is an issue every year with influenza. We ought to have that opportunity to rehearse each year, and we do. It is ensuring that the right people are kept informed in communicating, and that is at the top and all the way down to the local level.
In terms of the priority groups for vaccine receipt, that was one of the responsibilities of the Pandemic Vaccine Working Group, to which I belonged. I can tell you that this emphasized for me why it is so critical to have evidence and surveillance data available. Ideally, you are trying to make decisions to prioritize vaccine, to sequence vaccine during periods of vaccine scarcity right at the beginning when it is just starting to roll out. Do not forget, we were rolling out vaccine pretty much around the time of the peak of the pandemic, so we really wanted to ensure those who were at greatest risk were being protected because, thereafter, they are not going to get the same kind of benefit.
You want to make that decision based on who is at greatest risk of the disease, while taking into account the social priorities. For instance, what emphasis do people place on children versus the very old? We must recognize that most parents want their children protected before themselves.
It is really a balancing of those different perspectives, and that is why it is important to have that surveillance data available to know who is most at risk: Is it the 90-year-old or is it the 9-year-old and what kind of risk? That evidence, that surveillance data underpins every decision, and should, that we make. That is why we really have to emphasize getting that information. The decision was made by the policy-makers and the public health network, et cetera, that Dr. Butler-Jones led with advice from the Pandemic Vaccine Working Group.
Dr. Low: It is very difficult when health is a provincial responsibility, whereas in the U.K., it is a little bit easier to roll out the same message across the country. It is difficult when provinces make different decisions about whether to have the same priority group and how they will deliver the vaccine.
I am not sure that there is an easy answer for that question. Maybe Dr. Butler-Jones can speak to it. We found differences in two ads in The Globe and Mail. It would be ideal to avoid mixed messages. It is unfortunate, but people sometime use such messages as an argument.
Concerning priority groups, this is all part of surveillance and working together and gathering information so that we can use it intelligently. We will do better next time than we did this time.
During SARS, we had patients who were getting four different drugs with absolutely no evidence that any of the four made any difference whatsoever. It would have taken only a clinical trial of 20 patients and we could have saved a lot of grief by not administering toxic drugs; but that never happened. As we progressed through SARS, we continued to administer because we did not have the ability to do the science in real time, which we have to be able to do. Dr. Skowronski referred to the fact that we have to pull that information in quickly so that we can make proper decisions.
Dr. Tamblyn: It is interesting that there was actually a pandemic vaccine prioritization framework developed by the Pandemic Vaccine Task Group about a year in advance of the pandemic. It was done to be able to help us out in exactly this situation, and was waiting for a chance to exercise it before it was published. Well, we got a real time exercise. That prioritization framework was published and made available on the website before the process actually happened. It is a comprehensive framework based on the framework that provinces and territories use for deciding what vaccines to buy. It includes not only the scientific evidence but also the ethical considerations and program considerations; issues such as strategies, logistics and the acceptability of doing it that way; and additional policy considerations, including looking at WHO recommendations and what our neighbours to the south will be doing.
In doing the work and making the recommendations this summer to work on that, the process in the meeting where those recommendations were worked up included provincial and territorial representatives, so they could advise us on feasibility, as well as representatives from the Paediatric Society, the Society of Obstetricians, First Nations, et cetera. There was a great deal of consultation before they were accepted.
Certainly, these were national recommendations. I had hoped, and I still hope, that at another time they would be applied more consistently across the country. That was a lesson learned. They were tailored quite carefully to what we expected the vaccine availability would be but, of course, that changes over time. There is a need to look more carefully at them at the time you are ready to roll out, but that has all the difficulties of last minute decision-making as well. People need to know where to go. If there were difficulties in applying them, it was because there were variations across the country. At first, people wanted to be able to not send away those who did not fit criteria and make them come back. They wanted to be able to accommodate them but then realized that it was not going to fit with the vaccine supplies. Many lessons were learned in the provinces and territories. I note again that it is a huge challenge to target these people and to deliver such a program. Many lessons were learned that will be captured, I hope, to know how to do it better next time.
