ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic

Executive summary

Introduction

The Lessons Learned Review examined the response of the Public Health Agency of Canada and Health Canada to the 2009 H1N1 influenza pandemic. The purpose of this joint Review was to gain an understanding of what worked well and areas for action. Health Portfolio management and staff will use the findings for planning and decision making in preparation for future pandemics and other types of national public health events.

The Review analyzed information from multiple sources. First, key internal documents were examined, such as assessments conducted by operational areas within the Public Health Agency of Canada and Health Canada or by various groups within the response structure, including those with provincial/territorial officials and expert advisors. Second, reviews completed by other organizations were analyzed (e.g. provinces, non-governmental organizations and other countries). Third, written feedback was solicited from external organizations engaged by the Public Health Agency of Canada and Health Canada during the H1N1 pandemic. Finally, interviews were conducted with key senior managers.

Background

Influenza pandemics have the potential to cause serious illness, death, and extensive social and economic disruption. There were three influenza pandemics in the 20th century: 1918-19, 1957-58 and 1968-69. Each pandemic differed in severity, duration and the populations most affected.

The virus responsible for the 2009 pandemic was a unique combination of influenza virus genes never before identified in either animals or people. Determined to be the cause of severe respiratory illness outbreaks in Mexico in March 2009, the virus spread to Canada within weeks. The first Canadian cases of H1N1 were confirmed by the Public Health Agency of Canada on April 26, 2009.

Influenza pandemics are difficult to predict. At the very outset of the pandemic, the Public Health Agency of Canada was instrumental in achieving a better understanding of the virus that emerged in Mexico and its impact on populations around the world. The National Microbiology Laboratory was called on for laboratory assistance and five Public Health Agency scientists helped with testing in Mexico over the course of six weeks. Due to the National Microbiology Laboratory’s work, Canada was the first country to characterize the entire genomic sequence of the pandemic H1N1 influenza virus. This made a significant contribution to international scientific understanding of this novel strain.

As knowledge of the H1N1 virus evolved, information to Canadians also evolved, which, at times, contributed to uncertainty and anxiety among some Canadians.

As one key informant noted, the Health Portfolio "dealt with constantly evolving knowledge and evidence requiring it to adjust its advice and manage the flow of information in ‘real time’ across 14 jurisdictions, each with different needs and capacities, and spread across six time zones."

To date, Canada has experienced two distinct waves of H1N1. The first wave occurred in spring 2009 between April 12 and August 29, with influenza activity reaching its peak during the first three weeks of June. The second wave reached its peak in early November 2009. On January 27, 2010, the Public Health Agency of Canada announced that the second wave of the pandemic in Canada was over. Later in the year, on August 10, 2010, the World Health Organization announced that the world had entered the post-pandemic phase.

The Health Portfolio’s initial response to the first wave of the pandemic had an exponential tempo. The Health Portfolio Emergency Operations Centre was activated quickly and ran 24 hours a day and seven days a week for several weeks.

Canada’s second wave resulted in four to five times more hospitalizations and deaths compared with the first wave. Increased rates of hospitalization, intensive care unit admissions and mortality were found to be highest among Aboriginal people, pregnant women and individuals with at least one underlying medical condition, although the risk for Aboriginal people and pregnant women decreased considerably in the second wave compared with the first wave.

The virus is still having an impact. Some of those who experienced the most serious symptoms have reported lingering effects.

Pandemic response is a shared responsibility among municipal, provincial, territorial and federal governments, and involves a complex interface of multi-jurisdictional players, policies, plans and procedures. The Health Portfolio plays an important leadership role, as outlined below.

The Public Health Agency of Canada is the lead federal agency responsible for addressing pandemic influenza preparedness and response. Key activities include the following:

• conducting scientific research to better identify, understand and track the virus
• obtaining surveillance (or tracking) information from its federal, provincial, territorial and local partners, as well as non-governmental organizations (influenza surveillance helps to determine: when, where and which influenza viruses are circulating; their intensity, spread and impact; and if specific population groups are at higher risk for illness)
• ordering sufficient vaccine for the Canadian population, in collaboration with the provinces and territories
• stockpiling pharmaceuticals, equipment and supplies to assist the provinces and territories with surge capacity
• providing information and advice to the general public and particular groups, such as vulnerable populations, as well as issuing guidance for health professionals and other stakeholders
• providing regional coordination of federal health emergency activities
• managing international aspects of pandemic preparedness and response, including liaising with the World Health Organization and acting as the focal point for coordinating the implementation of the International Health Regulations
• developing and supporting the process required to update and maintain the Canadian Pandemic Influenza Plan for the Health Sector, in cooperation with Health Portfolio and provincial/territorial representatives.

