Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 14 - Evidence - October 18, 2010
OTTAWA, Monday, October 18, 2010
The Standing Senate Committee on Social Affairs, Science and Technology met
this day at 6:31 p.m. to study Canada's pandemic preparedness.
Senator Art Eggleton (Chair) in the chair.
The Chair: I had to bang the gavel a few times because it is such a
big room; I do not know how long it takes to send the noise back there. Welcome,
Welcome to the Senate Standing Committee on Social Affairs, Science and
Tonight, we continue with our hearings on pandemic preparedness and response.
We have a number of provincial as well as federal witnesses in two panels
tonight. We start now with a panel, as you see at the end of the table. Then at
8 o'clock we will switch to a second panel, which will include a video
conference from British Columbia.
Starting off with this panel, we have from the Ministry of Health and
Long-Term Care, Province of Ontario, Allison Stuart, Assistant Deputy Minister,
Public Health Division. Also from the Province of Ontario, we have Dr. Arlene
King, Chief Medical Officer of Health. From the Province of Saskatchewan, we
have Dr. Moira McKinnon, Chief Medical Health Officer. We also have an entity
that has been here for almost every meeting, the Public Health Agency of Canada.
Today we have Dr. Gregory Taylor, Director General, Office of the Public Health
Practice, who will speak to us. Also here to answer questions is Dr. John Spika,
Director General, Centre for Immunization and Respiratory Infectious Diseases. I
think we have had some reference to Dr. Spika in past meetings. Welcome to all
five of you.
I will take you in the same order, unless you have another preference. I will
start with Ms. Stuart. If you can give your opening comments in about seven
minutes, that would be appreciated.
If I call you doctor, I can call everyone doctor. Is that okay?
Allison Stuart, Assistant Deputy Minister, Public Health Division,
Ministry of Health and Long-Term Care, Province of Ontario: I am not a
doctor, but go ahead.
Thank you for the invitation extended to Ontario to discuss pandemic
preparedness from Ontario's perspective.
Ontario's experience with the outbreak of severe acute respiratory syndrome,
SARS, in 2003 exposed us to painful truths about our health system. Despite the
extraordinary measures of many people, the overall system proved inadequate to
the need at the time.
After SARS, there were extensive studies and reviews to analyze the lessons
learned, and these have helped to influence and shape both Ontario's health
emergency management program and our pandemic preparedness efforts. These
actions were key to Ontario's response to H1N1.
Since SARS, Ontario has made significant investments in public health renewal
activities including health emergency management, infection control and
communicable disease capacity, health human resources and health system
The experience of SARS focused the province's attention on the need for
effective coordination and communication.
To support this need, a purpose-built ministry operations centre was
established, bringing together staff throughout the Ministry of Health and
Long-Term Care to provide direction and operational management and support to
the health sector during a crisis, and this centre was the primary locus of our
The operations centre adopted the incident management system, IMS, to
strengthen further the province's ability to respond to complex emergencies. As
you heard previously, IMS fosters communication and cooperation with, and among,
organizations to mount a cohesive response to emergencies.
The years since SARS have brought additional stakeholders to the public
health landscape in Ontario. They include the Ontario Agency for Health
Protection and Promotion, a centre for providing scientific and technical advice
to protect and promote the health of Ontarians.
Although less than a year old at the outset of the H1N1 pandemic, the agency
played an important role, including leading the scientific response team, which
provided expert advice on the emerging novel virus. This was done in conjunction
with other colleagues at the provincial and federal levels.
Having experienced SARS without the benefit of a Public Health Agency, and
H1N1 with the benefit of a Public Health Agency, I believe that we have not yet
fully utilized the wonderful resources available to us at the national,
provincial and territorial levels through the public health agencies in British
Columbia, Quebec and Ontario, to work in conjunction with Public Health Agency
of Canada. We need to integrate and formalize the services that these agencies
can offer for our plans. This integration will benefit all of us.
I will talk for a moment now about the Ontario Health Plan for an Influenza
Pandemic. The province is working currently on its sixth iteration of the plan.
It outlines the roles and responsibilities across Ontario's health system and
across different levels of government, providing guidance and tools to support
preparedness and response activities.
Most of the decisions and strategies we implemented in response to H1N1 were
contemplated and established in Ontario's pandemic plan. Our years of planning
ensured that we had clear policy objectives in place prior to the pandemic. The
key challenge was titrating the responses to a mild pandemic when our plan, like
the plans of other jurisdiction, contemplated a moderate to severe pandemic.
Work is required now at all levels to reflect a range of severity and a range
of responses. In other words, we need to be able to turn the dial up or down, as
Our ongoing consultation with front-line providers and associations during
the planning process was key to our success in Ontario. The relationships we
built through this process enabled us to support the close collaboration that we
saw during the H1N1 response. We do not want to meet people for the first time
in the middle of an emergency.
Effective collaboration is as important at the federal-provincial-territorial
levels. Moving forward, there is a need to clarify roles and responsibilities
further, particularly as they relate to communications and information sharing.
For example, during H1N1, there were health professionals who were confused on
whose advice to take when they received clinical guidelines on the same topic
from provincial and federal sources, along with their own professional
associations and perhaps the local medical officer of health. The good news is
that the messaging was, in large part, consistent. However, it is unfair to
expect the busy health professional to read through all the documents to
conclude that all documents said roughly the same thing.
We need to coordinate and leverage better the strengths and focus of the
various levels, while allowing for adjustments to reflect the unique and varying
needs of each jurisdiction.
Through the Public Health Agency of Canada and the Public Health Network
Council, we have a forum for developing integrated planning and response within
the public health sector. Linkages with other aspects of the health care
delivery system are less well developed, and would have been beneficial in our
H1N1 response. I believe that there is a general recognition that this is an
area of further work for us, at the national, provincial and local levels.
In Ontario, we are reviewing our H1N1 experience. Three reports have been
developed so far, or are in the process of being developed, examining areas of
the H1N1 response. An initial report was prepared by Dr. King in her role as
Chief Medical Officer of Health as an update to all Ontarians. A second report
was prepared by an internal audit team that examined the specific response of
the Ministry of Health and Long-Term Care as the lead ministry within the
province of Ontario. A report soon to be finalized will weave together the
findings of the two previous reports as well as the feedback gleaned from
surveys, focus groups and deliberative dialogues with front-line service
providers, professional associations, media, the public and our colleague
Lessons learned, first from SARS and now from H1N1, will help us continue to
refine and enhance our pandemic planning and our preparedness strategies because
we know the question is not if, it is when. Thank you very much.
The Chair: Thank you. Staying with Ontario, we will move to Dr. Arlene
King, Chief Medical Officer of Health.
Dr. Arlene King, Chief Medical Officer of Health, Province of Ontario:
Good evening. Thank you for inviting us here to address the important issue of
pandemic preparedness and the knowledge we have gained from our response to
pandemic H1N1 in 2009.
While I served previously as the Director General of the Centre for
Immunization and Respiratory Infectious Diseases at the Public Health Agency of
Canada, my comments today are from my perspective as Chief Medical Officer of
Health for Ontario.
As you may be aware, I released a report in June, The H1N1 Pandemic — How
Ontario Fared. Today I will focus on some of the province's challenges
during the immunization response.
It is important to note that the pandemic immunization program was the
largest and most rapidly executed immunization rollout in Canada's history. It
was characterized by the real-time application of science to policy and program
development and by real-time public and professional education and
communication, often delivered in the space of hours and days. We ordered more
than enough vaccine, and it is estimated that as many as five million Ontarians
were immunized. Every person who wanted the vaccine received it.
Not surprisingly, though, not everything went smoothly. From the beginning,
we had a mismatch between vaccine supply and demand. Early on, the demand was
high, catalyzed by the tragic and highly publicized deaths of two Ontario
children, and the supply was limited or non-existent. Later in the campaign, we
had plenty of vaccine, but the public's interest in being immunized had waned.
Second, we underestimated the logistics of delivering a mass immunization
campaign in tight time frames.
Third, although federal, provincial and territorial partners had agreed upon
the priority groups to receive the vaccine, this prioritization led to concerns
from the public that there was inequity in how the vaccine was administered.
Additionally, the sequencing posed many problems for vaccine providers in many
parts of Ontario and, I believe, ultimately reduced vaccine uptake.
Finally, the packaging in 500-dose shoeboxes posed problems for many vaccine
A number of additional lessons are to be learned from Ontario's experience
with the province's H1N1 immunization rollout that may be relevant to other
jurisdictions and the federal government. Public perceptions of the safety of
the vaccine and severity of the disease played important roles in the desire of
Ontarians to receive the H1N1 vaccine. These perceptions were compounded by
confusion over the differences between the adjuvanted and unadjuvanted influenza
vaccines. These issues speak to the fact that there is a need for us to work
together at all levels to promote the safety of influenza vaccines better, and
to communicate clear and consistent messages in support of future immunization
campaigns in Canada.
I will also speak for a moment about surveillance. Defining the
characteristics of a new emerging infectious disease, and tracking and managing
an immunization response are important to every jurisdiction. I applaud the
efforts of the federal government to develop a pan-Canadian public health
information management solution to track and respond to infectious diseases more
effectively. I look forward to the day when this technology, called Panorama,
will be implemented in Ontario.
It will enhance the province's ability to collect, share and analyze
information about infectious diseases and our immunization programs. This
enhanced level of information will be of benefit at the local, provincial and
federal levels. Once a robust public health information system is implemented in
Ontario, I will be in a much better position to provide more timely and
comprehensive information about infectious diseases and our immunization
programs. That system will also greatly support our efforts to manage future
infectious disease outbreaks.
As with Panorama, the federal level is also well placed to coordinate
activities such as the procurement of vaccines and antiviral drugs, the sharing
of epidemiologic information on infectious diseases and liaising with the World
In closing, I want to underscore the observation that we must capitalize on
the lessons learned from the H1N1 pandemic, and most importantly, act swiftly on
them to ensure that we do not miss this opportunity to strengthen further
Canada's health emergency readiness. Now is the time to take steps to ensure
that we will meet the next influenza pandemic or other health emergency with a
robust and highly effective response for the benefit of all Canadians.
Ontario remains committed to continuing to support pandemic preparedness, and
we look forward to working in partnership with our federal, provincial,
territorial and local partners to implement the lessons learned from H1N1.
The Chair: Now we will move to Saskatchewan, Dr. Moira McKinnon, Chief
Medical Health Officer.
Dr. Moira McKinnon, Chief Medical Health Officer, Province of
Saskatchewan: I thank the Senate committee members for this opportunity to
present on issues on pandemic preparedness and lessons learned from a provincial
Saskatchewan, as you are aware, has a population of approximately one million
people. It is unlike many other provinces in that its population is
predominantly rural. The two major cities, Saskatoon and Regina, each have a
population of approximately 200,000.
The Ministry of Health was notified on April 19 that a novel influenza virus
had been identified and was associated with clusters of severe respiratory
infections in Mexico. The response from the Public Health Agency of Canada was
swift, with excellent collaboration between provinces and territories.
The key committee, the Scientific Advisory Committee, met on an almost daily
basis. It was composed primarily of the key leaders in the Public Health Agency
and the chief medical health officers, and was chaired by Dr. David Butler
Jones, Chief Public Health Officer of Canada, and Dr. Perry Kendall, Chief
Medical Health Officer of British Columbia.
The excellent work of the Public Health Agency of Canada and the network of
public health practitioners across Canada resulted in an effective response to
the H1N1 pandemic.
At the time, the Ministry of Health in Saskatchewan was in the process of
revising its pandemic plan. This process was accelerated, and as the uncertainty
as to the severity of the pandemic became apparent, it was nuanced to embrace a
range of clinical severity and to bring in risk assessment as a key need in
determining response rather than a proscriptive response.
An inter-ministerial committee was set up, and the response to the pandemic
virus became a whole-of-government response. These early conversations and
deliberations, particularly with Crown corporations, made future discussions and
actions easier than anticipated, particularly in regard to keeping schools open,
implementing infection control in workplaces and acceptance of vaccine
The daily business of emergency response in Saskatchewan to the pandemic was
set around the federal meetings, and the response awaited key decisions from
The Scientific Advisory Committee meetings were often arduous and with
detailed debate in regard to lengthy guidelines. An improvement here could have
been to extract the key decision points from the guidelines and discuss those
points while the remainder were dealt with off-line. As time went on, many of
the guidelines could not be agreed upon, and jurisdictions began to take
decisions in the absence of guidelines. The infection control guidelines,
including the use of N-95 masks, were an example of these decisions.
Major challenges existed in information flow, collection and rapid analysis.
Some of the infrastructure nationally does not exist to enable an almost
real-time need for information to make day-to-day decisions, especially when
faced by resource limitations. The lack of information was most evident in
regard to clinical impacts, the clinical picture and rates of intensive-care
admissions. There was not a constant definition, for example, for hospital
admissions, which created analytical discrepancies in data between provinces. In
some jurisdictions, the definition was an admission to an emergency room; in
others, like Saskatchewan, we chose to define hospital admissions as those
people that stayed longer than 24 hours.