Dr. Butler-Jones: We do not hope to ever have this again, but there are always events of some kind.
One thing that crosses over to a number of these questions is the importance of testing the plans. Many local health authorities thought they were ready for pandemic influenza immunization but suddenly their two city clinics were overwhelmed. They never really tested but thought they were fine. To everyone's credit, they adapted quickly as they found ways and learned from each other to move it. Testing is important.
In terms of ads, there was close coordination of provincial and federal ad messaging in terms of everyone having the same information. Even with having the same information, once in a while someone would choose to do something different. That is the nature of the federation. More consistency is better. A number of reporters commented on their frustration because we were all saying the same things, so they sought out different opinions, even though some were ill informed. Some people said that the vaccine would not be ready until January for various reasons. Where did they get that information?
Senator Cordy: Did that surprise you?
Dr. Butler-Jones: No, but the amount of it surprised me. Priority groups, as described, are established initially. The purpose of the plan is to reduce severe illness, mortality and social disruption. We found in the first wave that those who were dying, by and large, were pregnant women and those with underlying risk factors, not kids. Kids were more likely to come down with it but they were unlikely to die. To immunize all the kids and leave out vulnerable young adults with asthma or obesity did not make sense. The priority groups for the initial wave were based on those who were most likely to get ill. We knew we would have enough vaccine for everyone so the message, although not always heard, was that those not in a high-risk group were to please wait and be assured that there would be vaccine available for them. In the meantime, whether a fire fighter, a police officer or a Walmart greeter become ill and needed the vaccine, we had enough antivirals to treat everyone. It was primary prevention for those likely to die and secondary treatment for those who might get the disease in the meantime.
We funded the research network in advance, which was another lesson from SARS. We could move some of those more quickly but a lot are longer term. As well, we brought together ICU experts, public health people, clinicians, et cetera, in the summer to look at the lessons learned in the spring on how to better treat in the fall. We think that made a dramatic improvement in terms of mortality and how people were best treated. We could move such lessons learned up even further.
Senator Callbeck: Welcome, and thank you for coming. It is great to hear that we have made tremendous strides since SARS. I am sure those strides will continue.
Dr. Low, you said that the public wants to hear the same message. The agency put out the guidelines and, as I recall, some of the provinces decided they were going to administer the vaccine to all seniors while other provinces decided they would not do all seniors. Some decided they would have the H1N1 vaccine and seasonal flu vaccine together and other provinces disagreed. There was an awful lot of confusion among the public. How will we avoid that confusion next time?
Dr. Skowronski: We ought to be able to explain to people the reasons that we have chosen one approach or the other approach. We ought to have documented why we chose one approach or the other. Then we should ask why some provinces are veering away from that and on what basis. That is why I think it is important that we clearly document the careful benefit risk analysis we did in going in one direction versus another direction. People will understand if you explain it to them. People will understand if you tell them the reasons. Perhaps we need to be better at explaining the rationale. Why did people come forward even though they were asked to stay back to allow other more high-risk people to come forward first? Perhaps they did not understand the rationale. Perhaps it is a question of credibility and trust. Why do we not have their credibility and trust?
It comes down in large part to our ability to explain ourselves to the public and to communicate to the public and to clinicians and others at the provincial and local levels the reasons for the decisions we have made and for them to explain why they want to veer from those decisions.
Dr. Tamblyn: I think you have an opportunity, because I understand you will be having more discussions on federal- provincial-territorial relationships. It is important to identify what is really important to do the same across the country. That may be some aspects of the program and of the response. In other parts of the response, it might not matter if one province does it differently from another. That might be who actually gives flu shots, because they might want to use their regular model.
There are some things that are quite critical on which to have national consensus and then try to roll out the same. I think this experience, when you tease out what things bothered people when they were not the same, would help to inform where we need to be working toward national approaches versus having this diversity, according to a more local need.
