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, everyone.


Welcome to the Senate Standing Committee on Social Affairs, Science and Technology.


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 preparedness infrastructure.

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 H1N1 response.

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 required.

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 ministries.

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 providers.

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 Health Organization.

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 perspective.

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 sequencing.

The daily business of emergency response in Saskatchewan to the pandemic was set around the federal meetings, and the response awaited key decisions from those committees.

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 events.

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 assessment centres.

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 agency.

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 decision making.

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 national response.

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 ministers.

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 and responsibilities.

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 emergencies.

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 year.

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 appreciate.

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 comment?

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 contradictory messages.

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 issue.

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 report.

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, will you?

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 organizations.

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 Ontario.

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 liked.

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 newspapers?

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 that campaign.

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 activities.

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 for improvements.

Senator Kochhar: I thank the panel for the outstanding job on their presentations.

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 enough.

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 moment.

The Chair: Perhaps the provincial representatives can talk about the differences in the number of people who were vaccinated from province to province.

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 populations.

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 that issue.

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 strategies.

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 correct.

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 doses each?

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 areas?

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 during H1N1?

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 to pandemics?

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, Health Canada.

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 H1N1 influenza.

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 Canada.

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 hand.

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 normally see.

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 daily basis.

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 developed.

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 communication piece.

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 forward.

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 occurred.

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 deliberations.

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 Canada responses.

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 learned.

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 sector.


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 was key.

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 jurisdictions.

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 previous panel.

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 there.


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 provinces.

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 improving surveillance?

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 made?

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 guesstimates.

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 anything.

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 jurisdiction.

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 things better.

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 other people.

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 tavern?

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 issues.

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 available.

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 improvements.

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 provinces.

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 process.

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 care workers.

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.

Thank you. With that, we are adjourned.

(The committee adjourned.)