Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 15 - Evidence - October 28, 2010
OTTAWA, Thursday, October 28, 2010
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:32 a.m. to study Canada's pandemic preparedness.
Senator Art Eggleton (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
Today we continue with our study on pandemic preparedness and response. The two panels we have today are here to look at the experiences of other countries.
In this first panel, we have with us from the Department of Health in the United Kingdom, by video conference, Professor David Harper, Director General of Health Improvement and Protection. He has been the Chief Scientist and Head of Profession for Scientists in the Department of Health since 1996. He was appointed to his current post as Director General for Health Improvement and Protection at the beginning of 2008.
Professor Harper had previously been Director General of Health Protection, International Health and Scientific Development since 2003. He is a Fellow of the Institute of Biology and also of the Faculty of Public Health of the Royal College of Physicians.
We welcome you, sir, and we thank you for taking the time to help inform us about how the U.K. has dealt with the issue of pandemic preparedness. Much of the testimony to the committee at this point in time has been about H1N1 and SARS — severe acute respiratory syndrome — prior to that.
Please give us your comments to open up our meeting, and then we will take it from there with some questions from the senators, who are now beginning to fill the seats.
David Harper, Director General of Health Improvement and Protection, Department of Health, United Kingdom: Thank you, chair and senators, for inviting me to take part in your hearing on pandemic influenza preparedness and response.
I am very pleased to be able to share with you the lessons the U.K. has learned from its experience of dealing with the pandemic. Naturally, some things went well, and some things did not go quite so well. I will touch on both of those in turn.
Following the pandemic, the government here in the U.K. commissioned an independent review of our response. The review of the response is on the website, and that review was conducted by Dame Deirdre Hine. If you have not already, you should be able to access that in due course.
It goes without saying that a further influenza pandemic remains a potential risk for all of us. The government here intends that the U.K. remain as well prepared as possible to deal with any future pandemic. For this reason, we are reviewing our national framework for pandemic influenza, and we plan to publish the revised national strategy in the coming spring.
The new strategy will build on the plans that are already in place, and the focus will be on any enhancements and adjustments necessary in the light of any new scientific evidence, the recommendations made in the independent review I just referred to and the lessons learned from the H1N1 swine flu response. We will also review our plans to ensure they are as adequate as possible for the potential of a more severe pandemic, bearing in mind that we need to take account of the current financial position.
What went well as far as we are concerned in handling H1N1? During the pandemic, the U.K. worked closely with colleagues across the world, not least of all with the Global Health Security Initiative. We also worked with the World Health Organization, WHO, and closely with colleagues across the European Union.
I think the international collaboration worked particularly well for enabling the sharing of information in a secure environment and for facilitating discussion. Whilst on this particular subject, can I pay tribute to the Canadian Secretariat of the Global Health Security Initiative? A great deal of credit for facilitating that close collaboration within the network is due to them.
Our response in the U.K. was helped by detailed pre-pandemic preparedness planning, including the building up of stockpiles of clinical countermeasures. We already had enough antivirals at the outset of the pandemic for 50 per cent of the population here. We then increased that to be sufficient for 70 per cent to 80 per cent of the population.
We also had established plans for a web-based and a telephony-based distribution arrangement for antivirals. This we called the National Pandemic Flu Service, and it was designed to do three things: first, to enable antivirals to be made available as rapidly as possible to all those who needed them; second, to reduce the burden on front-line primary care service as much as possible by providing a second route of access and collection for antivirals; and third and very important, to enable the sick people to stay at home, thereby, we think, reducing the spread of the disease.
The service was launched in England on July 23, 2009. To give you an idea of the scale of operations, from July 23, 2009, to February 11, 2010, when it was switched off, more than 2.7 million assessments were performed through the service over the phone and using the Internet; 1.8 million treatment courses were authorized, which is 66 per cent of the assessments; and 1.2 million courses were collected for patients, and that is 64 per cent of the authorizations.
In addition to making antivirals available, we put in place a vaccination program. This was targeted through general practices at those at greatest risk — those with underlying conditions, pregnant women and household contacts of immunocompromised people. It was also offered to all front-line health and social care workers because of their increased risk of contracting and passing on the illness and to children under five.
In total, about 6.8 million vaccinations were given in the U.K. during the pandemic, and the take-up rate in most clinical at-risk groups was between 35 per cent and 40 per cent.
Naturally, as I am sure you would expect, we spent a good deal of time considering our communications strategy. Throughout the pandemic, we sought to provide a comprehensive and as far as possible transparent approach to public communications, with regular weekly press briefings from our chief medical officer.
Finally, we contributed to the international effort in a number of ways. We donated over £24 million to help countries prepare for swine flu. We also made 3.8 million doses of vaccine available to the World Health Organization, in addition to the £37 million that had been donated to improve global preparedness for avian and pandemic influenza.
What did not go so well? There will always be things that we could have done better in handling the pandemic, and we have to be careful to learn the lessons and to share good practice.
The key headlines are, first, that we want to ensure a more flexible and locally responsive approach — that is locally within areas in the U.K. This is very important for the next time we need to manage a pandemic.
Second, people need to understand and accept the limitations of science and modelling. That made certain key decisions difficult — for example, when we moved from the slowing-the-spread phase of handling the pandemic to the so-called mitigation phase.
Third, inevitably we will face the challenge again of communicating effectively the concept of what we called the reasonable worst-case scenario. That is really in the context of planning assumptions for our National Health Service and for others. However, in communicating that, I think we learned a number of useful lessons.
To conclude, I would like to thank you again, chair and senators. I am happy to answer any questions you might have for me.
The Chair: Thank you very much. Let me start with exploring further the question of communicating information on the safety of the pandemic vaccine and also the prioritization of groups within that. You commented on that briefly. It is an issue we have had some discussion on here. Maybe you could talk a bit more about the lessons learned in going through the process of trying to convince the public of the safety of it. In Canada, some people felt it was a rushed situation of getting the formula into a vaccine form, perhaps without many clinical trials, so there were concerns by the public. We ended up with about 41 per cent of the public taking the vaccination. Maybe you can tell me what your percentage was, as well.
In addition to that, there is the question of prioritization. There were many local groups — for example, firemen — who said they should have been part of the priority. So many have said they should be given priority that we need a priority to the priorities. Perhaps you could comment further on that.