Dr. Low: There is a great quote from the Pirates of the Caribbean: "They are only guidelines." They are guidelines, and you will have this variation as people weigh the risk benefit in different regions of the country. I do not think we will ever solve it. It would be ideal, but it will always be an issue.
Dr. Butler-Jones: Sameness is sometimes a virtue and sometimes is a real problem because different communities may experience it differently. Dr. Skowronski referred to the importance of looking at the evidence. If, in your community, seniors are at greater risk, you will not doggedly follow a national guideline.
Similarly, guidelines needed to change over time, and collectively we were all criticized for it: A month ago you told us this and now you are telling us that. Probably the best response to that, again, is transparency, the conversation, but sound bites do not pick it up very well, the nuances. We need to find more effective ways to do that.
Vincent Lam, who won the Giller Prize, commented that standard protocol that is not working with a patient with congestive heart failure must be altered to help the patient. He commented that he does not doggedly continue with something that is not working.
Somehow, at the community level, when we see the pandemic or disease evolving, or the fact that antivirals work no matter what age, we do not say normally we do not give them after day two. We say yes, use them because it makes a difference. Then that gets interpreted as: you guys do not know what you are talking about. No, we are taking science, taking evidence and adapting it to the situation, which I think is very important.
To Dr. Low's point, we will never completely get around that. I am thinking from the lessons on this, we will focus much more on that in the future in terms of how that messaging occurs.
Senator Callbeck: The national average was 45 per cent. In my own province, we were the second highest at 62 per cent. What was the lowest and the highest, percentage wise?
Dr. Butler-Jones: The percentages were quite broad. One of the challenges, back to surveillance, we do not have an accurate count. Somewhere between 45 per cent and 50 per cent, much higher in kids, back to the need for better systems to actually track it. There were a couple of provinces on the lower end, in the 30 percentile, and a few at 60 per cent and 70 per cent. That is less of an issue. Part of it is geography, culture and timing.
The Chair: We have a chart.
Dr. Low: Yes. Ontario did the worst.
The Chair: That is right. It is in your document, but it is also in one of our background papers.
Dr. Skowronski: To underscore what Dr. Butler-Jones said, we do not have a good system — is that not shocking — in Canada for measuring vaccine coverage. That ought to be routine by now. It is not like we are novices at immunizing. We should have a system. We should demand a system in Canada for measuring vaccine coverage. If Walmart can track its merchandise, we ought to be able to track who we are giving vaccine to, right?
I would say, for instance, in some provinces they said, yes, we do need a registry, and they set one up real time. For instance, Quebec set up a registry to track who was getting the pandemic vaccine. That is a responsible thing to do. This should be a lesson learned. We must have that immunization coverage measure. Then we need to have the infrastructure and system in place to collect, summarize and analyze that data. It comes back to the need for information and evidence. If you do not have the infrastructure in place, you will have to set it up fast, real time, during a pandemic because you will not be able to answer these kinds of important questions.
Senator Seidman: Thank you very much for coming to see us as we start this study.
My question is about data. I am not sure you could even give us the data, but, just for the record, it might be helpful.
Do we have basic descriptive statistics comparing our H1N1 experience with the ordinary influenza for that period?
Dr. Butler-Jones: Yes.
Senator Seidman: Do you have the data on hospitalizations, ICU admissions and deaths?
Dr. Butler-Jones: We have a fair bit of information. It is still being collected. We will not ultimately know the burden of mortality in terms of the number of deaths until we get the vital statistics. Many of them are not directly influenza but secondary to influenza.
We have probably one of the best surveillance systems in the world in terms of tracking this stuff, but about two thirds of hospitalizations with flu, and we were only seeing H1 as flu, were not picked up in that first round. You never get everything, but we will be getting a more accurate picture as we move forward. That is not to underestimate the importance of continuing to improve the surveillance systems we have.