During a pandemic, Health Canada engages and coordinates efforts among domestic and international partners in the following areas:

• developing a regulatory framework for the review, approval and release for sale of pandemic vaccines and other health products used to prevent or treat the H1N1 influenza virus
• ensuring new influenza vaccines meet standards of safety, quality and efficacy
• undertaking surveillance and risk management of post-market safety issues related to the use of health products to treat or prevent influenza, including antivirals, masks, hand sanitizers and disinfectants
• protecting public health on conveyances (e.g. aircraft and ships) and related infrastructure (e.g. airports and seaports) to reduce the spread of the pandemic into, across and out of Canada.

Health Canada is also responsible for ensuring that health services are available and accessible to on-reserve First Nation communities. This includes assistance in the development, testing and revision of pandemic plans. In collaboration with provinces and territories, the First Nations and Inuit Health Branch of Health Canada is also responsible for distributing and administering vaccines and antivirals, reporting adverse effects of immunization and treatment, as well as providing culturally appropriate information and guidance to health care workers on reserves.

Findings and recommendations

This was the first pandemic in 40 years. It tested the Health Portfolio’s ability to respond to a pan-Canadian and international public health event.

What worked well?

Overall, the response of the Health Portfolio to the H1N1 pandemic is considered to have been effective. Strengths can be identified in all nine areas of pandemic readiness and response capacity. The following were identified as high-level activities that worked particularly well during H1N1. The Public Health Agency of Canada and Health Canada should continue to build on these successes.

Surveillance, science and research

• Existing networks, systems and tools facilitated the prompt exchange of science, surveillance and research information
• The Public Health Agency of Canada helped identify, understand and monitor the H1N1 virus
• Health Canada’s review of the H1N1 vaccine’s safety was conducted promptly
• The Public Health Agency of Canada and Health Canada were leaders in the international response to H1N1

Collaboration with provinces and territories

• Federal and provincial/territorial governments demonstrated a high level of collaboration
• Basic mechanisms to support federal/provincial/territorial collaboration were in place
• New structures were created to respond to emerging issues

Guidance

• Guidance documents were produced for a variety of audiences
• Expert advisors were effective in assisting in the development of guidance

Stakeholder engagement

• A stakeholder engagement plan was put in place
• The Chief Public Health Officer established a Science Advisory Committee of researchers from the academic community
• There was strong collaboration with other countries, as well as international organizations

Communicating with Canadians

• Communication with the Canadian public was a key priority during the pandemic
• Key spokespeople, like the Minister of Health and the Chief Public Health Officer, were visible throughout the pandemic
• Advance planning ensured key communication products and activities were quickly implemented
• Social marketing efforts helped to change infection prevention behaviours
• There was strong and effective coordination of communication activities between federal and provincial/territorial governments

Federal response in on-reserve First Nation communities

• Many First Nation communities had pandemic plans in place
• Vaccination clinics on reserves were generally successful
• Antivirals were pre-positioned in remote and isolated communities for the second wave and personal protection equipment was purchased
• There was good cooperation among Health Canada, the Public Health Agency of Canada, Indian and Northern Affairs Canada, the provinces and First Nations leadership
• Health Canada appointed a Senior Medical Advisor to oversee the H1N1 on-reserve response

Emergency stockpile

• Advance planning ensured antivirals and emergency medical supplies were readily available

Vaccine

• Advance planning for the vaccine supply ensured timely access to a safe and effective vaccine
• The Canadian rate of immunization was one of the highest in the world
• There was close collaboration with the World Health Organization and international regulatory counterparts
• Science, policy and regulatory experts worked together as a team
• Interim orders were appropriate regulatory measures to expedite access to the H1N1 vaccine, as well as to antivirals for children under one year of age

Operational management

• Key structures, resources, relationships, plans and tools were in place
• Staff showed remarkable dedication and endurance
• A financial framework for pandemic influenza had been already established
• Internal communications with staff began early and was extensive

Areas for action

Notwithstanding these strengths of the Health Portfolio response, improvements are required. Specific areas for action are identified below:

Surveillance, science and research

• Finalize agreements on sharing surveillance information across jurisdictions
• Consider options to ensure that appropriate mechanisms exist to facilitate the rapid conduct of critical research
• Refine approaches for translating scientific knowledge into information useful for planning, decision-making and communications

Collaboration with provinces and territories

• Continue to work with provincial and territorial partners to review and streamline the federal/provincial/territorial governance structure for pandemic influenza
• Clarify and communicate the roles and responsibilities of the various advisory groups within the pandemic governance structure
• Clarify decision-making processes during a pandemic and communicate them to expert or advisory groups