Mr. Harper: Certainly, Mr. Chair. You have asked a number of questions there. First and foremost, the communication issue was very important, but I do not think we had the public concerns about safety of the vaccine. We had a number of professional concerns to ensure that we went through all of the necessary hoops.
You might be aware that within the European context, we had, in our preparedness phase, arranged a novel way of dealing with licensing or market authorization of pandemic flu vaccines. Within our European context, we had arranged a mock-up vaccine that had a variety of different data associated with it, particularly in the preclinical sense. It was designed primarily to allow us to fast-track the marketing authorization once the virus that was responsible for a pandemic was identified and once we had the potential for a pandemic-specific vaccine.
We had a considerable amount of previous consideration of the safety issues, recognizing that this would be a novel vaccine. However, in a sense, the vaccine was going to be based on a vaccine that had been used countless times before — even in the case of a relatively novel flu vaccine with a particular adjuvant and added ingredients to it. However, the adjuvant itself had been used many times before. We were careful to provide as much information as possible to our independent expert advisory committee, who were the authority for us in the U.K. for advising government on the best course of action.
When it came to prioritization, we certainly took the advice of the Joint Committee on Vaccination and Immunisation, but we recognized that there were different types of prioritization. You have just alluded to them in the question.
We had the risk groups that I mentioned in my introductory comments, where the advice was very clear from the independent expert committee. However, we then had the issue, which I think you touched on, about identifying key workers and how we might best prioritize those.
We had had a great deal of consideration in advance of the pandemic, not just in the context of an infectious disease but in the context of any large-scale emergency — it could be about a fuel crisis or flooding — where attempts were made to identify key workers.
Very quickly, we felt this was a challenge too far. Trying to identify key workers becomes an issue of how long is a piece of string. Each key worker, or each worker in many cases, can make the case for why he or she is so important in handling, in this case, a response to pandemic influenza.
Therefore, we took a different approach, which was to say which of the workers were most likely to be in situation where they could encounter the virus and in some way be linked with the possible spread of the virus, particularly to vulnerable groups. In that context, we felt a good starting place was health care workers and social care workers who, by definition, are in close contact with people who might be infected but also who are then in a place where they could transmit the virus on to vulnerable people. That was the basis for our selection of the non-risk group element of our priority groups.
Senator Eaton: You talked about the distribution of your antiviral drugs. Were they free, or did people buy them?
Mr. Harper: The antivirals are free. The way our National Health Service works is that essentially that sort of medicinal product would be free. The challenge we had was how to get sufficient antivirals to those people quickly enough for them to have any impact on their infection.
Senator Eaton: You talked about separate routes and collections. In July, how did you roll it out?
Mr. Harper: A great deal of thought and effort had gone into setting up, as part of our preparedness work, National Pandemic Flu Service. We had prearranged for contracts for call centres, but a particular type of call centre, which had the necessary algorithms based on good clinical advice and clinical oversight of those call centres. People could phone up and be taken through a series of questions and, according to their answers, be given a unique identifying number that either they or somebody on their behalf could take along to one of the antiviral collection points. In a similar way, in an Internet-based approach, people could fill in those questions and the responses themselves and be issued with a unique number to be able to pick up their antivirals or send somebody to pick up their antivirals.
Senator Eaton: That is very clever. Obviously you communicated this to the public before it started — ``If you think yourself in doubt,'' et cetera. Did you do this on television and radio?
Mr. Harper: We had campaigns. It was not before it started but when it was necessary. To avoid any confusion as far as we could, we had a concerted campaign using various channels, including posters and other ways of highlighting the telephone number and also highlighting the route there that people could go.
Senator Eaton: As you know, in Canada, health is divided between the provinces and the federal government. Health delivery is largely through the provinces. As we listen to our witnesses, we are finding that we are quite siloed, at some point, and we do not often have one central voice, which was lacking. In other words, one province would deliver the system one way, and another province would deliver it another way.
In England, for this national pandemic flu preparedness, you spoke with one voice. Was there one voice that came out every day or once a week, or did you have several voices, depending on the area of the country you live in?
Mr. Harper: If I answer the question that you asked, in England, we had, as far as we could, one voice, and that was the chief medical officer who made many personal TV and radio appearances and did many interviews. He was responsible for a weekly press briefing with all of the health correspondents or as many of them who could make it to those press briefings. That was the one source of authoritative advice. It was absolutely consistent and was informed by the ministerial discussions that, in terms of timing, had taken place just a little before the press briefing. We felt it was important that we had a highly regarded professional, authoritative source of advice.
The reason I frame my answer in that way is that you asked about England. Within the U.K., we have other countries, and they also took a similar approach, but I am answering on behalf of the England situation.
Senator Eaton: Would Scotland have done something else, as would Northern Ireland?
Mr. Harper: They would have done, but with respect to the information being used and the ministerial discussions, in fact, the four health departments and the four health ministers were working very closely together to ensure the messages were entirely consistent.
Senator Eaton: Thank you very much.
Senator Ogilvie: Dr. Harper, I wanted to get your further opinion with regard to the use of the antiviral. Over here, we refer to it as Tamiflu, and it is a prodrug converted to an active form once consumed.
The literature seems to be a little bit mixed with regard to the efficacy of Tamiflu. Much of the evidence arises, of course, from use against the so-called normal or annual influenza. You indicated that the antivirals were perhaps an important part of your approach to dealing with this situation. Could you give me a sense of how effective you felt Tamiflu specifically is and perhaps was during your treatment of the situation?
Mr. Harper: I will answer the question as far as I can, and you will probably want to come back. I cannot give an answer to the specific question you asked because we do not have the information, and I think you alluded to that yourself. I can give you the basis for our use of Tamiflu to give you an indication of our thought processes.
As you rightly say, the bulk of the information has been, over the years, from countries such as Japan that tend to use Tamiflu, or antivirals at least, in the context of seasonal influenza. Of course, we have to make some assumptions because we are preparing for a virus, and we do not know the identity of the virus or its disease profile or indeed whether it will be sensitive to antivirals. Given the countermeasures that are available to us, or the lack of countermeasures, I think it was prudent, and I would advise again in the same way, that we take what we have and deal with it as if it will be effective. However, we put in place other strands of our preparedness, what we have been calling in the U.K. a defence in depth, to ensure we are not totally reliant upon one countermeasure working. As countermeasures, I include both the more medicinal or clinical countermeasures, such as antivirals and in due course a vaccine, recognizing that we would not in any case have a vaccine at the start of a pandemic, and public health countermeasures, such as social distancing, school closures, and of course one of the mainstays in dealing with anything of this nature, personal hand hygiene and the sort of things I know you will be familiar with.