Manitoba experienced many serious cases in the first wave. Saskatchewan
struggled to obtain information during the first wave on the number of hospital
admissions and severity of cases in Manitoba. These cases occurred early in the
pandemic and many before a diagnostic test was available. Concerned personnel
from First Nations and Inuit Health set up a series of webinar presentations
that began to shed light on the clinical picture. The Public Health Agency
followed suit and set up a clinical symposium in September in Winnipeg and
keynote speakers included scientists and policy officers from the southern
hemisphere — Chile and Australia — as well as an in-depth discussion of
Manitoba's experience in the first wave.
We were able to determine that a significant number were from First Nation
communities, and affected communities included those close to the northern
border of Saskatchewan. Our response was to heighten surveillance in those
communities, both in the first and second waves. Although Saskatchewan followed
in general the antiviral guidance determined by the Scientific Advisory
Committee, we decided that in the vulnerable communities, predominantly in the
First Nations, the antivirals would be made available freely to those with mild
disease, not only to those with moderate disease. We urged the regional medical
health officers to work with chiefs and councils to assess the risk in
communities and to increase the vigilance of the communities as a whole. This
approach worked well, and collaborative decisions were made with chiefs and
councils, for example, in promoting infection control and in deferring festive
Saskatchewan made all antivirals currently in pharmacies free including
waiving of the dispensing fee. Dispensing free antivirals applied to all
Saskatchewan residents, including those under non-insured benefits. A small
amount of the antiviral stockpile was released and mechanisms were set up in
remote communities for prescription by nurses through phone order.
Information availability was also lacking in regard to vaccine technical
detail. I felt considerable discomfort in declaring to the Saskatchewan public
that a vaccine was safe when I was not privy to the full information in regard
to that vaccine. The Pandemic Vaccine Working Group had access to that
information, but the chief medical health officers did not and were asked to
trust the expert group. Concerns expressed led to some of the information
becoming available and also the use of the National Advisory Committee on
Immunization, a well-respected body, to become involved to examine the technical
detail and report to the chief medical health officers.
The sequencing of vaccine discussion took a great deal of time and, in the
meantime, the epidemiology of the virus was becoming better known. We were
making decisions on data that was only a few days old. If we had known the
real-time data, the decisions may have been a bit different.
The vaccine, as you are aware, rolled out in relatively small amounts, the
first shipments on October 26. Saskatchewan determined that people living in
remote and isolated communities and health care workers were to be vaccinated
first, followed by pregnant women, women up to four weeks postpartum and
children from six months to five years. Existing infrastructure in health care
settings was used to provide these vaccinations.
As the vaccine program began, cases of H1N1 were reported, mainly in the
northwest. Five people moderately and severely ill with H1N1 were evacuated from
remote communities. The communities were being vaccinated at the same time.
There were no more evacuations following those first five evacuations. I see
this situation as a measure of the effectiveness of the vaccine program in the
North. Vaccine rates between 70 per cent and 80 per cent were reached in most
Northern communities in the early stage of the second wave. However, the
influenza was spreading in the South and many regions set up influenza
The next priority group for vaccination designated by the Scientific Advisory
Committee was all people with chronic diseases under the age of 65 years. This
group was estimated to be about 300,000 in number, approximately a third of the
population of Saskatchewan. The number of vaccines in each allotment was
generally known only a day or two before arrival and, in the second week of
November, the allotment was only 30,000. This factor was one that led to the
reconsideration of vaccine sequencing in Saskatchewan.
Three factors determined Saskatchewan's move to vaccinate children up to the
age of 13 years rather than to opening clinics for those with chronic diseases:
First, there was insufficient vaccine to provide equitably to the chronic
disease group; second, there was evidence from the U.S. that childhood
admissions for severe disease were increasing; and, third, there was a clear
expression from the community that they would like their children protected. The
children were vaccinated using school immunization program infrastructure and
processes. Vaccine supply improved, and Saskatchewan opened community clinics in
its major centres in the third week of November, rapidly moving from inviting
those under the age of 35 with underlying health problems to those under the age
of 65 with underlying health problems, and then to all who wanted the vaccine.
We did not experience delivery issues or difficulties with queues.
Daily assessment of vaccination rates was available through the Saskatchewan
Immunization Management System, a data collection system that has been used for
over 10 years. Prior to the pandemic, enhancements were made to the system that
allowed for timely, easy access to information by region and subgroup. The
overall immunization rate in Saskatchewan was close to 50 per cent. High rates
were achieved in seniors, health care workers and children. Immunization rates
were lowest in young adults. Saskatchewan is committed to working closely with
federal- provincial-territorial partners in going through the lessons learned
from the pandemic.
The Chair: Thank you. From the Public Health Agency of Canada, two
doctors are here but Dr. Taylor will speak for the agency on this matter.
Dr. Gregory Taylor, Director General, Office of the Public Health
Practice, Public Health Agency of Canada: I thank the Senate committee for
this opportunity to share some of the lessons learned from the H1N1 pandemic
from the perspective of the Public Health Agency of Canada and in relation to
the roles of the federal-provincial-territorial governments.
Throughout the H1N1 response, I assumed various roles, including shifts as
event manager of the Health Portfolio Emergency Operations Centre; an alternate
federal co-chair of the federal-provincial-territorial Special Advisory
Committee on H1N1, SAC; and I also assisted with internal mechanisms training
our staff to work in the operations centre and executive decisions in the
In previous presentations from SAC and provincial and territorial witnesses,
this committee has learned about the significant progress that
federal-provincial-territorial governments have made in working together since
the SARS outbreak to improve Canada's overall pandemic planning and response
capacity. In my remarks today, I will focus on some of the mechanisms and
arrangements that were in place or that evolved pursuant to the H1N1 outbreak to
facilitate intergovernmental collaboration and evidence-informed, consistent
As we have already learned through deliberations, responsibility for public
health in Canada is shared among local, provincial, territorial and federal
governments. Where a public-held event or infectious disease outbreak occurs
that involves more than one province or territory or that may affect other
countries, the federal government will take a leadership role in coordinating a
Canada has made significant progress in establishing effective public health
networks across jurisdictions to plan for and respond to infectious disease
outbreaks. The establishment of the Public Health Network, which my colleagues
have alluded to, in 2005 was a key milestone and provided the structure for
facilitating a coherent national response during H1N1.
The Public Health Network is an important federal-provincial-territorial
mechanism with a mandate to serve as a forum for multilateral intergovernmental
collaboration on public health issues. The network is a permanent body that
meets regularly and includes participation from all provinces and territories,
Health Canada's First Nations and Inuit Health Branch and the Council of Chief
Medical Officers of Health.
As has been discussed previously, the Pan-Canadian Pandemic Influenza Plan
for the Health Sector was already in place when the H1N1 virus emerged. Because
the Public Health Network was involved in the development of this plan, the
initial response to the H1N1 outbreak was extremely swift. As initial reports of
a potential novel influenza virus began trickling in from multiple sources, a
number of federal-provincial-territorial and expert public health working groups
activated their pandemic response procedures and protocols. This response
allowed us to work together to synthesize and interpret emerging public health
information and provide timely and informed advice to decision makers. The
evidence-based transparent and collaborative approach that
federal-provincial-territorial deputy ministers of health took in responding to
the H1N1 pandemic was mirrored by health ministers and other officials across
the country, both within their respective governments and in the public
communication. This approach ensured a more effective response.
During the H1N1 outbreak, deputy ministers and the Public Health Network met
more frequently than usual and federal-provincial-territorial governance
structures evolved to enable timely decision making. As the potential scope of
the crisis became more evident, deputy ministers implemented a
command-and-control-type structure that allowed for effective collaboration in
several core response areas. This collaboration was made possible by a healthy
level of trust between jurisdictions.
One of the most important federal-provincial-territorial committees to emerge
during H1N1 was the federal- provincial-territorial Special Advisory Committee
on H1N1. Co-chaired by Dr. David Butler-Jones and Dr. Perry Kendall, the
Provincial Health Officer of British Columbia, this group brought together
membership from the Public Health Network Council and the Council of Chief
Medical Officers of Health. The group met daily at the outset of the pandemic,
and then with decreasing frequency as the outbreak progressed. SAC became a key
focal point for providing timely public health advice on H1N1 to deputy
ministers of health and, through them, to federal-provincial-territorial
Under SAC, another important committee was the Pandemic Coordination
Committee, which oversaw an extensive federal-provincial-territorial workplan
involving a number of task groups and hundreds of staff, which resulted in an
extensive list of materials, including guidelines and recommendations to SAC.
This innovative management approach has since been recognized for its ability to
dispense timely advice to all levels of government through its nomination as a
finalist for the 2010 Innovative Management Award of the Institute of Public
Administration of Canada. The implementation of this governance structure added
stability to the federal-provincial-territorial H1N1 response and allowed deputy
ministers to have increased oversight and decision making.
During the pandemic, communication was perhaps our strongest asset. There was
an unprecedented level of collaboration between federal, provincial and
territorial governments to ensure Canadians received clear, consistent and
timely information in regard to making appropriate decisions to protect
themselves and their families from infections. Federal-provincial-territorial
communication officials had the benefit of a detailed plan, which can be found
in Annex K of the Pan-Canadian Pandemic Influenza Plan for the Health Sector.
Annex K outlines common communication objectives at each stage of a pandemic
declared by the World Health Organization, and delineates jurisdictional roles
I also note that First Nation, Inuit and Metis representatives participated
within the Public Health Network as part of the response to the H1N1 virus.
Early involvement of their leadership was seen as integral to an effective
response to related communication.
In an environment where the scientific evidence on the virus was constantly
evolving, the success of a response effort was, in large part, due to the
dedicated effort of all jurisdictions to learn from each other's experience and
base decisions on the best available advice from the chief medical or public
health officers and experts. The lack of a pan- Canadian electronic public
health surveillance system created challenges for jurisdictions during the
outbreak and hindered the real-time ability to adapt responses to the
ever-changing environment. This situation demonstrated the need for a more
robust pan-Canadian public health surveillance system, in which work is
currently under way.
A memorandum of understanding on roles and responsibilities in pandemic
influenza preparedness and response for the health sector in the 2009 H1N1
outbreak was agreed to in principle by all federal-provincial-territorial
ministers of health except Quebec, in September 2009. This important milestone
built on other agreements delineating jurisdictional roles and responsibilities
that followed the SARS outbreak, and were key parts of the overall Public Health
Network mandate. For example, the MOU was instrumental in facilitating
negotiations of the 60:40 federal-provincial- territorial cost-sharing agreement
for influenza vaccine and antivirals. The federal, provincial and territorial
governments are already working hard to finalize a post-H1N1 MOU for pandemics.
Finalizing formal agreements on federal, provincial and territorial roles and
responsibilities and other initiatives, such as the Multi-lateral Information
Sharing Agreement, will further strengthen collaborative preparedness efforts. A
fully established federal-provincial-territorial body has already reviewed and
ratified the proposed direction for information-sharing agreement development,
and the Public Health Network Council has agreed to a multilateral approach; the
inclusion of biological substances; and a generic main body on infectious
disease, plus technical schedules dealing with specific infectious diseases and
public health events.
Collaborative multi-jurisdictional agreements will continue to be
strengthened, and governments will apply lessons learned from the H1N1
experience to update and refine the national pandemic plan. Work is under way in
these areas and federal-provincial-territorial governments will continue to work
together to address several of the issues we have outlined today. For instance,
the Pan-Canadian Public Health Network has initiated a comprehensive review and
update of the Canadian Pandemic Influenza Plan for the Health Sector.
At the federal level, the health portfolio has an opportunity to learn from
its experience in responding to the pandemic and is currently working on a
lessons-learned review for the portfolio. Information gathered during this
review will inform the response to future pandemics and other national health
In closing, I am proud of the response to the H1N1 pandemic of governments,
our partners, and of individuals. At every step of the way, all players
understood the imperative to work together to better protect the health of
Canadians. We have been fortunate to have a network that links all these players
with stakeholders and provincial, territorial and federal governments.
For the agency specifically, the H1N1 pandemic was a critical test of our
abilities on all levels. Specifically, the relationship between provincial and
territorial governments and the Government of Canada was a key factor in
mitigating the impact of the H1N1 outbreak on the health of Canadians.
The Chair: Thanks very much to all of you. I also want to welcome Dr.
Butler-Jones, who has been with us before. He is seated in the audience tonight.
We also have Senator Kochhar here, who is a guest senator. Welcome.
We will go to questions, and, as usual, we will start with the first segment
and then go to members of the committee.
First, I will ask a question of Ms. Stuart. You referred to three reports
that you are preparing in Ontario, one of which is soon to be released. When
will that report be released? Is it in the time frame of our study? Is that
something we may find beneficial? Can we obtain copies?
Ms. Stuart: We can commit to sharing with you the report once it is
released, and I anticipate that will be completed before the end of the calendar
The Chair: If it is released sooner, that will help us. We will be
finished before the end of the calendar year as well. Whatever information you
can supply that is part of your review and that may be helpful to us, we will
An area that has been discussed by each of you is the
federal-provincial-territorial memoranda of understanding. Supposedly, these
MOUs are to provide for better coordination between the different entities that
are responsible for pandemic preparedness and response, and yet various comments
have been made that indicate room for improvement.