Dr. Skowronski: We actually do not even have good systems in place for monitoring serious outcomes due to seasonal influenza, and that is part of the problem. People are trying to compare what is happening during a pandemic when everyone is focused on case counting to seasonal influenza when no one is paying much attention. Many of the estimates that we have generated for seasonal influenza are based on statistical manipulations of administrative data. It is not actively going out and swabbing to confirm a case. Frankly, by the time a case is hospitalized, you often cannot detect the virus it anymore, even if influenza was the initial cause.
Again, this comes back to why we are not tracking. Look at how much money we are spending on influenza prevention and control every year. Why do we not have good tracking systems for serious outcomes due to seasonal influenza? That would then form the proper baseline to compare during a pandemic.
Dr. Butler-Jones: We will obviously be providing you with a fair bit of data in terms of the difference. It is a different disease, fundamentally. As I was saying, 90 per cent of mortality in seasonal flu is the very elderly and those with serious underlying conditions. In this case, 90 per cent of the mortality was in relatively young people. This is the second highest year of life lost since 1918, and the pattern of disease in terms of who got it. We are continuing to collect that information.
There are two things. One, what is the information you need to actually manage the situation? What is the information you need to reflect on it later to draw conclusions as you move forward? You need both.
What we had at the time, in terms of managing it, was sufficient to manage it in terms of guidelines around who should be treated, et cetera. We will be able to refine those as we get more information. The ultimate burden of this we will not know until after the whole mortality review, and all of those things that can take some time.
Senator Seidman: Indeed, as you say, there are two reasons to collect the data. One is to track it at the time so you know how to deal with the situation and your rapid response, and the other is to analyze what really happened. Will you be able to give us the data when you have it, although I do not know if you will have it before we complete our study?
Dr. Butler-Jones: There is a lot we can provide to the committee, because obviously we are interested in understanding how this is different from previous pandemics and seasonal flu and how we move forward.
Senator Seidman: Do you have the differences among provinces, for example, in hospitalizations, ICU admissions and deaths?
Dr. Butler-Jones: That information is collected. You may need to get some of that from the provinces, but we will provide what we can.
Dr. Skowronski: The only thing I would caution is you do not want to compare apple and oranges. You want to make sure the data is collected in the same way. The way it was collected during a pandemic reflects how it is collected with seasonal influenza. You must pay close attention to the quality of the data.
Dr. Butler-Jones: Interprovincial comparisons are fraught with all kinds of other things. Even with other jurisdictions we can draw some conclusions by patterns.
For example, I was just in China, a country with a population that is 30 times larger than Canada. Their official mortality is only about 100 more than Canada's. Is that a surveillance issue? Is that because the disease was different?
Senator Seidman: I would like to ask Dr. Skowronski to confirm for the record that the World Health Organization describes the phase that we are in, so to speak. In other words, we are dependent on WHO evidence and their declaration of the level of the pandemic phase. Is that the case?
Dr. Skowronski: That is with international input and surveillance data collected globally. Then the World Health Organization, in consultation, will make a decision and declare it. However, this is not done in isolation; it is done in consultation and with input from countries around the world.
Senator Seidman: Once they make that declaration, it applies across the board to every country; is that correct?
Dr. Butler-Jones: There are two aspects. For example, level 6 of the pandemic levels is where multiple regions of the WHO are all affected by the same bug. We were in phase 6, in terms of Canada, back in April and May. We were in the pandemic. The fact that it had not spread to Asia or other continents at that point was irrelevant to us.
That is one of the issues in planning. As Dr. Tamblyn alluded to, when you get to level 6, you have to do this, this and this. We had companies and others in Canada saying, "At level 6, we have to do this, this and this," when in fact it really was not appropriate. Therefore, it is not about the level. That certainly has great interest and significance internationally in terms of a number of international conventions and other activities, but in terms of Canada, we were in phase 6 before the summer, before we had to respond.
Dr. Skowronski: It is important to say that we were acting as if we were, so we were preparing and taking the necessary steps in advance. The declaration of the levels is to help encourage others to do that as well.