In terms of efficacy, we were looking at and using antivirals in different ways, both as a post-exposure treatment, where much of the information has been gathered in that context, and also, where we could, in a post-exposure prophylaxis sense. We certainly considered how, in the early stages of the infection occurring here in the U.K., we could give Tamiflu quickly to those people who might have been exposed to the person who was the index case in a particular outbreak.
Senator Ogilvie: Your response is entirely consistent with what I have been gleaning from other sources and my own sense of what the situation is. One is in a very difficult position as a pandemic arises, as you say, with no proven tools in advance against a specific agent. I really appreciate the challenge that all health authorities have in attempting to calm the public and to help bring the situation under some sort of reasonable control.
I suppose in that sense, even something that much of the evidence might suggest operates in the realm of a placebo effect, which we know is a real effect, does have a positive benefit. The placebo effect is not a negative; it is a positive. Even in that sense, there is a value to the use.
I will not explore the question any further because the answer you gave me is thorough and totally consistent with what I have been able to develop elsewhere. I think health authorities were wise to attempt to use something that might have only a marginal benefit; a placebo benefit is nevertheless a benefit. Thank you very much for your response.
The Chair: Unless you any further comment on that, Dr. Harper, I will move on to the next senator.
Mr. Harper: No, I think I am happy to take the next question.
Senator Martin: I want to go back to the communications strategy that you highlighted as one area you felt the U.K. had done well in. Could you elaborate further on your strategies in developing your communications plan? We have heard from different witnesses that it was one area that was a challenge at all levels.
We live in an information age where the public as well as the officials are hearing all sorts of information from various sources. With social media and with the challenge of our Canadian jurisdiction with provincial, federal and then international authorities, the information is out there and it is quite abundant.
You spoke about the consistent single voice, yet there must have been other sources that could potentially have caused confusion. There could have been conflicting information. What strategies did you develop? What was the plan that gave you the success for this past outbreak?
Mr. Harper: Part of the challenge is absolutely where your question has stemmed from: In a situation such as a pandemic of influenza, there are many experts out there, national and international, and dare I say even some self- professed experts, people who are more than happy to talk about something such as pandemic influenza.
In previous emergencies or public health crises, it has depended very much on the particular issue at hand. Within the last few years we had a public health situation around polonium-210. It was a particularly specialized area of knowledge. In fact, there were no experts on it. It was very interesting to see that the people who were expert were actually within government or within the government family of related agencies. That was quite a unique experience for me, where it was actually very well controlled. I do not use the word ``controlled'' ill-advisedly there. The information flow and the information that was going out was clear and came from one source. Whoever was approached out there was tending to use the same information, and not very much was known about that particular element.
The situation is completely different with something like pandemic influenza, as I say, with many people out there prepared to talk, but we also know that there are some key individuals who are generally approached by the media and who will give quite a legitimate view. Part of the strategy was to ensure, as far as we could, that those people, if they were to be approached, had access to and were a part of the communication machinery. That is relatively easy to say and quite difficult to deliver. It could never be complete or comprehensive coverage.
Nevertheless, in the early days, people who do have their expertise and are approached by the media were asking about preparedness of government, preparedness of the U.K. and actions that had been taken. I felt we were well placed, certainly in retrospect, for people to be able to give the views that were very supportive, particularly in the early stages when it was critical and when confidence can possibly be won or lost in a major way as far as public communication is concerned. We were able to call upon some of the very good relationships that had been built up long before the outbreaks themselves. In a sense, that was something that could not be turned on or turned off as part of the response mode, but it was very important in terms of the preparation.
I have already said that we had decided in advance to learn from some of the lessons from previous crises, not polonium-210 in this case, but it could be SARS, which I think the chair mentioned earlier. One of the difficulties there very clearly was having different sources of advice and people saying things that either on the face of it or substantially were inconsistent.
Having taken the decision, the coordination we were able to achieve was possibly because of our infrastructure, among other things — and I think you touched on the difficulties that might be presented that are different with your provincial arrangements and in those countries that have a federal arrangement. Our biggest challenge in that sense was the one I touched on, which was to ensure that our four countries were in the same place to be able to have that consistency of communication, even where local actions were going to be different because of differences in the prevalence of the virus, the pressures on the health systems or the way the health systems might run differently in the four countries. That is a devolved responsibility after all from Westminster.
Where we had a particular challenge, and this is a generic issue, a challenge that I know colleagues in other countries have faced and one thing that I think did not go so well, is how we communicate the uncertainty, particularly in the early stages of the pandemic. The uncertainty is inevitable, as we have just touched on. I am not clear yet how we do better, but this is what we are working on.
It was particularly important in trying to communicate figures that we felt needed to be put into the public domain, but they were principally figures that were being pulled together to allow the professional groups, the health service and others, to plan for whatever scenario might develop in an unknown situation. I recall a press briefing where we had a particular figure for the reasonable worst-case scenario for the number of deaths. The chief medical officer said to the correspondents, ``I will give you this figure. I know there is a risk. Can I just ask you, can I plead with you, in fact, not to misuse this figure. It is a figure, and this is the purpose; this is the qualification; this is the uncertainty.'' He said, ``I have done this before, and I know there is a risk that it will be put out there and it will not be put in context.''
In fact, in the majority of cases, the correspondents reported it very responsibly, but once the figure is there, it can be misused. It is that challenge about communicating uncertainty that is one of the biggest issues for us in the future.
Senator Seidman: Thank you, Dr. Harper. One issue that has come up repeatedly in our hearings is the importance of surveillance producing real-time data and the value of well-coordinated and standardized electronic systems. Our committee would appreciate it if you would explain how the U.K. deals with these.
Mr. Harper: I am very happy to. Could I just be clear, though, that in terms of surveillance, there are a whole range of different things that we look at. I can give you answers that will be different for the different parts of surveillance. If you are primarily interested in the spread of the virus, then I can answer that part. If you are interested more in how we can do better with real-time information, for example on infections and who might or might not be admitted to hospital, and of those, who might or might not be admitted to intensive care, I can go some way to answer that.
Senator Seidman: I understand there are many aspects to surveillance, including adverse events.
Mr. Harper: Yes.
Senator Seidman: Could you briefly give an overview? Could you touch on what it is that you keep track of in your surveillance system and the approach to some kind of standardized electronic management of all this?