Ms. Stuart, you said there is a need for a better job of coordinating and
leveraging the strengths and focuses of the various levels, while allowing for
adjustments to reflect the unique and varying needs of each jurisdiction. You
spoke about health professionals being confused as to whose advice to take when
they receive clinical guidelines.
Dr. McKinnon, you said information also is not available with regard to
vaccine technical detail and that you felt considerable discomfort in declaring
to the Saskatchewan public that a vaccine was safe when you were not privy to
the full information in regard to that vaccine. The Pandemic Vaccine Working
Group had access to that information, but the chief medical officers did not,
and were asked to trust the expert group.
Is this MOU on sharing of information an effective tool? Where does it need
to be improved upon? Who wants to start? Maybe I will ask Dr. McKinnon. With
that last comment I made, where do you think the improvement needs to be?
Dr. McKinnon: To begin with, the Public Health Agency responded
quickly to those concerns and we became privy to additional information. In the
complexity of relationships among the vaccine industry, the federal government
and the provincial governments, some detail can be streamlined so that certain
people receive additional information about some of the key technical aspects of
vaccines, particularly when we have to move the vaccine so quickly.
The Chair: Does anybody from the Public Health Agency have any
Dr. John Spika, Director General, Centre for Immunization and Respiratory
Infectious Diseases, Public Health Agency of Canada: There were issues in
terms of what could be shared and what could not be shared. In regard to the
information on the vaccine, a lot of information was the result of studies that
all had proprietary information. The groups that were mentioned that were
reviewing the vaccines had to sign confidentiality agreements to have access. We
need to look more carefully at how some of that information can be shared
better, and perhaps, who it needs to be shared with.
Obviously, there was an interest from people using the vaccine to have more
access, and not restricting access only to the people who were making the
recommendations. That access is something that needs further discussion because
it clearly is an issue.
The Chair: These people who did not have that information were chief
medical officers. That sounds like a fairly high position. I do not know why
they would not be trusted with that information.
One issue raised was that there was not a lot of the vaccine available in the
initial instant when the demand was high, and by the time that vaccine was
available later, the demand had substantially decreased.
How do we make this vaccine more readily available, and how do we ensure the
information is distributed so that the chief medical officers of health can have
that kind of information and the trust to be able to divulge it as is necessary?
Dr. Spika: I agree. In part the issue was more a mechanical one. A
company required signed confidentiality agreements, and maybe it was a matter of
not having the process in place to pull off that requirement rapidly, but we
could in the future.
Dr. Taylor: Perhaps I can make a comment in general about the MOU.
That MOU and information agreement signed by all jurisdictions has broad strokes
about sharing the information in an emergency. We are trying now to craft the
specific details of the information-sharing agreements, which are intended to be
legally binding and multilateral, that is, all jurisdictions, at least
initially, signing one document because the jurisdictions can agree to share
information between them. In those agreements is the attempt to iron out some of
the specifics. However, in all cases, we can never foresee every possible bit of
information we will need to share so it is a balance between formalized
arrangements, which commits government-to-government sharing — and that is what
these MOUs and information-sharing agreements will be — and informal
arrangements. When something comes up, they have to build a trust between
jurisdictions to make the call to obtain the information they need.
The Chair: Another issue that has come up is what some people thought
was a contradiction in messaging between the Public Health Agency and the
provinces or people at the local level, messages pertaining to vaccine safety
that we were talking about, as one example.
How do you propose to resolve that issue? The public can become confused with
different messages and the media will report, of course, all the different
messages that are there.
Dr. Spika: From a federal level, we tried as best we could to ensure
that the messaging was consistent, at least between the provincial and
territorial governments and ourselves. We heard that there were differences in
the messaging based on local situations, but there was also a lot of messaging
taking place outside what the provinces, territories and the federal government
distributing, in part because, as we discussed before, we were in the Internet
technology age. Cell phones were used. The information we were working with was
not black and white. We had to deal with many unknowns. Perhaps that challenge
is the real one. We have to work forward on how one messages and creates common
messaging when there are so many unknowns to deal with. An interesting
perspective would be how provincial-territorial governments might view that
messaging be done in a better way.
There were so many voices. Particularly some of the larger provinces had
major challenges with spokespeople addressing all kinds of issues.
The Chair: Provinces, what do you say about that challenge?
Dr. King: I will comment on the challenges associated with introducing
a new vaccine in the middle of a pandemic. We had not had any previous
experience using an adjuvanted influenza vaccine in this province, so in
addition to the usual messaging around vaccine safety that we provided, we also
had to explain about the new phenomenon, which was an adjuvant.
This recommendation to use an adjuvanted vaccine, or a dose-bearing vaccine,
was made by the WHO. Canada agreed to those recommendations and supported them,
and the product we used largely was an adjuvanted product.
One lesson learned is that it is difficult to implement anything new in the
middle of an emergency. In future, therefore, we need to think hard about the
kinds of technologies that we introduce on the spur of the moment. I believe we
have a better appreciation of the challenges associated with introducing new
technologies in the middle of a lot of concern, and trying to roll out a program
at the same time. That is my initial comment about trying to convert science to
policy, to programs and to public and professional communications in a
contracted time frame. That challenge was an unprecedented feat for all of us.
One key lesson learned is to try to avoid something brand new in the middle
of an emergency.
Ms. Stuart: Part of the question that you asked was in terms of
contradictory messages. One lesson we all need to come to terms with is that in
this day of instant messaging, we need to change our approaches to
communication. I can speak only for the Province of Ontario, but approval
processes to deliver the new message, ensuring it is properly crafted and so on
takes more time than two individuals sending little tweets to each other that
then are passed on to many other people. The situation requires all of us to
rethink our communication — to look at and understand that there will be
contradictory messages, especially in instant messaging, and how we manage those
Dr. Spika: To pick up on something Dr. King mentioned in terms of a
vaccine, the one thing we do not want to do during a pandemic is to introduce
something that is new. Unfortunately that is what we did. We need to take a more
strategic approach to what kinds of vaccines we use on an annual basis so
hopefully we do not have this situation happen again.
Ten years ago, when we put in place the existing 10-year contract we have for
pandemic vaccine supply, an adjuvanted vaccine was already licensed in Europe
for the elderly. Cell-culture vaccine was well on its way in terms of
development, and the nasal vaccine was under licensure approval in the United
States. However, in 2009, when we had the pandemic, none of those technologies
were yet available in Canada. We would like to have had access to those kinds of
technologies; cell-culture vaccine because it could have knocked perhaps four
weeks off the time it took to obtain vaccine for us.
If we have a more strategic approach in the future to bring these vaccines
into use in Canada, although that approach may mean extra costs because the
vaccines are more costly, we will be better positioned in the future.
Senator Eaton: I find this discussion fascinating.
Did all public health officers and Health Canada have a daily morning phone
call to discuss the latest issues of the pandemic, how things were rolling out
and the messaging?
Dr. Taylor: Initially, yes, the Special Advisory Committee met daily.
Senator Eaton: The delivery systems of some provinces seemed to have
functioned with more ease than others. Have you talked since to share
information on what worked and what did not work?
Dr. King: Yes; you make an important observation. One of the top three
lessons learned that we have identified in discussions among ourselves is
sharing of information on our strategies for the rollout of immunization
programs so that we can identify practices for rolling out these programs. This
issue was discussed at our most recent Public Health Network council meeting,
and I understand there will be a session specifically where we discuss this
It has been identified as an important issue. We have not yet had an in-depth
discussion around what worked and what did not work in our jurisdiction so that
we can identify best practices.
Senator Eaton: That information would be enormously useful to our
Dr. Spika, something you said bothered me, and perhaps due to ignorance on my
part. You were talking about health, process and policy put into practice.
Canadians listening to television and radio ads were made to feel that the
pandemic was a form of war.
I live in Toronto and am a member of the St. Michael's Hospital board, where
SARS was a big deal. Pandemics are a form of war, are they not? Do we need to
learn to be quicker on our feet? Yes, you introduced a vaccine in the middle of
a pandemic, but you do have to be flexible in wartime, do you not? You have to
roll and move with the punches and adapt quickly. Do you feel you performed as
well as possible under those conditions, or do you think you could have managed
the situation better? However, you will never have the same conditions again,
Dr. Spika: We learned that we have to make decisions even when there
are many unknowns. I think we did a super job of communicating the decisions to
the public, given the new communication paradigm we are in, but there is
obviously much room for improvement. We need to come up with better ways to
address the other sources of guidance that exist; to be more proactive and
respond to them.
Senator Eaton: Dr. King, do tertiary care hospitals in Ontario have
all they need for another pandemic? Are these hospitals equipped such that, if
there were a pandemic this winter, they would be prepared?
Dr. King: As Ms. Stuart pointed out, we are identifying all the
lessons learned, and will make a consolidated report involving input from all
sectors of the health field in Ontario, including tertiary care and health
That being said, I arrived on June 15 in the middle of the first pandemic
wave, but an impressive infrastructure that was in place in Ontario was the
Critical Care Secretariat. That infrastructure enables the province to work
locally, then regionally, and then provincially on identification of critical
care beds in the province so that, if there is excess demand for critical care
in local hospitals, there is an ability to move people into different critical
care beds in the same region and then, ultimately, to the provincial level.
That model is important to optimize the use of scarce resources. This
optimization is being done well at the provincial level. That being said, health
systems were stressed, unquestionably. We managed, but health systems were
stressed. Therefore, we need to think more along the lines of how to make those
kinds of mechanisms even more robust, not only at the provincial level but also
at the national level.
To comment on something you asked earlier, yes, we are fighting a war, but we
need to think constantly about the ``what ifs.'' We know that vaccine safety is
a growing issue and a challenge, and because of the constant media scrutiny that
was applied to our immunization campaigns, the issue of vaccine safety was
scrutinized and discussed at a level we did not properly anticipate. In Ontario,
we know that we need to talk more about vaccine safety, and we hope that this
discussion will be the basis of a national discussion, because communicating and
ensuring vaccine safety in Canada is a joint federal-provincial-territorial
responsibility. Much of the planning is in the anticipation. There will always
be plenty of surprises, but we have to think upfront about those things that we
know will be a challenge.
Senator Callbeck: In answer to a question from Senator Eaton about how
often you communicated, Dr. Taylor, you mentioned that the Special Advisory
Committee talked on a daily basis at the beginning. I notice that your
presentation says, ``with decreasing frequency.''
How often did you talk? Initially, you talked daily: Did that happen for two
weeks? How often did you have discussions from then on?
Dr. Taylor: Initially, it was once a day, but that was not the only
way we were communicating. As was mentioned, the Special Advisory Committee had
several other committees reporting to it, and those committees were populated by
federal-provincial-territorial people. A web of communications was operating all
the time. The Special Advisory Council communicated twice a week until January
of this year. The Public Health Network, two pieces of which SAC was formed
from, have ongoing meetings. The frequency varied. As well, calls were sometimes
made non-stop. The SAC was not the only forum for communicating.
Senator Callbeck: The fact that you did not touch base on a daily
basis, or more often than you did, did not create problems? Twice a week does
not seem a lot to me.
Dr. Spika: Communication between the provinces, territories and the
federal government occurred at least once a day, but certain committees, like
SAC, may have communicated twice a week. The Pandemic Coordination Committee met
on a weekly basis and task groups within that committee were meeting regularly
as well. A lot of talk was taking place.
Senator Callbeck: I realize that there were a lot of committees, but
the SAC was the top group, was it not, to make the decisions?
Dr. Spika: The Special Advisory Council made recommendations, when
indicated, up to the deputy ministers. The deputy ministers met as well, which
you will hear about in the next session.
Senator Callbeck: How do the provinces feel about this group? Was
there communication? Did the group communicate often enough?
Dr. McKinnon: The communication was good. At any time, any of the
chief medical health officers could indicate concern to the federal agency and
an extra meeting could be called.
As Dr. Spika said, officially the group met twice a week, but it was three or
four times a week some weeks. We felt the communication with the Public Health
Agency was good.
Senator Callbeck: Dr. King, you said that early on, when the demand
was high, you did not have the vaccine; and that when you had the vaccine, the
desire of the public to be vaccinated waned. What can be done about that
situation if we face the same one? I notice that you prepared a report in
In some provinces, the percentage of youth vaccinated was a great deal less
than that of senior citizens. I want to hear your comments on how we can perform
the job better of vaccinating more people.
Dr. King: You ask an important question. One of our biggest challenges
was the implementation of a priority group and sequence access to the vaccine.
You can imagine, at a local level, a mom with two kids and other family members
wanting vaccine but there was no ability to administer it to anyone except those
in the initial priority groups. This situation posed many challenges for local
health providers, whether physicians or public health officials.
The solution is being able to obtain a lot more vaccine more quickly,
unquestionably. We need a well-developed system of mass immunization to be
implemented and ready to go from the outset. The solution is a combination of
having the supply and the capacity to deliver it.