Senator Patterson: One important aspect of communications is the provinces and territories, and Parliament, which I think had quite a role in the public awareness on this issue. With regard to relations with the provinces and territories, how has this rolled out? How often did you talk? How well did that work?
Dr. Butler-Jones: Quite honestly, there was unprecedented collaboration. The provinces and territories — and we at the official level — were in contact daily. We had senior officials meetings and deputy meetings several times a week by phone, as well as ministers in regular contact with our minister. In addition, there were regular briefings of the opposition critics. I made it open to any MP who wanted to come. We had a number of question-and-answer sessions, providing responses to whatever questions arose.
This was not just at the intergovernmental level but with the different organizations. The willingness to collaborate and offer up their help was unprecedented, whether within the federal government or from deputy ministers and other ministers in terms of the role of the federal government, or with our provincial or territorial colleagues or people working in professional associations. As Dr. Low mentioned, this was a very different experience than during SARS. We did not always agree, but it was an open and transparent opportunity to have that disagreement and to come to a common conclusion, where possible.
Senator Patterson: You mentioned Parliament. I must say that some of the questions and statements in the House of Commons, and even in the Senate, I did not find helpful. Were efforts made to brief the opposition critics and members of the House of Commons Health Committee? How did that work out, as far as you are concerned?
Dr. Butler-Jones: To her credit, the minister was enthused about the idea of briefing the opposition critics, having a forum for MPs, and both of us engaging in a range of activities for the public and others. This was something I had not seen before to that extent, and I think it was very important to do. As we see everywhere, people draw their own conclusions and make whatever statements they will. This was absolutely essential and I would certainly do it again; if anything, even more.
We made it open to MPs. Maybe it is a measure of their confidence in the spring, generally, but basically only the Health Committee and a half dozen others, at most, came. Everyone is busy. That is a symbol that people were getting their questions addressed and that the answers made sense, and we will continue to do that.
Dr. Low: The communication is obviously critical, but we have to find out how we can do it most effectively. During these events, you become paralyzed with teleconferences. You can be on teleconferences from 9 a.m. to 10 p.m. When is there time to do your work? It is a real challenge.
[Translation]
Senator Champagne: Perhaps I will repeat what you said back to you. You are telling us about preparing a plan that will be better than the one you had during SARS and H1N1. Now all of you, Dr. Tamblyn, Dr. Skowronski and yourself, are telling us about the importance of monitoring what is going on, the importance of analysis, the importance of study. Dr. Tamblyn, you were saying that we have not quite done enough study at the moment.
Once you have really put this plan into action, it can always be improved. We can always do better. Do we have to wait for the declaration from the WHO? We can say no, this is not a seasonal flu that is a little more serious this year than in other years. Which age group is at greatest risk of infection, of more serious infection, so that we can avoid the things we saw during H1N1 where a 70-year-old with asthma was told to go home; we have younger people and they are more important. That is a little troubling.
At what point do you say: now we are going with the plan that we have worked on, studied and really put into place to make sure that everything goes well? Do you press the button and say: now we are going with our pandemic plan, this is no longer just an epidemic of flu?
Dr. Butler-Jones: Plans are essential. Planning is essential. But when the situation arises, the plan is a guide. The time to start the plan, to start the action, is one parameter of the problem. The first goal is to notify others and to get a commitment from the provinces and territories that they will get ready.
Senator Champagne: To tell the factory to start making vaccine, because something is really coming.
Dr. Butler-Jones: When we have a virus like that, the conversations with the companies who make the vaccines and the antivirals start just like the ones with the provinces and others to decide on the revised process. The plan is changed according to the context.
Senator Champagne: That does not happen overnight. So you see something coming because of what is happening elsewhere and you say: we may be affected too. If it does happen here, when do you act? I am sure that the plan is going to be excellent and that it will cover everything it needs to. You have more experience now. At what point do you decide to tell people to take precautions?
Dr. Butler-Jones: When Mexico asked us for help with the virus, we started communicating about the research.