Mr. Harper: I will pick on the two that are probably the easiest. The first you just mentioned, the adverse incident records and reporting. Our Medicines and Healthcare Products Regulatory Agency is responsible for collecting information on adverse events. They set up a special enhanced reporting system with a single portal, and I think in the context in which you are asking the question, the IT elements of that surveillance system, that was single authority, single use, but informed by a fairly tried and tested process for what we have in the U.K., which is a yellow card system, where with any adverse event, that card is filled in and put into the system. We built on that and enhanced it.
We also had surveillance, if you like, on the microbial agent side, the virus, through our Health Protection Agency and others, and that was part of an international surveillance system. Nationally, our Health Protection Agency is the leading authority to collect and collate and analyze information, and that was the information we used as the basis of the information that was being then used in the press briefings by the chief medical officer.
It was I think routine almost every time where either the chief executive of the Health Protection Agency or the chief executive representative would sit in a panel with the chief medical officer whilst the chief medical officer gave his press briefing. If there was any particular question that related to that side of things, the Health Protection Agency would pick it up.
The third bit is the one I touched on at first. I should say that although information comes in and is collated and analyzed and so on, we do recognize that of course if we are detecting symptomatic individuals, we need to consider at least what might be happening with people who might have the virus but who are not symptomatic, so asymptomatic infections or people who had not yet gone on to develop symptoms. That was particularly important in the context of a milder disease such as the one associated with H1N1 swine flu virus.
It is particularly challenging is to get real-time information, but even if not real-time then very rapid information on hospital admissions, and to try to get an attack profile, a disease profile for the particular disease that we were considering, and to look at subsets of the population who might be most affected by the virus in the most severe way, and also then to have an indication of the deaths. That is tough even with the systems that we have here in the U.K., which perhaps lend themselves more to collecting that sort of information. We must remember that with something like seasonal flu, of course, we collect the information, but it is not analyzed and made available until many months after the season during which the illness has occurred. Therefore, it was a particular challenge to pick up that sort of information.
However, we set up different ways of doing it. The chief medical officer himself initiated a special, confidential collection of information around some of the areas I have just touched on, but in the main, I think we tackled the problem in a way that our system allowed us to. We went much further in some areas, such as looking at deaths and intensive care, but that was probably one of the most challenging areas.
Senator Seidman: I want to clarify that your electronic systems were standardized enough throughout the U.K. to allow you to collect this data and analyze it centrally.
Mr. Harper: That is not entirely right. Among the four countries, some have different arrangements. I will not go through the detail because the Health Protection Agency does cover in some cases more than England alone, but I was speaking really about England. As far as we could arrange it, the information came through one organization, but we had different surveillance systems. We have our Royal College of General Practitioners' sentinel surveillance system, which works generally to pick up different sorts of illness. That is quite an extensive network across the country, and we needed to ensure that any differences were either recognized or reconciled or explained between the different sources of information. However, the figures we were using essentially were on the basis of information coming from the Health Protection Agency.
Senator Cordy: Thank you for helping us in our study of lessons learned so that our preparedness for the next pandemic will perhaps be better than it was in the past, which is always important.
I would like to talk about the U.K. within the context of the European Union. I know you had a conference in 2001 in the European Union on pandemic preparedness. Who actually takes the lead on pandemic preparedness? Is it the EU or is it each national country within the EU?
In Canada we have some challenges around the mobility of health care workers even from one province to another within the country. I am wondering about the mobility of health care personnel. I know the mobility of workers in the EU was done fluidly. What about the mobility of medical workers within the EU if one particular country within the EU was having a pandemic of greater severity than perhaps the U.K. or other countries? Is the fluidity there for medical workers to go from one country to another to work on the pandemic?
Mr. Harper: Thank you for the very interesting question.
The first thing to say is that there is free movement within the European Union. That is one of the basic principles of the treaties that have been developed over the years for the way the European Union works. It is not that straightforward — it will never be that straightforward — and I think in the context of a pandemic there would be an issue about a wholesale movement of medically qualified staff from one country to another to help, although the principle is very clear and could be managed.
However, of course all of the countries will be looking at the plans and their own preparedness to see that their own populations are protected as well as possible under the circumstances. Even if there were to be free movement in the purist sense, whatever that is, whether it would happen in a pandemic situation, I really could not say.
On your question about the lead responsibility, again I am afraid my answer will sound like a civil service answer, though it is not in any way meant to be. The countries form the European Union. The European Commission, as the civil service for the European Union, if you like, has certain responsibilities. Within the pandemic context, it might be something like our European Centre for Disease Prevention and Control, which played a very active role and helped in communicating information and so on. However, when it comes to the risk management and the health service provision, those are country responsibilities.
Senator Cordy: Thank you very much. We now have the theoretical and the practicalities of what can really happen. Thank you for your answer.
I would like to follow up on the chair's question about vaccine sequencing and the priority groups. A number of witnesses talked about who specifically should be in the priority group — of course everyone wants to be in the first priority group — and how to deal with it. I certainly would not want to be the person making up the priority list, because every group that appeared before us had great reasons for being within that group.
Did you have priority groups within the U.K., and if so, who developed the priority groups? Also, you said you would like to ensure more flexibility and locally responsive approaches to dealing with pandemic. Are the priority groups national, or does each region within the U.K. have the flexibility to change the priority groups?
Mr. Harper: The prioritization that I was describing earlier was very much at a national level. It was in two senses. One was on the basis of the risk groups, where we sought advice from our independent expert advisory committee, which is our normal process, and they advised us based on the risk profile, as far as they could, how we should prioritize.
I will not run through the obvious examples again because I went through them in my introductory comments, but they are what you would expect, I think. There was at least a degree of international agreement, even in a post hoc analysis of the situation very close to the time.
The other group was really the workers that we might choose to have vaccinated, and we went for health workers and social care workers on the basis, as I said earlier, that they would be in a situation where, first, they could be infected, could be exposed to the virus given the nature of their work, and second, once infected, they could transmit the virus to particularly vulnerable people. We felt that was the way to prioritize.
Of course, in the early stages once vaccine had begun to come on stream, there was also an issue about how we got vaccine out quickly enough and, in a sense, fairly enough to allow the people who had to administer the vaccine and make some local decisions to get the vaccine as quickly as possible in a way that they could use, with the appropriate guidance that had been established nationally.