Not surprising to me, priority groups are a challenge to implement for many
reasons. People justifiably feel that they deserve to be immunized quickly, that
they are important to society and that they deserve protection. There is fear as
well. Trying to mitigate these challenges as much as possible in the next event
will be an important way to meet and match demand and supply. Work is under way
in this area to try to increase the amount of supply we will have from the
outset to meet that demand.
Ontario worked hard on communications to try to improve uptake in youth. We
implemented a campaign called Join the Resistance to try to promote immunization
in youth, once we were able to offer vaccine to youth. We were dealing with the
same challenge: by the time we had enough vaccine, there was less concern about
the severity of the pandemic, so there was not as much uptake as we would have
The campaign was a worthwhile effort and the kind of campaign worth thinking
about not only provincially but also nationally in future pandemics.
Senator Callbeck: Was that campaign on television and in the
Dr. King: Posters were in subways and movie theatres. I cannot
remember the full scope of it, but we can provide that information. It was in
French and English. I will be more than happy to provide the details related to
Senator Callbeck: Ms. Stuart, I will read your earlier sentence:
I believe we have not yet fully utilized the wonderful resources available
to us at the national, provincial and territorial levels through the public
health agencies in British Columbia, Quebec and Ontario. . . .
Please elaborate on that thought.
Dr. King: The agencies in those jurisdictions played an important role
in H1N1, but it was somewhat ad hoc in that the role had not been pre-planned.
The agencies tried to fit themselves in where they could be useful. At times,
they assumed where they could be most useful, whereas there might have been
other perspectives on that role.
The focus we need to have is that we are lucky enough in Canada to have these
resources, and they should be built into our pandemic plans. We need to have
specific roles for these agencies and not simply have them help out as they are
able. The agencies need to have a concrete role to allow us to streamline
Senator Callbeck: Dr. McKinnon, you talked about inconsistent
definitions. How can we correct or improve these definitions for the future?
Dr. McKinnon: That is an important question. In public health, we were
moving into an area that perhaps should have been guided by clinicians. The need
for a clinician network similar to a public health network would have been
useful to have had parameters around the clinical hospital, and for obtaining
information quickly and analyzing it in a population framework. That area is
definitely one we can improve on that will help with information.
As I mentioned, in Saskatchewan we were concerned in particular about what
was happening in northwest Manitoba. We wanted clinical information to enable
our response. That area has been highlighted in the discussions and in debriefs
Senator Kochhar: I thank the panel for the outstanding job on their
I am troubled. This pandemic was not the first in Canada. Did we learn
lessons from SARS that we could have applied here? We had so much vaccine that
we did not use. Did we make enough efforts to educate people about the need to
be vaccinated? What went wrong? H1N1 was not the first pandemic in Canada.
Dr. King: We obviously have to continue to learn and to apply every
lesson we learn from each of these emerging infectious disease events that we
confront. It is important to remember that pandemic influenza is different in
that we had a vaccine to address it. However, a vaccine was not an element in
the response to SARS because it was not possible to create a vaccine quickly
Fortunately, some of our tried-and-true methods of public health care, such
as isolation and quarantine, paid off, and were able to stop the outbreak of
SARS globally and within Canada.
The issue related to the vaccines was the timing of the availability of the
vaccine, the amount of vaccine we had at the outset and the demand. The issues
simply never aligned at any point, at least in the province of Ontario. The
issue of supply and demand never ever coincided. We have to work hard to make
that situation better next time.
There are challenges with this area, unquestionably. With the vaccine
technologies we have, it is difficult to shorten the duration from the initial
identification of a new influenza virus to the actual full-scale production of
vaccine. This period is about 16 weeks. It is difficult with existing
technologies to shorten that time period.
We need to look back at every single step of the pandemic, such as how
quickly we identified that there was a new virus in the world, period, and then
how long it took us to identify that seed strain, make it usable, and then
produce our new doses of vaccine.
We need to look at new technologies to speed up that process so that we can
have a vaccine available in a more timely fashion in Canada.
Every single step along the way would have enabled us to respond better and,
therefore, we need to dissect our experience closely.
Dr. McKinnon: We can say that we reached the most vulnerable groups.
Most of the vulnerable groups, certainly in Saskatchewan, had high rates of
vaccination. The other remarkable thing is that — I am not sure federally — we
had no notifications of H1N1 after Christmas. In Saskatchewan, we had normal
cases from about the third week of December, which is remarkable. That situation
meant a six-week flu season, which is almost unheard of. We achieved sufficient
vaccination to protect the population, so that enough people were vaccinated to
stop it spreading.
We did not reach the 75 per cent or 80 per cent that we would like to have
reached, but the vulnerable populations were protected and the rate of
transmission was affected so much that it was brought to a halt. I think that
point should be kept in mind.
Dr. Spika: It is important to recognize that pandemics occur only
three or four times a century. There were three in the 20th century and the last
one was in 1968, which is 41 years ago. Compared to 1968, we performed much
better in terms of having vaccine available still in the second wave.
What we have learned perhaps is that we almost maxed out, as was mentioned,
the availability of our interventions using existing technologies. We need to
change those technologies and obtain vaccines that are available earlier, either
using cell-culture or DNA technologies. That kind of thing is in the works.
Regarding communication, in 1968 we had television, radio and newspapers. It
was a lot easier to control messaging. Now information is readily available on
the Internet. We had major challenges in trying to have our message compete with
all the other messages out there. We have learned a lot. We have performed much
better, but we still have a way to go.
Senator Kochhar: For information, what was the cost to the taxpayer of
the H1N1 vaccine? What percentage of the vaccine was used in Saskatchewan where
51 per cent of the people were vaccinated? Is that percentage the same in all
parts of the country? If not, why not? If Ontario was only at 25 per cent, why
did we lag behind Saskatchewan? What did we do with the rest of the vaccine that
was left over and what is the lifespan of this vaccine? Maybe I am asking too
many questions in one breath, but I am finished.
Dr. Spika: Some of these questions have come up at previous sessions.
In terms of the cost of the vaccine, I would have to send that information to
you, but it was in the high $300-million range. That cost needs to be taken into
the context that initially, based on the best available information, we thought
that two doses of vaccine was required, whereas only one dose was required. Had
we known that information in advance of the time we had to order, we could have
saved half our vaccine costs, if not more, because of the usage.
Through renegotiation with GlaxoSmithKline, our supplier, we were able to
reduce some of our vaccine costs. In a substantial amount of the vaccine, we
were able to save at least the adjuvant, as opposed to the adjuvant and antigen,
which is a combination. The adjuvant is about seven eighths of the cost of the
vaccine. That adjuvant is currently being stored and, in the next several years,
we hope to use it for seasonal vaccine.
In terms of the actual costs at this stage of the game, we would have to get
that information to you because I do not have it at the tip of my tongue at the
The Chair: Perhaps the provincial representatives can talk about the
differences in the number of people who were vaccinated from province to
Dr. King: In Ontario, our coverage rates were estimated to be about 38
per cent. We used about 5 million doses of our ultimate allotment, which was
negotiated, and I believe we ended up purchasing about 9.3 million doses in the
end. We used about 5 million out of 9.3 million doses.
I want to pick up on something Dr. McKinnon said. I am proud of the way we
operated, and worked collaboratively with Health Canada in our response to the
First Nations and isolated remote communities in the northern part of the
province. We achieved unprecedented coverage, much higher than 38 per cent in
most of our remote and isolated communities. This population was one that I was
worried about because of a whole range of environmental and pre- existing health
conditions in this population. We were able to achieve good uptake in those
Overall, our population coverage was about 38 per cent. In terms of why there
were differences, why Saskatchewan had 50 per cent, why Ontario had 38 per cent
and why Atlantic Canada had extraordinarily high rates of coverage is something
we need to study. Returning to the question asked by the other members, why is
it that we had such dramatic differences — literally, twofold differences across
the country — in terms of immunization coverage during this pandemic, I have my
theories but it is better that we have a discussion and a thorough evaluation of
Senator Ogilvie: Perhaps, for our colleague, I will mention that we
had a thorough discussion on the issue of differences across the provinces and
the basis for many of those differences, so we can provide you with the tables
that have been presented.
Ms. Stuart, you had an interesting comment; at least, it was interesting to
me. You indicated that you, like other jurisdictions, contemplated a
moderate-to-severe pandemic but when it turned out to be less severe, you were
thrown off-base. I am used to the idea that we plan for the worst and if
something good breaks out, we are in better shape. How did preparing for the
worst possible case when a milder version occurred cause you a dilemma?
Ms. Stuart: That is a good question. In general emergency management,
we plan for the worst cases and hope those plans will not be required.
The work to prepare for that moderate-to-severe pandemic assumed certain
approaches that would be used, whereas when planning for something milder on the
continuum, we would not use those approaches at all; we should use other
For example, some of the discussion in a moderate-to-severe pandemic is
around closure of schools and whether that is something we introduce. If we
prepare all our plans and we are not in that area at all but in a mild pandemic,
we need to have the right kinds of strategies worked out in advance so we can
apply them to that mild situation.
We started to work out those strategies with some aspects of our pandemic
plan, but clearly not with enough of them. The field has provided us with the
feedback that it would be helpful to be able to titrate what is done according
to the behaviour of the virus so as to ensure we respond at the right level.
That is something we will do in subsequent pandemic plans.
Senator Ogilvie: I think Dr. King answered my question. I thought I
had read that Ontario, at least initially, did not have a strategy to target
selected groups. However, I understand from Dr. King that information is not
Dr. King: That is correct, yes, we did; we followed the national
priority group process faithfully.
Senator Ogilvie: Thank you. Dr. King, you mentioned that the packaging
in 500-dose boxes posed problems for many vaccine providers. I assume when you
say vaccine providers, you are referring to those distributing the vaccine; you
are not talking about the company that makes the vaccine, right? You are talking
about delivery within the health care districts, are you not?
Dr. King: Yes, I am talking about the ability of the immunizer to use
500-dose shoe boxes.
Senator Ogilvie: That is, the end user.
Dr. King: Correct.
Senator Ogilvie: Were those 500-dose boxes packaged in units of 10
Dr. King: Yes, they were.
Senator Ogilvie: Why was it a major issue to distribute them in
500-dose boxes, which were made up of 50 10-dose packages?
Dr. King: It would have required repackaging. It took us time to be
able to repackage. In fact, there were regulatory issues as well that we had to
address to make that new packaging and distribution satisfactory. I think it
took at least three weeks for us to obtain the regulatory approval to repackage
from the 500-dose shoe box to the new mechanism we used to try to send out the
doses to immunizers.
The primary challenge with our immunizers was physicians. The physicians were
willing to participate. However, they could not manage such large quantities;
the packaging simply would not fit in their fridges.
Senator Ogilvie: My final question is for Dr. Taylor and Dr. Spika. We
have heard a great deal about the difficulties in delivering information on the
vaccine. However, when one looks back over the history of vaccine development in
response to a new challenge, and even though we have an annual flu vaccine, this
vaccine is different and it therefore poses a new vaccine development challenge.
In your experience, was the length of time it took to obtain a working
vaccine unusually rapid or slow, given the historical perspective in these
Dr. Spika: In terms of pandemic planning and knowing the production
cycle for influenza vaccine, we anticipated it would take us about 20 weeks from
the time the manufacturer received the seed string to the time the vaccine
started to roll out. From that standpoint it met our expectations. Vaccine
availability was in the ballpark range.
Flu vaccine is new and yet not new in that flu vaccine is used on an annual
basis. The strain changes that occur on an annual basis do not require a lot of
adjustments, from a regulatory perspective. New in this case was that we were
using an adjuvanted vaccine, which put a new twist into the approval process.
From a standpoint of timelines, despite using an adjuvanted vaccine, we still
met the 21-week date we expected in terms of having the vaccine available.
Senator Ogilvie: Thank you. I am a little concerned. The basic science
was successful in identifying a way to develop a vaccine that could be grown and
produced in quantity in a relatively short period of time, from my perspective.
I am concerned that we are setting ourselves up to expect that, for every new
viral agent that comes along, we will be able to respond in the same kind of
speed with a vaccine that can be identified and successfully grown, and that is
stable and safe to use.
I welcome your comments because from my perspective, looking back over time,
I think we were fortunate.
Dr. Spika: I agree, given the existing technology. Looking forward
with DNA vaccine, we could have had the vaccine perhaps eight weeks sooner than
we did. The technology used for DNA vaccines — where they basically sequence the
component they are interested in, plug it into another organism and grow it —
would be more transferable to other viral vaccines than the current process.
I hope we have not set ourselves up. We are still struggling with an HIV
vaccine and it is now 30 years since HIV was recognized.
Senator Ogilvie: I have one quick comment. I hope the DNA concept
leads us to vaccines quickly. I know a bit about DNA and I am not convinced that
every pathogen we identify will suddenly lead us to a vaccine simply because we
know a genetic sequence that is useful to us. I take your point. I am hopeful,
too, but I am concerned.
The Chair: We have five minutes left, with two senators remaining.
Senator Martin: I will focus on one question, then, and briefly make a
comment. Dr. Taylor, when you talk about the web of communication, in my mind I
am imagining the complexity of dealing with a pandemic situation. I commend all
of you for the work that you are doing, the work that you did and the work you
will continue to do.