[English]
As it evolves, you bring in more, depending on your level of certainty.
Initially, for example, we had the call from Mexico. We said we would be pleased to help. They sent us samples. We figured out what the virus was; it was, in fact, a new virus with the potential to be a pandemic.
Within two days we were seeing cases in Canada. At that time we had already gone public with the information. We were engaged and called up the vaccine manufacturer and others to start getting things ready so that once the virus is available, they could start the process, et cetera.
Things were engaged each step of the way: in activating our operations centre, ensuring the provinces and territories know what we know, et cetera. I was on the phone with Margaret Chan, the Director-General of the WHO, a couple of times a week at least just in terms of what is going on and to get a heads up. I was also in contact with my colleagues in the United States and Mexico, because it was initially a North American situation.
Together with an American team, we sent a team to Mexico and helped set up their lab and surveillance system to figure out who was at greatest risk, et cetera. That was then very helpful to us in terms of our own planning moving forward.
It really is an incremental, iterative process.
Dr. Skowronski: During a crisis, you want to buy as much time as you can, so you do not do things sequentially. You do them in parallel and then you watch and see, and ask yourself what if this happens? Am I prepared to deal with it? What assumptions am I applying now that might not apply later?
Therefore, you are buying contingencies; you are buying time by setting up parallel processes. Then you are monitoring to see in which direction things will go. Then you have both options. You want to keep your options open that way.
It is incremental and iterative, but it is also parallel rather than sequential.
Dr. Butler-Jones: For example, in seasonal flu, after a couple of days, the general wisdom is that antivirals are not very effective. Therefore some physicians would refuse to prescribe it if you were over two days in, unless you were desperately ill.
That lost us time, because with a novel virus, like a pandemic virus, those who get desperately ill have an immune system that is not able to deal with it. The virus keeps replicating. If you give an antiviral on day two, it is better than day three and day three is better than day four.
It was a matter of having this on one side and, at the same time, we are starting to get stories of this. If in doubt, treat. Again, that was just one example of needing to have parallel stuff while you are figuring out all of these things. There are literally dozens and hundreds of people all tasked each day to do different
Part of the reason I am now based in Ottawa rather than Winnipeg is because you cannot do it remotely and linearly.
Senator Chaput: Thank you for everything you have done and please keep up the good work. We need it.
Senator Ogilvie: Thank you all. At various times, you have alluded to this: The constitutional situation we have in Canada makes national response to complicated issues a real challenge in its own right, and SARS certainly demonstrated that we had not worked out an arrangement at that point.
Frankly, I am quite impressed by what I have read over the last several months in terms of how we have moved forward through the Public Health Agency and other developments to attempt to put ourselves in a much better situation. Clearly we have learned lessons that gave us advantage in this last situation.
The overlapping jurisdictions have to work together voluntarily to roll out a plan. Ultimately, it leads to delivery, which is at the local and regional level. I want to ask a specific question. On page 5 of Dr. Low's document, he indicates that at week 40 of our Canadian pandemic calendar, the local health authorities were mobilized to deal with the issue, and were given roughly two weeks to prepare to deliver the vaccine.
Dr. Butler-Jones and Dr. Low, was that because it was not until we had sufficient understanding of the nature of the vaccine and how it would be delivered that we could begin to provide the information to the local health authorities to determine how they would roll it out? Is that the reason it took until week 40 of our calendar to have them mobilized to be able to deliver the vaccine?
Dr. Low: I think Dr. Butler-Jones will be best able to answer this question. There was always concern that it would not be until mid-November that there would be enough vaccine available to start the vaccination process. It was fortunate that the vaccine was available earlier.
There was not enough vaccine available at the same time to vaccinate everyone, but at least those in the high- priority group could be treated. The rationale was to start the process rather than wait until mid-November. However, at the same time, it was difficult because local authorities then had to ramp up what they anticipated would have been a few more weeks of time to recruit, train and prepare for what was initially thought to be a vaccine process that maybe only 30 per cent of the population would receive.