Senator Braley: In your opening remarks you referred to a local approach. I would like you to expand on that. Were people involved locally in the planning? Could you touch on adjustments that were made, communications strategy, shortage of workers, shortage of delivery, and all the problems around that. Is that plan in place for something 10 times worse than what we went through? Is there a plan in place, or was the plan in place at the time?
You referred to being able to make some improvements and to one of the problems being the local approach. That is where the customers are, where the general populace comes, and that is where they get the customer service and then leave either feeling good or feeling bad.
Mr. Harper: Thank you for the question. On the severity side, we had been preparing, as I think many if not all countries had been preparing, for something more along the lines of H5N1, which of course could have resulted in a much more severe human infection. Our plans were on the basis of something more severe. In a sense, one of the lessons we learned was that we needed flexibility to accommodate a less severe disease, and that was part of what I touched on earlier.
The new plan — the new strategy that I referred to — will certainly be taking into account how we deal with a range of different severities of disease, up to and including the more severe kind that I have just alluded to.
Regarding local decisions and engagement, in preparing, there was a good deal of local engagement through a variety of channels bringing together emergency planners and public health officials to help us develop our strategy. I think that is probably what you would expect to hear. That is part of the preparedness. It is done in peace time, when we have the luxury of time and the ability to engage a wide range of interests, particularly, in the context of your question, the people at a local level.
In communication strategy development, we did what I would expect you would think of in terms of testing the sort of communication material that we might need to use in the pandemic response itself. We had something that was badged as ``catch it, bin it, kill it,'' which was a strapline for personal hand hygiene, but it had been tested before. People were familiar with it and I hope were able to respond accordingly.
We also had a very senior director on the National Health Service side who pulled together all of his National Health Service colleagues, once we were in response mode, to ensure that the cascade of communication was, we hoped, as good as it could be under the circumstances, given the pace at which things were moving on occasion.
When I was talking earlier about flexibility, I was thinking particularly of what we learned about the spread of the virus and that it naturally, I would say, was not uniform in spread. The whole of the country was not affected at the same time in a similar way. We had clear hot spots of infection where the pressures locally were considerable. They were considerable for the local population, for the health professionals and for the National Health Service. The sort of flexibility I was alluding to was really to allow people to take decisions within the overarching national framework that has been agreed by ministers and by the public health professionals at the centre so that they could address local conditions, which were partly or largely dictated by the spread of virus and the disease in those localities.
I think we were in a position where we had a blanket approach, which was the right approach to start with, but I think we need to consider very carefully, particularly if we have a more severe form of the disease or another disease, where we have different situations arising in different parts of England, but also as we had in different parts the U.K. For example, some parts of the country can switch on the National Pandemic Flu Service without antivirals going all around the country when they might not be necessary. It is that sort of thing we need to be very careful about, to try to build in, from the preparedness point of view, the flexibility for different arrangements locally, but in a controlled way.
The Chair: Dr. Harper, I will close this session with one further question, which deals with the global access to vaccines. Ninety per cent of the manufacturing production is done either in Europe or in North America. The World Health Organization has suggested that at least 10 per cent of the vaccines that the pharmaceutical companies produce should go to the developing countries.
It is important that we look at this from an international perspective, particularly if we end up with a pandemic that is a far worse situation. What should we be doing about this? How do we increase the supply of vaccines for people in developing countries and to better cover the world?
Mr. Harper: I wish I had an answer. I will give you a view in a moment that might be my final word on the subject for this particular hearing.
We need to work closely with the World Health Organization. Long before the pandemic, we recognized the global shortage of vaccine production. Much of the discussion that took place in the context of the pledging conferences around trying to generate resources, particularly to help developing countries with their infrastructure and their surveillance in other areas, but recognizing the need to address this global vaccine shortage issue, was targeted at that very key issue. There are no answers, in the same way that at the moment there are no answers for other things; it is not restricted to this particular vaccine. There is an issue, as you are well aware, around equitable access to medicinal products in the broadest sense. The World Health Organization and the assembly have been discussing this for many years. If there were simple answers, we would have made more progress more rapidly. We do need to focus on this.
My parting shot, with your agreement, Mr. Chair, would be to pursue some of the promising lines of research to develop a broad-protection vaccine, almost a universal vaccine against influenza, and some of the research under way is producing some very promising results in that context. In a sense, that would be the obvious way to address not just the preparedness issue — because if we could vaccinate against influenza and if there were a broad spectrum vaccine, much of the rest of what we were talking about would tend to fall — but it would also go a long way to looking at the global vaccine shortage because we could do vaccination in a peacetime environment where we could actually provide the vaccine for the people who need it on a global basis.
The Chair: Dr. Harper, thank you very much for being with us. Given your time zone, have a good evening, and thank you for the contribution you have made to our consideration of this matter. It has been most valuable.
Mr. Harper: Thank you very much.
The Chair: For the second session today we are in video conference. We have two officials from the Ministry of Health of Mexico. Let me say welcome to both doctors. Thank you for taking the time. I would like to introduce you both.
First is Dr. Mauricio Hernandez-Avila, who is Deputy Minister of Prevention and Health Promotion. Dr. Hernandez-Avila earned his medical degree from the National Autonomous University of Mexico. In 1980 he went on to earn a master's degree and a doctoral degree from Harvard School of Public Health. He is a researcher of national and international prestige, and his work is in the areas of environmental health, cancer, epidemiology and public health policies.
We also have Dr. Hugo Lopez Gatell Ramirez, who is a specialist in internal medicine. He is currently Director General of the Mexican National Directorate for Epidemiology. He is also an assistant professor at the school of medicine at the National Autonomous University of Mexico.
I do not know whether you both will make an opening comment, but if you take a few minutes to make some opening comments, the members of the committee will then have questions for you, if that is okay.
Dr. Mauricio Hernandez-Avila, Deputy Minister, Prevention and Health Promotion, Ministry of Health, Mexico: Good morning to everyone. We are glad to participate in this conference and provide information and answer any questions you may have regarding our participation and the Mexican response in the H1N1 epidemic.
We have prepared a set of slides. I do not know whether it will be feasible to show them. It is a 20-minute power point presentation to provide you the background, if that is okay.
The Chair: I do not know whether the PowerPoint slides will come up, but you can try. However, if you could keep it a little shorter, we would appreciate it because we have less than an hour, and I want to be able to get your opening comments and also some questions from our senators.