My question goes back to Ms. Stuart's comment about the resources that we
have in various provinces, British Columbia being one of them. In the last
pandemic experience, British Columbia weighed in ad hoc but one of the
recommendations would be for them to have a concrete role. I know in the next
panel we will speak with a representative from B.C.
However, from your perspective, what concrete role do you see these other
agencies perhaps playing in the next situation?
Ms. Stuart: I think my colleagues are perhaps even better placed to
respond to that question. We know the expertise the agencies bring is well
developed in the area of science, technology and the related impacts that
understanding of the virus gives, so we can do the right things and we have the
right action plans.
It is important to ensure we use the agencies to focus on the science and on
the impact of the story being developed as we develop more understanding of the
virus and its behaviour and how people respond to it. Then we will be able to
use that information better to make the appropriate kinds of policy decisions to
take us forward.
Nothing I am saying should suggest that the agencies were not fully engaged
and part of what we were doing. I think we can formalize it and it will be more
successful for the next time.
Dr. Taylor: We agree fully, and currently, lots of interactions are
taking place with all those organizations. For example, we place our field
epidemiology trainees — as we have been placing them successfully with the
British Columbia Centre for Disease Control for years — in the Ontario agency.
What Ms. Stuart said was to formalize those interactions. As it turns out,
the agency's senior management, including our chief public health officer, are
flying to Toronto next week to initiate formal discussions with the Ontario
agency to do precisely what you suggest. It is a matter of taking advantage, as
strategically as we can, of the expertise we have in the country while working
on a coordinated basis.
Senator Martin: Are you saying you are moving towards formalizing
specific roles and drawing on expertise? You are hopeful those roles will be in
place before the next pandemic?
Dr. Taylor: That is our intent. We have informal arrangements. We are
already working with organizations on two different areas, but next week we will
start discussions to formalize those arrangements with the agencies, so stay
tuned. We are looking for a better approach.
Senator Braley: In reading the material, I focused on the roles of the
federal, provincial and territorial governments. You signed an MOU in September
of 2009, which is immediately before this chart starts to jump up high with the
number of cases reported. Has anything been learned from that experience, and do
any changes need to be made? Does this MOU also cover communications with regard
to the public?
Dr. Taylor: You are referring to the MOU on roles and responsibilities
Senator Braley: Yes.
Dr. Taylor: That is correct. We are now working on an MOU more
broadly. That MOU was limited to that specific pandemic. The MOU on roles and
responsibilities writ large is under way, and we have had bumps in terms of
cost- sharing formulas, but that one was specific to H1N1.
Senator Braley: Are the roles and responsibilities defined with regard
Dr. Taylor: Yes, that is what they are for. We have not finished the
most recent one.
Senator Braley: You are making adjustments.
Dr. Taylor: Absolutely.
Senator Braley: Does that MOU include communications to the public?
Dr. Taylor: I believe so. I believe communications are included.
Ms. Stuart: I am the provincial co-chair on the MOU on roles and
responsibilities in an influenza pandemic.
We have been working, off and on, on this MOU since, I believe, 1998. We
accomplish a lot of good work on it, but we become stuck on the issue of
financial responsibilities and the sharing of that financial responsibility.
That is where we always become stuck. We continue to work on that issue but, as
was stated earlier, stay tuned.
We are looking at restructuring the MOU itself so that we have less
line-by-line delineation and more of a principle- based document as to who does
what. In truth, having a document with multiple annexes and so on probably will
not be used.
We have those roles and responsibilities outlined in the Canadian Pandemic
Influenza Plan. It delineates roles and responsibilities, including for
communications. Each group involved with those areas, whether communications,
vaccines or whatever it might be, is now reviewing based on what we have gone
through. It will be wonderful if we can move forward with our MOU and have it
signed, then be able to put that issue to one side and move on to other issues.
The Chair: Thank you very much. That brings us to the close of this
session with panel one. I thank all of you for being here and for the
information that you have provided.
Honourable senators, on this second panel we have three participants, one by
video conference. From Vancouver, we have Dr. Perry Kendall, Provincial Health
Officer, Province of British Columbia. I know him better in another role. When I
was Mayor of Toronto he was the Medical Officer of Health in Toronto, so I am
delighted to see Dr. Kendall again.
From Nova Scotia, and here in the committee room, we have Duff Montgomerie,
Deputy Minister, Health Promotion and Protection, Province of Nova Scotia. From
Health Canada, our federal agency, we have Glenda Yeates, Deputy Minister,
We have the three of you from now until 9:30. I will start by asking each of
you to give an opening statement of about seven minutes.
We will start with Dr. Kendall in Vancouver.
Dr. Perry Kendall, Provincial Health Officer, Province of British
Columbia: Thank you for inviting me to contribute to the deliberations of
the Standing Senate Committee on Social Affairs, Science and Technology as the
committee looks into Canada's preparedness for and response to the 2009 pandemic
I am the Provincial Health Officer of British Columbia, the senior medical
health officer in that province. By provincial government direction, I am the
lead in the health sector pandemic preparedness and response. For five years,
since its inception in 2005, I was also the Provincial/Territorial Co-chair of
the Pan-Canadian Public Health Network Council, which was established post-SARS
to provide a coordinating mechanism for federal, provincial and territorial
capacity and response to both communicable and non-communicable diseases in
In March, shortly after the isolation of the pandemic viruses in Nova Scotia,
California and Mexico, I was appointed as the Provincial/Territorial Co-chair of
the Special Advisory Committee on H1N1, SAC, that was established by Canada's
deputy ministers of health to provide advice, guidance, recommendations and
coordination through the pandemic period.
The SAC combined both the Public Health Network council members and all the
provincial and territorial chief medical officers of health. It was co-chaired
by Dr. Butler-Jones, and you have before you a number of diagrams showing both
the structure of the network and the governance structure that was put into
place to manage the pandemic.
We had the Special Advisory Committee on H1N1 and a pandemic coordinating
committee. That complex subcommittee structure reported through a pandemic
coordinating committee. The structure is also shown on another diagram that I
sent to you, which shows well the complexity of the tasks, the subject matter
and the clinical domains that we were coordinating for many months. The
structure worked extraordinarily well, considering everything it was challenged
with; and I want to commend, for the record, the work of that pandemic
coordinating committee and its members. I think Canada owes them a debt for
their work. I have also provided you with a copy of the summary report on the
British Columbia H1N1 experience.
To give you examples of the topics that the committee coordinated and looked
at, they included guidelines and information on remote and isolated communities;
guidelines on clinical care and antiviral management and usage; antiviral
stockpile management — the issue of xylanases and the Alberta pigs was an
example; public health measures from handwashing, distancing, school closures;
issues around technical and medical aspects of the vaccines; the logistics of
vaccine delivery —complex communications on a science that was changing
sometimes on a daily basis; guidelines and advice on infection control and
occupational health — a big component was surveillance, epidemiology and
laboratory workings and coordination; and finally, an ongoing review of the
Canadian Pandemic Influenza Plan, assessing its utility and updating it.
In summary, there are many challenges but I think Canada performed well in
international comparisons; and, contrary to some people, I do not believe we
overreacted. I think we were measured in our responses.
However, a number of issues have been highlighted and I will highlight them
again. In future, we need a scalable pandemic response plan, with activities
that are responsive to what is actually happening rather than a potential worst
case scenario. It would be nice to have a plan with a scale of mild, moderate or
severe intensity that will give us our responses to those scenarios.
We need to enhance our surveillance, epidemiologic and analytic capacities.
We need reliable, close-to-real-time information. I reckon we can do a better
job of coordinating the experience of the agencies that exist across Canada,
coupling them with the Public Health Agency of Canada for the next time.
We need to enhance global vaccine production capacity, and ensure that
Canada's domestic supply has a more robust delivery capacity, with backups on
We need to increase our ability to do science and evaluation in real time —
that speaks to engaging our agencies together — and to be able to transmit the
findings to policy and communicate them with our publics in a rapid fashion.
We need to ensure we maintain a public health delivery infrastructure, and we
need to have linkages to the acute- care side of the health care system that are
ideally as strong as those we have built on the public health side. We need to
coordinate our guidelines development process better for more expeditious
clinical input and timely distribution.
The Chair: That list is a long extensive one, too. That was well done.
Thank you, Dr. Kendall.
Duff Montgomerie, Deputy Minister, Health Promotion and Protection,
Province of Nova Scotia: Dr. Kendall's list brings back many memories.
Besides being deputy minister of the Nova Scotia Department of Health Promotion
and Protection, I had the rare privilege of being the liaison and
Provincial/Territorial Deputy Minister for the Public Health Network. When H1N1
happened, I became engaged in every call and every meeting at the Special
Advisory Council co- chaired by Dr. Kendall and Dr. Butler-Jones.
As a lay person, it was an amazing privilege to witness these officials
perform risk assessments on a daily basis based upon the evidence they had at
the time to recommend processes and next steps to deputy ministers and ministers
about the safety of Canadians. We owe these officials a debt of gratitude for
their professionalism and for the way they shared with each other and wrestled
daily to come to the right decisions.
On April 21, 2009, Dr. Butler-Jones, as the Chief Public Health Officer of
Canada, initiated and chaired a call to the chief medical officers of health in
Canada, where he gave us a heads up that a new flu virus was emerging out of
Mexico. Initial information seemed to indicate it was striking younger people
particularly hard. As a participant in that call, it struck me as dramatic that
suddenly we were beginning to see a virus that worked in reverse of what we
On April 22, because of that call, we were able to brief our premier, our
ministers and our emergency measures folks in Nova Scotia to give them a heads
up that heavy-duty challenges could be facing us in the days ahead, not the
weeks ahead. Regular updates from the Public Health Agency of Canada continued;
and on April 23, the first Canadian media reports about the new flu virus in
Mexico began to emerge.
In Nova Scotia, the Capital Health District advised us of a flu-like illness
at King's-Edgehill School, a private school. Some of the students had returned
from Mexico. On April 24, Nova Scotia then decided to activate our emergency
operations centre of the Department of Health Promotion and Protection.
On April 21, we had the heads-up from Dr. Butler-Jones. By April 24, we were
activating our own emergency system. Full briefings were held with elected
officials, including those from the opposition, deputy ministers, Emergency
Management Ontario and so on.
A lab in Nova Scotia gave us the heads-up on April 24 that specimens they
were sending to the national lab in Winnipeg, shown as influenza A non-typeable,
they strongly felt would come back as H1N1. We began to prepare for the possible
receipt of H1N1 positive results, the first in Canada.
Dr. Robert Strang, Chief Public Health Officer of Nova Scotia, met with the
media for the first time — not about this particular part, but for an
information briefing around H1N1. National communications calls now began on a
On April 25, at 11:30 p.m., Dr. Strang and I were advised by Dr. Butler-Jones
and lab officials in Winnipeg the tests from Nova Scotia were indeed
H1N1-positive. On April 26, at 7 o'clock in the morning, preparations were begun
to work with Capital Health District, King's-Edgehill School and, more
importantly, to prepare Dr. Strang and his team to announce publicly to Nova
Scotians and to Canadians that H1N1 has been found in Canada.
Mid-morning, we were advised through the normal communications network that
British Columbia colleagues also had H1N1-positive tests. We began to work with
British Columbia and the Public Health Agency of Canada, but at the same time we
were dealing with King's-Edgehill School, Capital Health District and preparing
for a major press conference for that afternoon.
By noon, Nova Scotia alone had 100 media calls because we had announced that
Dr. Strang was going before the media at 2 o'clock. There is no better feeling
in the world than telling The New York Times that they had to wait in
line. We had CNN and every imaginable media come to us.
At 2 p.m., Dr. Strang faced the media in Halifax, and therefore the national
networks. At 3 p.m. his British Columbia colleagues faced the media. At 5 p.m.
Dr. Butler-Jones faced the media.
In this day and age, the thing we worry about most is showing confidence to
Canadians that we are competent, prepared and giving them the right information.
My wife was the best judge. She said, ``I could not believe it. I saw three
government officials say the same thing after three major press conferences.''
Think about the questions you asked about sharing information and timeliness.
The fact that with 24 hours notice, three jurisdictions were able to speak to
Canada in a united voice around this incredibly complex issue in the early days
speaks volumes to the post-SARS strength of the Public Health Agency of Canada
and the relationships the various public health departments across Canada have
I will take you through that time sequence simply to demonstrate how far we
have come in the post-SARS period. The caution I use even with our own officials
in Nova Scotia is not to forget the capacities that were built up so the system
worked. I tell them not look away from these capacities.
Briefly, and you have heard this phraseology time and again, this event was
real-time driven. Everyone asks what that phrase means. Because the science was
continually evolving and we are still trying to understand the magnitude of the
virus and the immediate work that had begun to develop the vaccine, we knew that
the science would evolve and change almost on a daily basis. Dr. Strang, in his
second press conference after the first major one, adopted a phrase that he
would use with the Nova Scotia media day after day: ``What I tell you today may
change tomorrow.'' It may change because the science and information may change.