Dr. Butler-Jones: It is a very good question for which there is not a clear answer. I know from April to May I was certainly hoping to have vaccine by early November and telling people to be prepared for that month.
In the summer, just as an anecdote, I ran into a local medical officer and asked how the preparations were going. She said that they would be ready to start immunizing in December. I asked her why in December. Her explanation was that the vaccine would come in early November and then they would have to make certain preparations. I said it was not a regular vaccine campaign, but a pandemic. You cannot organize the same orderly way as you would during a seasonal flu when you have time to prepare and all parties are ready. In a pandemic situation, you have to do it as soon as it is available and change the planning.
One of the lessons learned was that we cannot deal with a pandemic or a public health crisis in the same way as our routine work. On all levels, politically, administratively or program wise we must be able to make the shift very quickly.
Senator Ogilvie: We are dealing with an evolution of learning as to how we prepare as a society for true pandemics, emergencies and these kinds of situations. We are focusing on the flu for obvious reasons but, as we have seen from SARS, there will be other issues. Heaven forbid that an Ebola outbreak or something like that could occur.
A couple of you referred to the necessity of being able to mobilize a research capability to be able to study the responses quickly as the situation is unfolding. Do we have the authority under existing legislation to force the mobilization of academic laboratories as a support knowledge asset, if that were appropriate, and if the expertise existed there? Do we have the authority in legislation under extreme conditions to be able to mobilize that capability along the lines to develop a highly organized approach to an extraordinary threat?
I think we handled this one quite well under the circumstances. We learned a lot. You have already pointed out a number of those issues, but I can imagine situations that can move much more rapidly and require a much more intense response.
Dr. Skowronski: I actually think the labs stood up well during this pandemic. We did tap into academic laboratories to contribute to some of the additional testing that was required. I think the labs did exceptionally well when you think about the pressure that was on them.
However, where I think we need to enhance our capacity is in the epidemiologist area, as I have said. For instance, you cannot just pull someone who has no knowledge, no experience and no expertise on influenza and expect that person to be able to do the kinds of analyses and interpretations that you need from an expert epidemiologist working on influenza all the time.
During the pandemic, there were many sections of my department for whom the pandemic made not a ripple to their workday, while those of us who were working on the immunization and influenza stayed very long hours. It was pointless to pull these other people into the workload because it would have taken more time to train them, to bring them up to speed and to make them knowledgeable. They became more of a handicap than a help.
We need to have a much-enhanced capacity. That is, we need a resource of epidemiologists who are working on these issues on a regular basis, and maybe not specifically on influenza but on respiratory pathogens that can spread quickly and can change quickly. For example, they might be working on a respiratory syncytial virus but have the required knowledge and skills particular to a fast spreading respiratory virus. I think the labs did well.
Dr. Butler-Jones: I think some measure of cross-training preparation, what is your surge capacity, a whole range of fields, scientific and otherwise, is key. Certainly, we made use of other epidemiologists. You need your specialized expertise for certain aspects, but many others can collect the data, do the analysis, et cetera. It is about building the capacity.
Back to your question of authorities, we will be reviewing this. We did have that with CIHR, namely, the fund, the network of researchers, et cetera. We were able to mobilize them quickly. Was that enough? Again, we will be looking at that. Could we have done other things differently? Es, we could have done more on the clinical studies side, yes. Some important information came forward, for example, one study showed that the N95 mask proved no better than regular respiratory masks in terms of protecting nurses. That information was very helpful.
In terms of the labs themselves, within two days of receiving the samples, our lab was able to identify that it was a new H1N1, different from anything ever seen. It was able to quickly develop the reagents and the methods so that all the provincial labs across the country were able to do their own diagnostics and it did not all have to come to the federal government. The labs and the lab networks, which have proven themselves repeatedly as effective mechanisms, worked well.
One of the things to Dr. Skowronski's point is that not everyone rushing in is actually helpful. They need to be trained. If there are capacities we need in advance, we need to have those people trained or cross-trained, as it were.