Dr. Hernandez-Avila: Then I do not know that we need to make a statement. Maybe we can get from you further information regarding the protocol for the meeting and then jump directly to the questions you have. Perhaps that will be more efficient for our time here and your time there.
We were both in charge of the response. I was at the national level under Minister Córdoba. I oversaw all the issues regarding vaccine and response to what is primary medical care and epidemiology. Dr. Lopez Gatell Ramirez was mostly in charge of surveillance and all the contact with the international advisers who came to Mexico.
It is hard for me to give an opening statement because I do not understand very well the nature of this session.
The Chair: Perhaps we can ask questions of you and take it from there.
At the request of the Minister of Health of our country, we are reviewing how Canada dealt with H1N1 and how we dealt with SARS before that, and we are looking at a pandemic plan going forward — what kind of changes we should make to the existing plan, how it worked, what are the lessons learned and which areas need some strengthening.
We are also looking today, particularly, at the international context and trying to understand what happened in other countries. We had someone from the United Kingdom on here for the first hour. We now have the two of you. We know the importance of Mexico both in the North American context and also as where some of this problem originated according to our information, and we know of course about the collaboration that went on among the three countries of North America, Canada, the United States and Mexico.
We are trying to get an understanding of how you dealt with the various issues that we also had to deal with. For example, on immunization, on the vaccine issue, how did you deal with public communications on the matter? How did you convince the public that it was safe? How did you work out the priorities of who got the vaccine first? Those are some of the issues we have been studying.
Also, we have been dealing with surveillance, the gathering of statistics and how that information needs to be improved, perhaps using better technology.
Another issue is the production of the vaccine. Much of it occurs in North America or in Europe, but many countries in the world do not have that capacity, and the next pandemic could be more severe and we may need more vaccine, so global access to vaccine is also a key issue.
Perhaps you could speak to some of those issues, and my colleagues might have further questions.
Dr. Hernandez-Avila: Thank you very much for setting out these starting points. Let me take them in the order that you mentioned them, and let me talk about the issue of the vaccine.
Regarding how we were prepared for the vaccine issue, because we had previously detected that the vaccine production around the world would not be enough in the case of pandemic, Mexico had taken steps ahead to produce these vaccines. We had already established a joint venture with Sanofi Pasteur for the production of vaccine in Mexico. We were halfway into the construction of two plants; one for antigen production, which would be the responsibility of Sanofi Pasteur, and the other a packaging and dosage plant that would be the responsibility of the Mexican government.
In this agreement, it was set up that in the case of a pandemic, Mexico would have access to vaccines and would get preferential treatment. This was a joint venture and was specifically to protect the Mexican population. That was mostly the status in which we were when we were hit by the pandemic, so realistically speaking we did not have vaccine production capability in Mexico.
With this situation in mind, once the pandemic started, Mexico immediately decided to share with no restriction the biologic materials regarding the virus, and they were circulated to the international laboratories in Canada and in the United States, at the Centers for Disease Control and Prevention, CDC; they were also shared with the WHO headquarters. We had unrestricted collaboration in that regard. We immediately initiated talks with our partner, Sanofi Pasteur, to have access to vaccines.
Now here comes one of the big lessons: Immediately we realized that we did not have an agreed commercial contract for the delivery and pricing of vaccines. This was left open. This is a big lesson, because I am sure all countries faced exactly the same situation. We did not have an already printed contract to rule or to direct the commercial relationship between the government and the company. That created weakness in our negotiations with the companies.
We realized also that the vaccine that Sanofi Pasteur supplied to Mexico would not be sufficient to protect our target population, so we also started negotiating with other companies, specifically GlaxoSmithKline, so we negotiated with two of those companies.
Eventually we paid a competitive price. We paid what we know was below what other countries paid, but when the vaccine eventually arrived, it arrived very late. Our epidemic peak had already passed, so we lost opportunity in the delivery. That was not a big surprise because we and the government had made that prediction. That is why we were constructing a company to have our own production.
Eventually, countries that produced vaccine had an excess that they began to offer for resale. Here, I would like to point out that Canada made a nice gesture to Mexico and let us use some of the production that we had already purchased from GlaxoSmithKline to be delivered earlier to Mexico. We thank you. We were very grateful for these gestures from Canada. The vaccine came out late.
Those were two big lessons: We need to have our own production capabilities, and we need to have printed agreements already in place with industry to negotiate price and delivery.
Your second question was about how we set priorities for vaccinating our population. We had our national committee. We invited experts from the fields of ethics, immunology and public health. We defined the target populations according to our profiles in Mexico. First to be vaccinated were pregnant women, where we were seeing high mortality rates, and young adults with some co-morbidity with chronic diseases, obesity and HIV. Second to be vaccinated were children aged six months to four years and health personnel running our health response. That gave us estimated 27 million people to vaccinate.
Our national immunization program gives the vaccine through universal coverage in Mexico. We used this network to deliver the vaccine to the Mexican states and from there to the target population.
I will stop here so that I may answer any questions regarding vaccine; and then we can follow with the other points that you raised.
The Chair: The only other issue we talked about here with respect to vaccine is its safety and convincing the public that it is safe. We had a 41 per cent participation rate. We made the vaccine available to all Canadians who wanted it, and 41 per cent participated, which generally is considered to be a good response. It took some convincing messages, and we found that communication is a key element.
Did you have any issues regarding the safety of the vaccine? The vaccine was produced in a very short period of time, of course, and did not go through the usual clinical trials. It took some effort with the communication. Did you have issues with respect to that or to prioritizing who would get the vaccine?
Dr. Hernandez-Avila: What you mentioned was a big lesson that we learned. The Internet set off a war against the vaccine. We suffered like everyone else through the misleading information that the vaccine could kill people and that it was not produced with the safety criteria that are normally used. We were sure that the vaccine was safe because it was produced every year under more or less the same circumstances. It was a vaccine that we know very well.
We experienced an important barrier to our population. We gave the vaccine for one month to the target population. We had, as you had, a 50 per cent response from the target population. We then opened the vaccine to groups outside of the target population, after which the vaccine was an issue because we did not have vaccine for 100 million Mexicans. We had enough for only 30 million people. The vaccine was distributed 100 per cent, but we did open it to groups outside those targeted as priority.
Most often, a vaccine production company will follow issues regarding adverse reactions to the vaccine. They have to combat rumours that hit the market regarding the vaccine. For H1N1 they did very little, and we were left alone to convince people that the vaccines were safe. We should have addressed that issue at the beginning with good and convincing information. We did not do that successfully.