Let me close my remarks by taking you through one day in
federal-provincial-territorial interactions to demonstrate the real-time
commitment. I know many senators were asking the earlier guests about the
In a typical day, we began at 10:45 a.m. Eastern time. There was a pre-call
of the co-chairs of the federal-provincial- territorial health deputies, which
was at the time Deputy Rosenberg from Health Canada, Arlene Wilgosh as the
provincial co-chair from Manitoba, Dr. Butler-Jones as the Chief Public Health
Officer of Canada and also Deputy Minister of the Public Health Agency of
Canada, and me as the liaison deputy to the Public Health Network. We had a call
15 minutes before a full deputies' call, and at that time we shared with each
other how we were doing, some of the bumps and blips, and determine if the
agenda for the next hour was in the right place and if we were in good shape.
Then from 11 a.m. to 12 p.m., and we usually worked hard through Deputy
Rosenberg and Deputy Wilgosh as the co-chairs to keep the conversation focused,
the deputies met with the recommendations coming forward from the SAC meeting,
which I will explain in a minute.
We were dealing with presentations from Dr. Kendall as the co-chair of the
SAC and from Dr. Butler-Jones at the deputies' table, and where appropriate, we
took those presentations to our respective ministers. In most cases, our
ministers had empowered us, where data was being discussed, simply to move
At 1:45 p.m., we had a pre-call before the Special Advisory Committee. That
committee was the heart blood of this organization. Dr. Kendall and Dr.
Butler-Jones co-chaired that committee. For the Government of British Columbia
to enable Dr. Kendall to provide as much time and effort as he could to this
national effort while looking after his own jurisdiction speaks highly of his
government, but more importantly of Dr. Kendall and his commitment.
Then at 2 p.m., the full call was under way, and that call could be anywhere
from one to three hours. Many expert groups fed into the chief medical officers
of health here with the latest data and information. Those chief medical
officers of health then had to wrestle with not having the full information, as
it was still evolving, but having to assess the risk and then give
recommendations to decision makers and, more importantly, to Canadians. They
then communicated to Canadians what the next steps were. Those conversations
were immense and tough. In many cases, they were incredibly detailed.
At 4 p.m., the federal-provincial-territorial communications people had a
discussion. Then, we had the deputies' call, the SAC call, and our
communications folks took the results from both those calls and began to ensure
that, on the message side, we were all saying the same thing to Canadians.
I will not go into what measures each province took after those calls. For
example, Nova Scotia at 5 p.m. every day had a major call with the chief
executive officers of our health authorities and their teams to share the
information from these other calls.
The SAC would recommend to deputies, deputies would agree and then they would
communicate to the system; to the doctors in their offices and to the providers
who put the needles in arms or provided information to citizens.
Finally, there was a small group of Deputy Rosenberg, Deputy Wilgosh, Dr.
Butler-Jones and me who had an agreement that we could call a meeting at the
insistence of any of those members of the group, and that agreement worked also
with the SAC committee. Dr. Kendall knew that if the chief public health officer
in Nova Scotia said he had an issue, then Dr. Kendall could share that
information with Dr. Butler-Jones and they would ensure those communications
To make a long story short, there was a fairly open, transparent and readily
available communication system at the highest level of the two governments
during this outbreak.
The Chair: Thank you very much for giving us the description of the
communication system and how it worked on any typical day, as you called it.
Glenda Yeates, Deputy Minister, Health Canada: Thank you very much for
the opportunity to be here with you today.
I am pleased to appear today before this committee with my colleagues from
provincial Ministries of Health. When I started at Health Canada May 1st, 2009,
we were right in the thick of the first wave of H1N1.
One of the first activities of my first day on May 1 was to participate in
one of the calls Mr. Montgomerie described. I was associate deputy minister at
that point, and the call was with the federal-provincial-territorial deputy
ministers of health on this topic. At that point, those calls were happening on
a daily basis.
I am a former deputy minister of health from the Province of Saskatchewan, so
I could say that I understood, I thought, some of the provincial-territorial
challenges that were faced, and I was struck by the degree of collaboration and
cooperation that I saw between governments.
Before I speak about the central issue today of
federal-provincial-territorial focus, I want to touch briefly on Health Canada's
role in H1N1 since I am not able to be here with you later in your
First, we had a strong role in the regulatory responsibility, the
authorization, for example, of the vaccines and the antivirals. I know some of
my colleagues from Health Canada have been here to speak to that process.
Second, we also have specific responsibilities of delivery of health services
to First Nations on-reserve in collaboration and partnership with the local and
provincial medical officers of health and others. I know you have had
conversations with Dr. Paul Gully from Health Canada and that you will speak
further to colleagues in future meetings about that function.
Third, Health Canada had a responsibility to coordinate across the Government
of Canada. We were the linkage from this federal-provincial-territorial process
to take that information forward to tables that included other government
departments — Canadian Food Inspection Agency, Department of National Defence,
Citizenship and Immigration Canada, Canada Border Services Agency and all the
other federal government departments — who along with our health portfolio
partner, the Public Health Agency, would meet as we sorted through Government of
Fourth, we had the responsibility to work with colleagues to ensure there was
as much coordination as possible. As part of that responsibility, we also have
begun the process that many jurisdictions have talked about, preparing their own
lessons-learned processes. We in the health portfolio, and I think Dr.
Butler-Jones spoke about this earlier, are preparing a health portfolio lessons
We at the federal-provincial-territorial table have also met specifically to
coordinate our FPT lessons learned. We met in April in Newfoundland and had a
good process of reviewing the lessons we felt we learned at that point and what
further work we wanted to do, and that work is still ongoing.
I will make four observations in areas about the review we have made as FPT
deputies of the work so far: first, the FPT governance and decision-making area;
second, communications; third, vaccine issues; and fourth, roles,
responsibilities and relationships between the provincial and territorial
governments in the Government of Canada.
First, on the FPT governance and decision making, as has been pointed out, in
the early days we moved to a command- and-control structure that we thought
allowed for effective collaboration and oversight of the many areas that have
been spoken about here: planning, operations, logistics, communications and
health services. Many people have alluded to the fact that the key role was
played by the Specific Advisory Committee on H1N1, and key decisions and
deliberations came up there to the deputy ministers for their decision.
While the governance structure that we put in place served us well, we will
continue to work with emergency management experts to consider the applicability
of the governance structure for H1N1 in future events that confront the health
Second, with respect to communications, many people have commented in the
previous panel, as well as Mr. Montgomerie and Dr. Kendall, that we thought this
area was a strong asset. However, we know there are areas here upon which we can
improve. People spoke about the fact that the information was changing. There
were many technical issues during the various stages of the pandemic and issues
that were a significant challenge to communicate, for example, why children
needed two shots while adults needed only one, or why it was recommended that
pregnant women receive unadjuvanted vaccine as opposed to adjuvanted vaccine.
There was considerable effort on the part of the communications officials across
the country to ensure that we had strong, effective and coherent communication
of messages from governments. We all recognized that consistency of messaging
In the case of First Nations and Inuit populations, we also knew that to
communicate effectively, we needed to involve communities or national
organizations. As part of our review that we have been conducting as an FPT set
of deputies, we concluded that we had a number of successes in communicating
effectively, but we noted that even minor differences in our messages or
communications were challenging. As part of that review, we want to build those
lessons into our future plans.
The third issue I will raise is in regard to vaccines. I think this issue has
been flagged as well. We had a significant number of Canadians who turned out to
be vaccinated, although there were differences across the country, as noted in
the previous panel. We think we had considerable successes in our vaccine
campaigns, relatively speaking to some of our international competitors. Canada
had a high rate of immunization. I think my provincial and territorial
colleagues will agree that some of the issues related to the production and
distribution of the vaccine did test the relationship.
During the height of the pandemic, the delays in the production of the
vaccine only increased the level of media interest and public anxiety.
From an operational perspective, this situation was challenging for all
Federally, we were dealing with extremely variable information from the
manufacturer that changed in some cases not even daily but from hour to hour. We
recognized the importance to the provinces and the territories of having
accurate information so that provinces and territories could develop the
planning they needed in terms of booking clinics, booking staff and telling the
population when the vaccine would be available. We did our best to provide any
information we had in a timely way.
Throughout the process, I think we all learned a great deal about what is
involved in manufacturing vaccine. We learned about some of the volatility in
that process. We have since made improvements by creating a new process for
vaccine contracting that allows for greater involvement by the provinces and
territories right from the outset. Officials will also consider the variance in
levels of vaccine uptake across the country and in specific populations with a
view to identifying best practices. I think that point was mentioned in the
Finally, regarding the roles and responsibilities of governments, we
identified a few areas where we are considering ways to improve the
collaboration across the sectors. Again, we felt we had good collaboration, but,
for example, a number of individuals have spoken about the fact that with public
health officials collaboration was very strong. However, we learned in the areas
of acute and clinical care that there would be room for improvement in terms of
the collaborative networks that we establish and the methods of communication
We are also looking at how to improve our surveillance system in order to
improve our ability to adapt our response to changing environments.
While there are areas for improvement, our overall ability to respond to H1N1
was a testament to the efforts that jurisdictions undertook to be well prepared
and to complete that work in advance of the pandemic. My provincial and
territorial colleagues and I remain committed to this collaboration, and to
making improvements to ensure the health sector is even better prepared for the
next pandemic or health emergency.
The Chair: Thank you very much for those helpful suggestions. In fact,
all of you have been helpful to us today.
I will start the questioning with Dr. Kendall. You cited a number of areas
for improvement where lessons learned come into play. I was writing them down
here quickly while you were listing them. I want to give you an opportunity to
expand on some of the ones that you think are the most important to give us a
clearer understanding of what you meant.
Dr. Kendall: We are working on our ability to capture the information
and to use the modelling capacities that we have. For example, Quebec has the
Institut national du santé publique du Québec; Ontario has the Health Protection
Promotion Agency; B.C. has the British Columbia Centre for Disease Control, and
other provinces have intellectual and analytical capacity. Those agencies
started working together over the course of the summer to pool their
intelligence and their resources. However, if we had thought more beforehand and
had those agencies positioned to work in the areas of mathematical modeling,
looking at the international experiences of the southern hemisphere and
interpolating those models to the Canadian scenario, we could have been a bit
smarter, more clever and more informed than we were. We pulled the information
together well over the summer and into the fall, but, if we started discussions
now, hopefully we will still remember it when the next pandemic comes around.
That is, how we can have agreements to utilize the capacity of mathematical
models, epidemiologists and influenza specialists and how, when we need to
launch specific inquiries into issues of epidemiology, of cause and effect or of
the impact of a pandemic on particular subgroups, we would have the capacity to
use those resources faster and in a more coordinated fashion. It is not that we
did not use them, but, with what we know now, we can have agencies prepositioned
so that we can launch these studies in a faster fashion.
We also need a way to have unexpected information and even information that
we do not want to hear distributed to a broader public for peer review and
acceptance. I refer particularly to the studies from B.C., Ontario and Quebec
that suggest that if people received the seasonal influenza previously, they are
perhaps more at risk of developing H1N1 infection, even though that infection
was more severe. We learned that over the summer. Peer reviews were completed,
but, had we been able to have a rapid peer-review academic acceptance process,
that information would have been available perhaps with more acceptance. We
could have challenged it more. As it was, decision makers — members of SAC,
physicians, et cetera — were able to hear about the presentations from the
scientists in those few provinces who had completed the work, but there was no
real public accessibility of the data until January or February. If we can work
up a fast-track way of generating the information, thoroughly peer reviewed,
critiqued and re-evaluated, I think it would help us in the future. We never
thought of creating that process before. Frankly, it was surprising information
that we were not expecting. It resulted in changes in the seasonal vaccine
program; in my province, it changed how we did things, as it did in other
That is an example of bringing our intelligence, our intellectual and
analytical capacity, to bear a little faster and more smoothly than we
experienced during the six months that it was taking place. We were fortunate
that we had the summer as a rescue period between the first and second wave.
That period gave us a chance to update our information, learning from the
southern hemisphere and applying some of those lessons to the public health
lessons we learned.
Linkages with the acute-care system need to be worked on. The acute-care
system is what you might call, a loosely coupled system. Physicians are
individual specialists, and hospitals often work on their own. Collecting
information from the intensive care units, bringing that information together
and being able to analyze the information poses challenges in a loosely coupled
system. We had that information finally, but it took until September to bring
the experts together to look at the lessons learned from the Manitoba intensive
care unit experience that happened in May or June. Next time around, we need to
be able to link in faster and have more accurate information. I suggest we look
at those three areas.
The Chair: Thank you very much. Do either of our other two panellists
want to pick up on that point?
Mr. Montgomerie: I want to support Dr. Kendall's point on the existing
resources we have; to know we can pre- position them and access them quicker,
particularly the three provinces he mentioned.
The governance structure came about as a result of that smaller group of
deputies recognizing there was not a fully encompassed governance structure. I
believe it was in July that we were able to solidify that structure finally.
Finally, the comments Dr. Kendall makes on the acute system are absolutely
accurate. The public health system has a history of collaboration because of the
nature of what they do. The acute care systems do not. For example, Manitoba
needed respirators and so on. There was not a clear-cut communication system
that Manitoba could refer to outside its own borders. You heard Ontario talk
about having its own internal process.