Dr. Low: Where we did fail was not providing the resources through CIHR for researchers in Canada. At the end of the day, only $1 million was made available. I think it was given to five centres. That is $200,000 each. It is a spit in the bucket, and it took a long time to get it. It took into the fall when this whole thing was over. We should have the ability to come up with the resources on a dime and get them out because we have a lot of great researchers out there who are willing to work on whatever problem we have. We have to give them the resources to be able to do it.
Dr. Tamblyn: On the same line, I will note that by luck, that approval for funding for a pandemic immunization grant co-funded between CIHR and the Public Health Agency of Canada came through just about the time the pandemic started. They developed a full range of activities. They moved up their agenda quickly to try to do as much as they could during the pandemic itself. Their results are just beginning to roll out. For example, four special studies were done on vaccines. One study looked at the response in Canada in Aboriginal populations and asked the whether they respond the same as non-Aboriginal populations. They looked at HIV-infected individuals and at results in adults. A series of other studies were fairly unique to Canada.
There are five aspects to that particular grant, but that was an example of the sort of thing where this type of funding can be useful. The pandemic grant project itself through CIHR is time limited and is producing so much good work that it should be supported in an ongoing basis.
Senator Braley: I do not have all the expertise that you have. Our family sat down, and the information was so confusing that you forgot who your customer was. You were dealing with all these operations. You were dealing with tests here and tests there and information coming out. The media was panicking. We were trying to decide, as a family, whether to get the vaccination. We decided not to get it because it was too confusing. Most of the people in my businesses and in my community did not either. We live in Ontario.
It seems that you forgot the customer in the communications. You did great work but we were confused. You could not convince people to be vaccinated because of that. You had great work done, but these things confused us. I am just making a statement because that is my feeling. You said that it was new. Then we heard that it was in South America for six years and that I would have protection already, as I was 69 years of age. We did not know what to do. When we had the same discussions in our employee groups at work, we had the same problems. We could not tell our employees what to do. That must come from leadership and form part of the communication plan. I am sorry, but I wanted to make those points.
One supplier is terrible. I would not let my company survive on one supplier; I would have a backup supplier. In fact, I have two. On my main product, I have three. One gets 50 per cent to 60 per cent, one gets 30 per cent and the other gets the rest. If you rely on one and he fails you for some reason or another, then you are in real trouble.
Dr. Butler-Jones: That is one of the challenges of the information age. That is why I would say listen to your local medical officer because they are the ones who know. All the other people on the media or the Internet did not have a clue and they make it up as they go along. That was a huge source of confusion to people. If there is a way of getting the message out, listen to your local public health officials. They are the ones who know what is going on.
Senator Braley: Try and talk directly to the public.
Dr. Butler-Jones: Absolutely. I tried to, but I do not know if people heard me. Thank you very much.
Dr. Low: It is difficult. The last point that I made in my presentation is about how we must learn how to deliver the right message.
The Chair: On that note, we will conclude this session. Thank you very much. You have us off to a good start with a lot to think about in terms of the coming hearings.
Committee members, we have another hearing tomorrow morning at 10:30 a.m., but we also do have another item on the agenda. We will excuse our witnesses and then we will go to this other budget item on the agenda.
Members of the committee, this should not take long. We have a request for budget authorization. This would take us to the Internal Economy Committee. This is not a big expenditure. We are looking at editing and revision services of about $900. We also need some ground transportation because we have a site visit.
Senator Chaput: Is that tomorrow?
The Chair: No. Do not worry. We are not going tomorrow.
This is the budget. In November, we have a site visit to Nepean. It is the nerve centre. We need a bus to get us there. It is a grand total of $1,550. It is the lowest budget of any committee going.
Can we get your approval to move this on?
Senator Seidman: I so move.
Senator Ogilvie: I second it.
The Chair: It is approved. We do now formally stand adjourned until 10:30 a.m. tomorrow morning. Thank you.
(The committee adjourned.)