The Chair: My question is about the global supply of vaccine. How do we increase global supply? As you pointed out, some of the vaccine was contributed by Canada. If we end up next time with a more severe pandemic, how will we cope with the supply of vaccine in the world? Most of the vaccine — 90 per cent — is manufactured either in North America or in Europe, but we have to get it to other countries as well. Do you have any thoughts about that?
In terms of the lessons learned from the H1N1 pandemic about your supply, have you taken corrective action to ensure sufficient source for the people of Mexico the next time this should happen?
Dr. Hernandez-Avila: You raise an important point. This time, we did not have enough supply worldwide to contain a more severe pandemic. That is very clear.
Two weeks ago, President Felipe Calderón negotiated the antigen production plan. By the end of 2011, we will be producing the antigen in Mexico; and by the end of 2012, we will be in full production of the vaccine in Mexico. We are moving in that direction.
What should we do to increase the global supply? When the vaccine was tested, we did not include a sufficient range of possibilities to increase vaccine delivery. Now with the information available regarding the potency of the vaccine and dosages, we could duplicate the vaccine that could be available. The only ways that we could increase vaccine availability would be by testing different dosages and by providing opportunities to produce more vaccine.
Your other point was what will countries like Canada, the United States, Europe or Mexico do to guarantee that all populations could receive the vaccine. You offered the vaccine to your entire population, as did the United States. You might question the ethics of this and whether the ethics around the prioritization of groups to vaccinate stop at our border. Suppose children in Chile, Honduras and Mexico are left and we decide to vaccinate our adult population, which is not at a high risk. That is an ethical question that must be addressed by all countries regarding how we will deliver vaccine to the most vulnerable population.
I can give you an example of this. At the beginning of the pandemic, we saw in Mexico that pregnant women had a very high risk of mortality. Indeed, we observed many deaths in pregnant women. We were looking around the world for a million doses to vaccinate our pregnant women, and it was literally impossible to get.
These ethics must be considered by countries and regions in advance of the next pandemic.
The Chair: Thank you for your answer.
Senator Seidman: My question concerns surveillance, which has been a big issue among our witnesses. We have discussed this often throughout these hearings.
What mechanisms did you use for surveillance with almost real-time data that you might need to track new cases, hospitalizations, deaths and adverse events? Did you have a general electronic system as well?
Dr. Hugo Lopez Gatell Ramirez, Director General, Epidemiology, Ministry of Health, Mexico: Thank you for the question. Surveillance was a challenge also for us during the pandemic. Since 1995 we have had a national surveillance system for communicable diseases, procedures, time for notification, et cetera, throughout the country. In 2006, in the spirit of preparedness for avian and pandemic influenza, Mexico switched its strategy, specifically for influenza, from a general surveillance approach to sentinel surveillance; we have a few hundred of the sentinel units across the country versus 19,000 health care units that routinely report all the communicable diseases. We wanted a more efficient strategy to assess influenza.
However, between 2006 and the start of the pandemic, and also during the pandemic, it was a big challenge for us to position the meaning of the data coming from the surveillance system with this approach. It seems to us that the experience that the United States and Canada had was more established using these more efficient approaches like sentinel surveillance and laboratory-based surveillance.
Here in Mexico, the expectation of both officials and the population is to have a full count of cases across the country. It was a big challenge to position the messages that came out of surveillance.
A good lesson, though, is that after the pandemic was over we developed our system stressing the importance of having full participation of clinicians and full participation of all the 32 states in Mexico, and that has improved.
Also, laboratory surveillance was a big challenge. That moved quickly with great collaboration from Canada that helped us to expand our laboratory network very quickly. When the pandemic started, our national records laboratory was performing real-time PCR — polymerase chain reaction — which is a more specific and advanced testing, but we had no state-level laboratory doing so. Within six weeks we were able to establish in every state in Mexico a state-level laboratory able to do that. That was very important.
From the international perspective, in the last five years, and more specifically in the last two, we have been working with the Public Health Agency of Canada and the National Microbiology Laboratory, as well as with the United States CDC, to mount a framework for information exchange among the three countries. When the pandemic hit, we three countries were communicating very well and were well aware of what was happening in the other two countries.
In our first meeting of the high-level advisory committee that decided on extreme public health measures, such as closing the schools in the entire Mexico City Metropolitan Area, we were fortunate to have the opinion of high-level experts from Canada and the United States, which was very helpful, and also to have the collaboration of Canada's National Microbiology Laboratory for testing specimens.
Finally, we have the challenge of establishing a national surveillance system in real-time platforms on the Internet. We have had that for the last seven years for other diseases, but we were not fully prepared for that. With the push of the pandemic, we also set up, in a period of eight weeks, a real-time notification information platform online in which all states can now participate.
It is also worth mentioning that the work Canada has done at the National Microbiology Laboratory in developing the Canadian Network for Public Health Intelligence gave us a model for establishing this, and we are thankful to the Government of Canada for that.
Dr. Hernandez-Avila: To add to that, it was 10 days from when we detected the first severe cases of influenza until the emission of the alert. We worked closely with the Canadian security agency and with CDC, because we did not have at that time, although we do now, the capability to make the DNA analysis of the virus. We knew it was an influenza virus, but we could not come up with the subtype of influenza virus. Our system took us 10 days to detect the increase, to alert other parts of the world and to come up with an open and transparent communication.
In the follow-up of the epidemic in Mexico, we did experience some problems, because we still do not have an electronic medical file, so it was difficult to come up with all the statistics from the hospitals. It was hard for us to have day-to-day statistics on how many people were hospitalized and how many were in intensive care units. We are working now to increase the speed at which we develop our electronic medical files.
Senator Seidman: I appreciate your responses, and I must say that it is very impressive to hear the progress you have made on this front in a very short time. Thank you very much.
Senator Martin: Thank you, doctors, for your insights into Mexico's experience. We have been talking a lot about the things that went very well in the last pandemic outbreak experience, both locally and internationally, and the role that Canada has played. It is very encouraging for us to know that we have a strong base on which to improve.
One area that is a challenge or weakness that has been identified is communications. How effective are the communications in the North American plan — Canada, the U.S. and Mexico? What were some of the challenges that you noticed in the international partnership? There are different time zones, and it is not hard to appreciate the natural challenge of trying to bring international partners together. Would you speak to the communication challenges in North America, as well as in the world, and what are some helpful strategies or suggestions for the next outbreak?