That is one area we are committed to, working with our federal colleagues to
bring about better communication.
Senator Seidman: Dr. Kendall, you referred to a need to enhance
surveillance systems. Ms. Yeates, you also talked about improving surveillance
systems. Can you tell us a bit about the kind of surveillance systems we had,
whether we had any real-time surveillance in reporting and whether we had
adverse-event reporting? Can you also address standardization of data across
provinces, data sharing, and perhaps whatever changes you might recommend for
Dr. Kendall: Lack of real-time surveillance, data collection and
linkage was identified post-SARS. In fact, the federal government has invested
considerable funds through Infoway in building a public health communicable
disease network and an electronic health record collection system, both of which
will collect data on a real-time basis, help us manage outbreaks, use vaccine
inventory, et cetera. That is the Panorama system. Most provinces are buying
into that system and will implement it. We have started off one of the modules
at the B.C. Centre for Disease Control, and that is inventory management.
Immunization collection is scheduled to start rolling out in 2011. This system
is complex, but it is under way. There has been considerable investment in that
system, probably in the order of $100 million-plus.
In British Columbia, we developed a system whereby we can look at doctor
billings for influenza-like illness, and that system tracks closely historically
with the influenza seasons. We were able to use that system to track doctor
visits for influenza-like illness. Once we coupled that system with laboratory
testing, we were able to track on a daily basis the previous 24-hour billings.
That information basically gave us our epidemic curve. We could tell when people
would become ill. The lab collection could tell us what they would become ill
with. We knew that at the peak of the epidemic, half the doctor visits for
influenza-like illnesses were due to H1N1 and the other half were due to a
mixture of other viruses. We built our epidemic curves and our responses based
on that information.
We also have five regional health authorities. They reported on a daily basis
as to what their emergency room situation was, what their intensive-care-unit
situation was and what their ventilator capacity was. That information was
coordinated into our operations room, if you like. Then we were able share that
information with our colleagues at the Public Health Agency, who could roll it
into their FluWatch program.
Most provinces could provide some of that information. I am not sure that the
doctor billing capacity is something that all provinces have.
Also, through our automated care program in the fall, we were able to monitor
closely who was receiving antiviral treatments, what age groups were receiving
them and the parts of the province where treatments were going. We could map
that information to the billings so we had a good sense of whether we were
meeting the need for treatment and whether that information matched what
physicians were seeing in their offices. We also used that information as a way
to switch on telephone triage. We put in special fees for physicians' offices
because we did not want sick people to go to their physicians only for advice.
We brought in a telephone fee. Once we reached a certain level of influenza
activity, we switched on that fee. When the pandemic peak was over and the
pandemic was subsiding, we were able to turn off the fee because we were
returning to normal business.
Ms. Yeates: I support Dr. Kendall's comment that there were lots of
pieces of good information in certain jurisdictions. With regard to your
question about consistency, it was often a matter of pooling. What B.C. had was
different, say, than what Quebec had. Both provinces may have had good
surveillance taking place, but again, that information was pooled to supplement
what the Public Health Agency had right then as an ongoing surveillance
mechanism. I think all of us think that a more robust and systematic way of
collecting this data would be useful.
I will speak to some of the issues we ran into when we reached the
immunization phase, for example. A reasonable question for Canadians to ask, and
the question the media asked was, how many people are immunized as of this day?
We could answer that we knew what vaccine had been produced and shipped,
recognizing that there were several steps between shipping the vaccine and a
province receiving it and delivering it into arms. Eventually we received the
information to answer that question, which seems basic, as to how many people
were immunized as of this day but not in a real-time situation. When we are
targeting who we are reaching and who we are missing, those kinds of real-time
immunization records that are being planned will be important.
I will speak to the First Nations responsibilities we had. We were tracking
influenza-like illness on a daily basis. I received daily reports. Sometimes we
were able to track that information through our Medevacs, for example, from
remote and rural First Nations communities. Again, that tracking was
labour-intensive. It was manual in many cases. It was not the kind of
information surveillance that we would want. We made it work. We had good
information to make decisions, although often putting the information together
in ways that I think we would all agree would not be the optimal way to collect
it on a go-forward basis, which is the reason for some of the investments that
have been spoken about.
Senator Seidman: Do you have recommendations of changes that might be
Ms. Yeates: Strengthening information and data is obviously a key
commitment and a key need. I do not have a specific sense of the Panorama
system's precise needs at this point, but perhaps the Public Health Agency has
oversight there, and it might be something to ask them when they are back. I
think we would all support as much consistency of reporting and as much
real-time reporting as we can have in the country.
Senator Seidman: Were adverse events monitored?
Ms. Yeates: Yes; there were two ways that occurred. The prime one in
terms of vaccines was the Public Health Agency, which has an adverse-event
reporting that was closely monitored and then the information was fed back. We
also, as the regulator in Health Canada, looked for adverse reports, for
example, to antivirals, those kinds of things. There are mechanisms for
reporting adverse events. Those were in all cases shared through the network.
The Chair: Let me ask if either Dr. Kendall or Mr. Montgomerie want to
add to that question from Senator Seidman.
Dr. Kendall: I would not add anything to that.
Mr. Montgomerie: From a deputy minister's perspective that in 2010 we
do not have a national electronic surveillance system, we need it. We need to
work together with our federal colleagues and with ourselves to try to make that
system happen. I am a layperson, but if that kind of communication system had
not been in place it would have made quite a difference.
Dr. Kendall: We can track antiviral usage in British Columbia because
there is an electronic record system, so I knew on a daily basis how many doses
of antiviral had been prescribed and given to people. I did not have a clue as
to the vaccine. We knew the doses that had been distributed to health
authorities, we knew the does that had been distributed to physicians, but it
was not until we conducted a household survey in April of 8,000 homes and
questioned 15,000 people that I was able to say that we thought we probably
immunized 40 per cent of B.C. It was not until April, May or June that I
received the data that we immunized only 41 per cent of the people. However,
when we break it down to target groups, we reached about 75 per cent of pregnant
women, 66 per cent of health care workers and 68 per cent of people with
underlying chronic conditions. In fact, the targeting worked well, but I was
flying by the seat of my pants until that point in time. We had only
Senator Ogilvie: My question is for Ms. Yeates, and I will switch from
vaccines to the antivirals for a moment.
To reconfirm, it is under your ministry that we have the responsibility for
the approval of drugs for use in Canada, correct?
Ms. Yeates: Yes, it is.
Senator Ogilvie: My question is one of process. Once a drug is
approved, in this case, Tamiflu — it was approved for use in Canada but it is
produced offshore — the drug is then imported into the country. Does Health
Canada conduct regular random testing of drug samples that enter the country?
Ms. Yeates: I do not know the answer specifically with regard to
Tamiflu. I will say that, in general, once a drug receives a notice of
compliance we do not conduct random testing of pharmaceuticals. We test general
manufacturing practices or we test certification of plants, for example, that
produce. If the drug is produced elsewhere, we rely on, if the drug is produced
by an American company, that country's standard. In the case of the U.S., that
standard would be a U.S. Food and Drug Administration standard, for example.
Senator Ogilvie: I was afraid that would be the answer. If the drug
were produced in North America, I would not ask you the question. However, the
answer to a question I put to Jim Hall on behalf of Roche Canada gave me real
concern. I asked him where the drug was manufactured and he refused to answer on
the basis that it was commercially sensitive information.
I have some passing acquaintance with the pharmaceutical industry, and that
answer came as a real surprise to me. Subsequently, I checked, and I find that
the company has a number of production facilities in rather interesting
countries around the world. That information gave rise in my mind to a real
concern about the degree of scrutiny we have on the composition of drugs, once
they are approved in this country. In regard to your answer, indeed, in North
America I think we would be fairly confident that the drug has met good
manufacturing practices because we have the ability to follow up in a number of
ways. However, in the roughly dozen locations that I looked at, I doubt we have
even seen some of those countries, let alone the production facility.
I will stop there, but I will pursue this issue through other avenues. Thank
you for your answer.
The Chair: Do you have anything to add?
Ms. Yeates: No, but I will be happy to obtain for the committee the
general practice — I do not have all the details here — of how we work with
drugs that are produced elsewhere, for example, to give that kind of assurance
and quality. I will be happy to obtain more of that information for you.
I have been passed a note that says drugs such as Tamiflu that are imported
into Canada are subject to identity testing, meaning that there is testing to
confirm that they are the correct product, and that the Canadian agent is
responsible for this testing. We will be happy to send you more information on
the precise nature of that process.
Senator Ogilvie: Mr. Chair, that is a question I asked: Do we in fact
analyze the composition of the drug that enters the country on the basis of its
purity and it composition? If the answer is yes we do, on a regular and
random-testing basis, then I have the answer that I was looking for, but that
was not the initial response I received.
Ms. Yeates: Your comment about whether we have random testing, I do
not believe that to be the case. I will undertake to make sure you and the rest
of the committee have a clear sense about what kind of testing we conduct, how
frequently and whether the testing is random or systematic.
Senator Ogilvie: Thank you.
Senator Martin: Dr. Kendall, as a British Columbian, I want to thank
you for the leadership role you had taken with the pandemic plan, the rollout
and the experience that we successfully completed as a country. Your leadership
role and others had that impact, so thank you on behalf of British Columbians.
I am curious about the summary report you gave to us, Dr. Kendall, and I have
a question for Ms. Yeates as well, whether every province and territory has
prepared such a summary that has been collected and examined. I can imagine the
volume of information that needs to be collected, in that we are barely
scratching the surface to understanding the complexity of what you undertook,
and what needs to happen to prepare for the next pandemic outbreak.
This report is a good summary report. We have had other presenters, but we
have not necessarily had a report from each province. Are there other reports
like these? If so, is Health Canada the one to receive them? Is there another
body that is collecting, analyzing and collating the reports, et cetera? I ask
that because I can imagine the process of undertaking even the collection of
this valuable information.
Ms. Yeates: When we met as an FPT group, we understood that every
jurisdiction was preparing their own reports. As Dr. Kendall has indicated, as
they are completed they are being shared.
We also felt that we needed to supplement the between-the-cracks issues, the
coordination and the compilation. That is what we are undertaking to do. I
cannot speak for each of the jurisdictions in terms of their plans for the
report, but my understanding is that the vast majority of them, if not all, will
be made public and we can then take a look at them.
Mr. Montgomerie might be able to speak more to the FPT perspective.
Mr. Montgomerie: Each province is, by the nature of legislation and
requirements, and some like B.C. and Ontario have already presented theirs and
shared them with our federal colleagues. In Nova Scotia, we are close to Dr.
Strang releasing his report to Nova Scotians, but underneath that is a 35-page,
in- the-weeds, detailed lessons learned report that we will share with the
health system in Nova Scotia, as well as with our federal colleagues.
The more important thing from a provincial perspective is whether we have
highlighted the key areas. Through our discussions with our federal colleagues
at our own level, and together as provincial colleagues, are we hitting on the
key areas so that we can go forward together? Dr. Kendall has raised several key
areas today; governance, electronic health records, vaccine contracts and other
constants that keep coming out.
By Christmas, almost every provincial and territorial jurisdiction will have
done their thing. We will check again at the FPT table to see if we missed
Senator Martin: This committee has been hearing recurring themes from
our witnesses. You said that your wife commented that three spokespersons spoke
on basically the same talking points.
This question is for all of you. Do you have a request of the committee? This
study is being undertaken to improve on this important national plan, to improve
on what has already been done. In terms of our collection of information, are
there things we should ask for? I know that you are attending only today's
session, but from following the study to date, have you any suggestions for us
on how we can focus and play a national role?
Dr. Kendall: That is a tough question.
I am not aware of any areas that you are leaving out. The witnesses that are
coming before you have a shared experience. We have completed our ``hot washes''
as we call them at the Public Health Network and the Special Advisory Committee,
and many of the issues that I brought forward surfaced during those hot washes
as well. Individually within provinces and territories we had somewhat different
experiences, and that is where we have our own learnings to implement. I think
that you will report openly and honestly on what you hear, and that will be
doing us a service.
Ms. Yeates: I echo that view. As I looked through the series of
panels, witnesses and topics, it struck me that a comprehensive study was being
conducted, and we all look forward to the findings, because you are in a unique
position to feed back those findings to us. I thought the coverage of your
topics was thorough.
Mr. Montgomerie: I think that any time an external body such as yours
that is not directly involved in such an event as this pandemic has the
resources and time to bring together a myriad of people, it is exceptional. To
Dr. Kendall's point, we look forward to your report. It will help us to ensure
that we have not missed anything.
Senator Martin: I am curious about the global reality. We are looking
at what happened in Canada and at our Canadian plan. However, as we know, what
happens globally has a domino effect and can affect us, especially when we are
talking about viruses.