Guidance

• Clarify the federal role in developing clinical guidance
• Formalize an expedited approval process for guidance documents
• Fill gaps in existing guidance
• Use appropriate language and formats for guidance documents

Stakeholder engagement

• Increase multi-jurisdictional coordination of information for stakeholder groups
• Enhance capacity to anticipate and respond to issues raised by all stakeholder groups
• Support development of guidance documents for health professionals
• Review Health Portfolio management of international relationships

Communicating with Canadians

• Improve consistency of information communicated to Canadians across different jurisdictions
• Review strategies to communicate uncertainty, risk and shifts in scientific knowledge in order to build public trust

Federal response in on-reserve First Nation communities

• Develop guidance on the logistical aspects of implementing pandemic plans
• Ensure timely availability of public health guidance for First Nation communities
• Respond to local issues by using regional spokespeople
• Address barriers for the movement of health professionals during a public health event

Emergency stockpile

• Review the National Emergency Stockpile System and the National Antiviral Stockpile in light of the H1N1 experience
• Consider options for prescribing and dispensing antivirals in remote and isolated communities during a pandemic
• Seek authority to donate stockpile supplies to other countries

Vaccine

• Implement an integrated surveillance system for immunization, including managing inventories, tracking vaccine uptake and monitoring adverse events
• Review the approach for federal delivery of vaccines to provinces and territories
• Establish a permanent regulatory regime for future public health events
• Effectively communicate regulatory processes and mechanisms

Operational management

• Governance during significant public health events
  • Examine the Incident Management System used in the Health Portfolio Emergency Operations Centre and adapt it for future responses
  • Develop a common understanding of the decision-making process during an emergency when public health and public policy issues intersect
  • Look for opportunities to streamline briefings and meetings involving senior management
  • Continue to distinguish roles and responsibilities among the Public Health Agency of Canada’s senior executives
  • Distinguish roles and responsibilities within the Public Health Agency of Canada between the emergency management and the operations groups
• Corporate support during significant public health events
  • Put mechanisms in place to ensure responsiveness of the Public Health Agency of Canada’s corporate services
  • Pay particular attention to policies, plans and procedures for human resources management

Cross-cutting recommendations

The 34 areas of action listed above can be clustered into three overarching recommendations for improvements within existing roles, responsibilities and structures. The first recommendation is specific to pandemic preparedness and response, and requires federal collaboration with the provinces and territories. The second recommendation is federally oriented and specific to emergency management. The scope of the third recommendation is limited to the Public Health Agency of Canada and Health Canada and focuses on strengthening science-based communications.

Recommendation 1 – Further strengthen federal/provincial/territorial capacity to prepare for and respond to pandemic influenza.

• Update the Canadian Pandemic Influenza Plan for the Health Sector with a particular focus on:
  • adaptability and scalability to different pandemic scenarios
  • efficiency and effectiveness of governance structures (i.e. roles and responsibilities of all partners, composition of committees/groups, as well as accompanying decision-making and approval processes)
  • collaborative processes to develop and strengthen guidance documents to ensure availability, accessibility and consistency of messaging
  • finalization and implementation of data-sharing agreements with provinces and territories.

Recommendation 2 – Continue to clarify, communicate and test federal emergency management roles, responsibilities and mechanisms, with particular attention to sustainability of response capacity and decision-making roles.

• Finalize the Health Portfolio Emergency Response Policy and update the Health Portfolio Emergency Response Plan with attention to:
  • decision-making roles and responsibilities and accompanying approval processes/timelines
  • activation and escalation standards commensurate with the severity of an event
  • principles and procedures for ensuring the sustainability of response with sufficient surge capacity.
• Continue to orient and train on emergency management.
• Consider a more integrated approach to lessons learned exercises.

Recommendation 3 – Improve the Health Portfolio’s ability to communicate science to various audiences.

• Develop plain-language approaches to convey complex scientific findings, processes, uncertainties, risks and shifts for various audiences/purposes, including:
  • Health Portfolio staff in areas such as policy, program, communications and operations
  • decision makers/decision influencers
  • stakeholders
  • the media
  • the general public.

Next steps

Planning is a continuous process. The lessons learned from the experiences from the Severe Acute Respiratory Syndrome (SARS) outbreak and other significant events, such as the 2008 listeriosis outbreak, laid the groundwork for improvements to the Health Portfolio’s pandemic response capacity. For H1N1, lessons learned from the first wave were applied to activities during the second wave. It is expected that the lessons learned from this Review will lead to an even more efficient and effective response to future pandemics and other types of national public health events.

Immediate steps should be taken by the Public Health Agency of Canada and Health Canada to implement the lessons learned highlighted in this report. Senior management should oversee the development, implementation and ongoing monitoring of a detailed action plan to respond to each of the findings and recommendations.