Dr. Hernandez-Avila: Communications were already in place. Health officials from Mexico and officials from Canada and the United States have been meeting at least for five years, drafting our plan. We were also doing table exercises regarding what the situation might initiate. I think we were prepared.
We knew each other. The communication went out right away. We knew that the United States had the virus, and we were able to identify that it was the same virus within days. There were reports that the one they had in California was the same one we were finding here in Mexico.
We were also in pretty good communication with the Canadian laboratories and public health authorities. I spoke many times with the director of CDC, Dr. Frieden, and with Dr. Butler-Jones. Therefore, I would say the communications were very good, both formal and informal. Informal are these communications, phone calls and conferences. The very formal were other communications that we needed to have in place with the international health regulation, which we were reporting. They also included area reports to our colleagues in Canada and in North America.
Communication with other parts of the world was a little more difficult. We used the Pan American Health Organization network to have early meetings with the health authorities of Latin America. We had the possibility to warn them, to mention what we were doing and the various things Mexico had done. That was well appreciated by the people in Latin America, especially in Chile and Argentina. We sent specialists to Chile and Argentina to help with their response.
With other parts of the world, other communications went through the WHO. I think we experienced miscommunication with France and England. Flights were cancelled immediately, and the tourists were not well informed. That was not so with Spain. Spain played a major role in re-establishing trips to Mexico.
However, I would say North American communication was safe, and we worked together very much. As you may know, in our sessions where we briefed our Minister of Health and health authorities, Dr. Butler-Jones and officials from CDC were on the phone and participated in the very early and important meetings.
Dr. Ramirez: I agree with what Dr. Hernandez-Avila said. You are aware that we are meeting next week in Washington with health and safety officials from Canada, the United States and Mexico. We are there to review the North American plan for pandemic influenza preparedness. This document was drafted in 2007 in the context of the Security and Prosperity Partnership of North America, which is now called the North American Leaders' Summit.
We three countries value keeping this plan moving and updating it with lessons learned during the pandemic. Our evolution of the communication, the aid, the openness and the transparency that is present in the framework of collaboration of the three countries of North America is very positive.
Senator Martin: It is interesting that there seemed to be a higher level of trust among the experts on the international and even North American stage than what sometimes happens locally. That could be true of Canada and the different jurisdictions.
Earlier Dr. Harper from the U.K. talked about self-professed experts who can weigh in and add sometimes conflicting information if they disagree with what the experts are saying. What you highlight about having this very clear line of communication and the trust among yourselves to work together so that the messaging is consistent and you are communicating that effectively is something to be learned in each of the individual jurisdictions.
In Mexico, did you have any communication challenges with regard to conflicting messages or self-professed experts who weighed in if they were not at the table or did not agree with what was happening with the federal plan? Did you experience any of those communications challenges?
Dr. Hernandez-Avila: We definitely experienced that type of miscommunication. However, it was addressed by having one speaker for the problem. The speaker was Minister Córdova, the health minister. He was the speaker right from the beginning of the outbreak, and he gave hundreds of interviews. We had official interviews morning and afternoon to provide information.
As everyone did, we had problems with counting the cases. Every epidemic experiences that type of situation, whether there are 500 or 600 cases.
We also had some problems with Mexican scientists who felt excluded. The international relationship mandates that we need to share our samples with our reference laboratory. Our reference laboratory is CDC. However, it was not clear to these scientists why we violated our national sovereignty and sent samples to the CDC before sending them to other laboratories. They provided some misinformation regarding the potential for mutation of the virus and regarding how well the government was prepared. However, all these issues were magnificently addressed by Dr. Córdova, who is an excellent communicator and who had the trust of the population.
We opened an incredibly large call centre, in which more than six million calls were taken. We were able to mount that because our telephone company provided that service for free. Telmex provided an immense calling centre where we handled most of the telephone calls. We also used instant messaging for mobile phones to send messages to the population to provide good information.
We had good and bad days. There were all kinds of rumours. There was a rumour that the virus had spread from a small pig farm in Veracruz, and that rated a lot of interest from the international journalists. Eventually, that was disproved, but at the moment we experienced all those problems with communications.
Another thing that helped very much is that under the preparedness measures that Dr. Lopez Gatell Ramirez has already mentioned, we worked with our colleagues from the United States and Canada to develop our own risk communication campaign. We already had messages that were tested for the population; we had a small cartoon in Spanish to bring the information. We were basically very ready to deliver information to all kinds of audiences.
What challenges did we face? We were very close to election time. That was not considered in our pandemic plan — what if this happens when you are going into elections? We have learned now, and we have a plan and lessons for how to do it. Those were things that we did not envision when we wrote the plan.
The Chair: Before we end the session, I have one final question. You mentioned that the vaccine was late in coming. What did you do in the meantime, particularly with respect to the use of antivirals, concerning social distancing — in other words, either isolation or trying to keep people apart to keep the spread down — or personal hygiene? What did you do in that interim period in respect of those matters?
Dr. Hernandez-Avila: Since the beginning, we established very strict measures of social distancing. We closed schools, which is the largest network of transmission that we have in Mexico. We took advantage of the fact that in May, there are several days in which children do not go to school. Therefore, we did not lose many classes, and we were able to close schools.
We started a very large hygiene campaign through the media. We distributed enormous quantities of alcohol for handwashing. We also prepared schools that did not have cleaning facilities, so that when the students would come back, they would have alcohol to wash their hands. We established screening points at the entrance to the schools. That helped us to prepare very well for their return.
We also had antivirals in stock, and we started to provide antivirals for free to all the people who had influenza-like symptoms. They were distributed to all the states. We had one million doses reserved, and we also received immediately donations from the United States, the WHO and other countries. We attacked with antivirals and social distancing and also communicating about personal hygiene.
In addition, we mounted a very large campaign in the mass media regarding the risk factors for transmission, showing people how to cough, telling people not to put their finger in eyes and mouth and all those public health measures.
The Chair: Thank you very much for your answers and for participating in our study of pandemic preparedness in Canada. Your input has been very valuable.
Dr. Hernandez-Avila: We also want to thank you as part of the Canadian government. I think you should be proud; you have very strong agencies that provided leadership and experience when we needed it. We value very much all the Canadian professionals who came early in the pandemic to help us. They were of much value; thank you very much.
The Chair: You are most welcome. I am sure that collaboration will continue.
(The committee adjourned.)