We heard from Mexico, and we know there is an international network of
laboratories and information sharing, but are global concerns an area that
someone will look at to see how those concerns will affect Canada? We can have a
great plan, but there will be impacts from what happens outside of our
Ms. Yeates: Absolutely, and it is the reason that we have been
supportive of the work of the World Health Organization. They are working on the
same kind of lessons learned internationally, but we want to be part of their
going-forward planning. A number of people asked, having planned for a severe
epidemic, how does the WHO need to alter its signals. We all based our planning
on their signals, and to the extent that their signals were based almost
exclusively on spread, as opposed to strength or severity, of the pandemic, we
realize that refinement is needed, and we have put forward that proposal to the
WHO, as have many countries. Our connection to the WHO is important.
Senator Cordy: This is Nova Scotia night, I think. Thank you for being
here to help us with our study of lessons learned. It is always a good idea,
after an experience such as H1N1, to look back to see whether we could have done
I will talk about communication first, because almost every panel that we
have heard from talked about how to improve communication.
Mr. Montgomerie, you did an excellent job of talking about the timeline,
about the federal-provincial-territorial leadership coming together so that the
right hand knew what the left hand was doing. However, I do not think that
coming together always filtered down to the general public, and I am not sure
who is at fault. Dr. Butler-Jones was on television nationally and Dr. Strang
was on television in Nova Scotia giving great messages, and as soon as they
finished, the media would have another doctor with an opposing view point, so
the general public was left wondering who to believe. There were mixed messages.
How do we overcome those things? The people at the top in Nova Scotia, and in
other provinces, I am sure, and nationally, were trying to deliver the message.
How do you interest the media today and tomorrow in learning about the
preparations that we are making for the next pandemic, which we know will come.
Is it possible to interest them now, or will the floodgates open only when the
next pandemic comes?
We were receiving mixed messages.
Mr. Montgomerie: The reality is that no matter what we do, there will
always be talking heads; there will always be experts; there will always be
We in Nova Scotia committed early to recognizing that Dr. Strang is the Chief
Public Health Officer of Nova Scotia. I have been around the scene for a long
time, and I used to sit in on media scrums frequently. I have a tremendous
respect for the media. One can tell quickly by their questions when they are
losing confidence. I went to most of the news conferences for that reason.
We knew that we had to make Dr. Strang available to the media whenever they
wanted, because they were using him. When they heard a question from another
expert on the Internet or on the news, they wanted clarity. They did not want to
hear it from Dr. Montgomerie or from the Minister of Health of Nova Scotia. They
wanted Dr. Strang's opinion.
I know that Dr. Butler-Jones went through the same thing on a daily basis,
and probably in a tougher forum with the national media. My advice is to stay
cool; stay calm; be available; state the facts based on evidence; and whatever
happens will happen.
If we had slipped badly in that area, we would have lost the confidence of
Nova Scotians and Canadians. I commend the political structure that had the
courage to support their chief public health officers on a daily basis.
The conversations I had with my premier about the United States of America
saying that they would have vaccines for every citizen by October 1 were not
easy discussions. The United States said that 80 per cent of their citizens
would be vaccinated by the middle of October, or the United States recommended
closing schools. Those kinds of political questions were ones that the premier
and the minister would ask, and rightfully so. They would have to explain to
their constituents why the United States would have vaccine on October 1 when we
would not see ours until November, which is factual; it happened.
I salute elected officials for supporting the chief public health officers
who continued to answer those questions on a daily basis. There was incredible
pressure on those people every day to face the media. I have to tell a cute
story: During the high-risk sequencing groups, we had a major call where we were
told that public health nurses had opened an extra vaccine vial of vaccine in
daylight. Once opened, it has to be used. They went across the street to a
tavern and recruited folks they saw as high risk. The media were all over us.
The next day, Dr. Strang was before the media and said, ``I salute those public
nurses for their initiative in ensuring that those vaccines were used.'' One of
the media people said, ``So, Dr. Strang, were there any shots given in that
Dr. Strang, without skipping a beat, said, ``I am sure there were some shots,
but they were not from us.''
There is no easy answer to your question other than my admiration for the
political process that supported the chief medical officers.
Dr. Kendall: It is inevitable that you will have people with an
opposing viewpoint. It helps if the people we have out there can be mostly right
— never be dogmatically wrong — and that they be credible, available,
transparent, and have as much information as they can have. If we disagree with
what a talking head is saying, we have good reason to say why we disagree.
``Trust me, I am from the government;'' or ``Trust me, I am a doctor,'' does not
work. We need to establish a level of credibility beyond that, which comes from
putting a lot of hard work into it.
Senator Cordy: We know that if we say we are from the government and
we are here to help, it is not always believed.
I want to speak about vaccination and vaccination distribution. Ms. Yeates,
you said earlier that we would like to have larger quantities. You talked about
preparing the vaccine distribution and delivery infrastructure to handle higher
capacity using a variety of immunization service providers and settings.
We also heard from the pharmacists who appeared before the committee that
during a pandemic we should use the supply chain already in place, and not
arrange a new supply chain during a pandemic. That is what they told us. Can you
comment on maintaining the supply chain already in place, as compared to having
a different one during a pandemic?
Can you also comment on the variety of immunization service providers and
settings? When a pandemic or flu comes, we are accustomed to treating the
elderly and children first. This flu was different because those over 65 years
of age had a built-in immunity while those who were younger still had that
immunity within their systems. That flu was a little different at the outset,
and people wanted to bring their children.
Can you comment on the distribution of the vaccine in light of some of the
things I have said?
Mr. Montgomerie: From a supply perspective, I will speak from the
deputy minister level. In Nova Scotia, we ensured ongoing conversations with our
pharmaceutical people, with doctors in Nova Scotia and with others because we
changed the way we supplied vaccines.
We had to change. If we went the normal way through doctors' offices, we
would have taken forever to immunize all Nova Scotians. We went to a public
setting through our district health authorities. This setting caused issues, in
particular in the beginning, but we worked them out. As we eased off the
sequencing, we went back to the traditional doctors' offices and ensured the
doctors had adequate supply. In the beginning, there were challenges.
The Chair: Are there other comments?
Dr. Kendall: Yes; we used a standard supply chain for publicly funded
vaccines because of the issues of mass volume, capacity, and the 500-vial boxes
that had to be repackaged and broken down with information on them. We needed to
ensure that delivery coaching was in place for the health authorities, who could
redistribute to mass clinics, doctors' offices or later, to pharmacists. We used
the supply chain that we would normally use because of the volume and capacity
The issue of children was a challenge. We prioritized children at risk across
the country — those with any underlying risk condition. Healthy children became
infected but had the lowest rates of complications, at least in British
Columbia. Even though The Globe and Mail is still castigating us for not
putting healthy children up first, there was no epidemiological reason to
vaccinate healthy children when there were people much more likely to become
seriously ill and end up in hospital. We added the healthy children between six
months and five years of age in the second wave of vaccine, once we had it
Ms. Yeates: From the regulator's perspective of the supply chain, I
will add the fact that we had a pre-arranged spot, or sometimes two spots in the
bigger provinces, where the vaccine was delivered once it was produced. Within
the tight time frames, we were able to provide some of the testing of each lot
that has to take place on an ongoing basis. We had the producer ship the vaccine
to those designated spots and have it held there while we were simultaneously
testing so that we did not lose the transportation time. We were able to give
the go-ahead, when we had satisfied and cleared the safety hurdles, to the lots
that were pre-positioned and in place. The individual jurisdictions were at
liberty to use whatever supply mechanism worked for them within the
jurisdiction. Some jurisdictions went to mass clinics while others used
physicians' offices. We felt that decisions on those differences were best made
by the individual jurisdictions.
We used innovation to reduce everyday matters in the process of supply, but
there could be no shortcuts taken in terms of safety. Some of that
pre-positioning allowed us to save on transportation time, which in a normal
seasonal vaccine would not be an issue, while ensuring safety of the vaccine.
Senator Callbeck: Ms. Yeates, you mentioned a number of improvements
in a new process for vaccine contracting that will mean greater involvement by
the provinces and territories. I want to hear your comments on those
Ms. Yeates: One challenge that we all faced was the sense that in a
seasonal situation, we have much longer time frames. I do not think we had ever
been as close to the daily vagaries of lot difficulties at the manufacturing
level. We are usually dealing with such long time frames and the manufacturer
takes care of those things.
For example, Health Canada sent someone to the St. Foy partner so that
someone on site could understand sooner when production challenges arose. That
additional information allowed us to know when we were likely to see larger or
smaller shipments as all the quality assurance mechanisms that take place in the
plant were dealt with. Some of that process had typically been a Government of
Canada process, and then we turned the vaccine over and shipped it to the
On a go-forward basis, we have agreed that there will be
provincial-territorial representation in the process of, first, defining the
needs in some of the terms and conditions of the contracts, for example. By
being more upfront in involving the provinces and territories, we were able to
understand some of their implications and they were able to be close to that
We created more of a federal-provincial process initially, as we worked with
the manufacturers in defining the needs. We cannot predict whether that process
will be important in a future pandemic but it well could be that there is a
transparency and that best thinking right from the outset.
Senator Callbeck: This time around, were the provinces involved in
defining the need in the terms and conditions of the contract?
Ms. Yeates: The Public Health Agency of Canada has the contracts and
would know more about the details.
We understood there had been provincial input but they had not been involved
in the same way as we suggested they be now, on a go-forward basis. It had never
been done in isolation of the provinces and territories, but there is
recognition that there will be an even greater, equal partnership in every step
of the process. We have learned that.
Mr. Montgomerie: We commend the federal government because there is a
lesson learned they moved quickly on. Our colleagues are engaged with the
federal government on this new contract. It is much different than the older
one. It has been helpful and it happened quickly.
The Chair: Do you have anything to add, Dr. Kendall?
Dr. Kendall: No; I agree it is a partnership now in determining the
terms of the contract, negotiating the contracts and on the bid evaluation as
well. We cost- share the vaccines and we are now sharing the responsibility for
what we negotiated and how we negotiate it.
The Chair: Unless colleagues have other questions, I will finish off
with a question about vaccine priority lists: How well did that priority list
work? Were there many variations between the provinces on this list?
We have heard from the firefighters with respect to first responders. I
believe first responders came further down the list, although that priority may
have varied from province to province. There were also controversies, such as
professional athletes receiving the vaccine first, or members of boards of
hospitals entered the lineups, and that irritated the public. The media love to
play up those situations.
Where do you think the improvements in creating the priority list can be
made, particularly as they relate to provincial variances?
Mr. Montgomerie: For context, it helps to understand that on July 23,
the SAC spent an afternoon looking at how many vaccines had to be ordered for
Canadians, because the company had to place an order soon. I think Dr. Spika
mentioned 20 or 21 weeks. We knew on that day that in 20 or 21 weeks, we would
receive our vaccine, but not all at once; it would flow over a period of time.
That flow meant we had to sequence.
That sequencing was an incredibly difficult sell. First responders are a good
example, because those of us on the ground in the provinces felt the full brunt.
Police and others were saying we should be looked after. It was back to whether
public health officials were sticking to messages. Yes, some provinces deviated
from those risk groups and that caused concerns.
The Chair: What do you think needs to be done about that problem?
Mr. Montgomerie: At the end of the day, as Dr. Kendall said, we are in
a democracy and governments make decisions. Our chief officer for the Public
Health Agency of Canada and I make recommendations to our government and they
make decisions. In Nova Scotia we are fortunate; we went through two governments
and both totally supported the message.
Dr. Kendall: For years, priorities of the pandemic plan had been,
first, to reduce morbidity and mortality in vulnerable populations and, second,
to ensure that the underpinnings of a civic society continue. Those priorities
were around health care response and capacities.
The dilemma appears if we have to put one group before the other group
because we have limited supplies. Do we focus on trying to keep people out of
hospitals and hope we have enough health care workers to manage them, or do we
protect the health care workers and enable them to care for more sick and
morbidly ill people? The sense was we would try to protect the most at-risk from
death and disease. The second priority was then to protect the essential health
We heard from many emergency responders. I had five groups, all wanting to be
first in the queue. Therefore, I asked them if they would help me prioritize
which of their colleague organizations were to be second, third or fourth in
queue. That suggestion turned out not be wise, but I lived with the fallout.
Ms. Yeates: It has been described how the special advisory committee
went through this process of putting together the data and information we had
about who was vulnerable and likely to be impacted, and then gave to us as
deputies the advice of the chosen priority groupings.
The deputies, as a group, asked many questions. There had been a good and
thoughtful process; we appreciated that the public health advice had coalesced
across the country to give us that advice. There was a real sense that it was
the advice that we would accept and take forward as the collective.
I also appreciate that, in certain circumstances, there may be other
practical considerations. For example, in the North, everyone agreed if we are
going to a remote community, we immunize the whole community. That approach is
what was recommended for rural and remote populations. Some circumstances led
individual jurisdictions with their particular delivery capacities and concerns
to take the priorities slightly differently.
As deputies, we were comforted by the fact that there had been so much
thought and evidence focused on this difficult question.
The Chair: We have come to the end of our time.
Thank you very much, all three of you — two of you here with us and Dr.
Kendall in a slightly better time zone out on the West Coast.
You have been most helpful to us and we appreciate the information you have
given us. We will take the information and talk to more people to come up with a
report before the end of the year.