ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic
From the beginning of the H1N1 pandemic in April 2009, the Health Portfolio recognized the need to provide guidance on responding to the pandemic in several different settings.
What worked well?
Guidance documents were produced for a variety of audiences
In response to the requests of stakeholders, including national associations for health professionals, between April and December 2009 the Health Portfolio facilitated the development of approximately 50 guidance documents. These documents addressed:
- clinical care (e.g. vaccine, infection prevention and control, treatment and clinical care, remote and isolated communities, continuing medical education)
- public and event organizers
- schools, daycares, post-secondary institutions and camps
- managing H1N1 influenza virus in various settings.
In addition to the guidance documents developed by the Public Health Agency of Canada and Health Canada, the Canadian Food Inspection Agency developed guidance information for veterinarians and swine producers, as well as information on the H1N1 influenza virus and food safety for the general public.
As guidelines became available over the course of the pandemic period, they were distributed through provincial/territorial health authorities and made available on the Public Health Agency of Canada and Health Canada websites.
A more detailed breakdown is provided in Figure 3.3.1 at the end of this section.Footnote 33
Expert advisors were effective in assisting in the development of guidance
As part of H1N1 planning and coordination, the Pandemic Coordination Committee was convened and Pan-Canadian Public Health Network expert groups were engaged (with subject-specific subgroups) to oversee the development of guidelines (see section 3.2, Collaboration with provinces and territories, for further details on the Committee’s structure). These groups provided technical expertise and advice to help draft high-level guidance.
The multidisciplinary composition of the Public Health Network expert groups enabled experts from across the country to share information on a host of issues including surveillance, epidemiology, microbiology, infection prevention and control, quarantine, and clinical management. This part of the guidance development process was considered to be effective since the expert groups were able to:
- provide timely technical assistance
- expedite and facilitate information sharing within the group and with the Public Health Agency of Canada
- issue recommendations.
Group members themselves felt that they were most successful at making recommendations on infection prevention and control.
Areas for action
Clarify the federal role in developing clinical guidance
Some gaps were identified such as the need for clinical guidelines for front-line health professionals. Some provinces and territories appear to have high expectations of public health leadership from the Public Health Agency of Canada, specifically regarding the provision of guidance documents, including clinical guidance to front-line workers. The Public Health Agency of Canada assumed this role: “[We were] asked for leadership and we provided it through our structures … there was no one else to do it. We were facilitators.” Another interviewee indicated.
There is no structure in Canada that is geared to address the clinician’s requirements and the emergency wards. Because we were dealing with provinces and territories and the provinces and territories have the health system, they identified [it] fairly early on as a gap at the same time that we were getting calls from the obstetricians, the emergency rooms and the other clinicians on “So what do they do?” [In response,] we added a clinicians’ group that did the guidelines.
The Public Health Agency of Canada established a guideline development and approval process. An expert advisory group of clinicians developed the guidelines and facilitated the process. Expertise was drawn from groups such as the Royal College of Physicians and Surgeons of Canada and the Society of Obstetricians and Gynaecologists of Canada.
During the pandemic, multiple levels of government provided similar, but not identical advice. These differences led to confusion about whose advice to follow. While the Public Health Agency of Canada’s advice was based on the best scientific evidence available at the time, the application of this advice varied across the country due to differences in provincial legislation and policies. During the second wave, the federal and provincial/territorial governments collaborated on positions on masks and gloves and tried to take a collective decision so that all were approaching the issue in the same way.
Clinically relevant and trustworthy information should be provided on a timely basis, even if levels of certainty are fluctuating. In their report Lessons from the Frontlines: A Collaborative Report on H1N1, the Canadian Medical Association, the College of Family Physicians of Canada and the Canadian National Specialty Society for Community Medicine called for a harmonized national response to the development of clinical practice guidelines.
Formalize an expedited approval process for guidance documents
The Public Health Agency of Canada becomes involved in a support or leadership role to coordinate a response when an outbreak involves more than one province or territory. Formal expedited processes for approving public health guidelines do not exist. This created some significant problems during the H1N1 pandemic. One interviewee indicated, “Using the processes, which are not appropriate particularly in an emergency, of back and forth, with lots of people and building consensus and a month or three later or six months later you finally get agreement; it’s not appropriate.”
The approval process took time. This was in part due to the need to engage a host of different levels of authority in the consultation and approval process. For example, guidelines circulated for approval among the expert advisory groups, provincial/territorial Ministers of Health and Chief Medical Officers of Health in each province and territory. At the federal level, in addition to senior levels of management within the Public Health Agency of Canada and Health Canada, the Privy Council Office and the Prime Minister’s Office also provided input to the guidance documents. While these discussions on wording and the value of evidence generated took time, it was observed that the guidance and recommendations generally remained stable and were reissued less often than those of other national jurisdictions.
Various factors had an impact on the development and dissemination of guidelines. Because the federal government communicates with Canadians in both official languages, documents need to be translated. Future planning should carefully account for the timelines required for this part of the process. Another factor was the decision to release documents in batches. This meant that guidelines ready for release were held back until others were completed. Again, future planning should take this into account.
Comparisons were made between the United States Centers for Disease Control and Prevention and Canada’s Public Health Agency. The Centers for Disease Control do not have official language requirements and may do more limited consultation, while the Public Health Agency of Canada must consult with multiple stakeholders, as well as effectively plan for the timely translation of its guidance documents. Several key informants noted that the earlier availability of the Centers’ materials led some stakeholders to take the United States guidance instead of waiting for Canadian guidance to be approved. “Maybe at the end of the day you have to agree to disagree. We don’t have time to go in circles. People get frustrated, lose energy. Events overtake us – by the time school guidelines come out, everyone is already making decisions.”
The fact that guidance documents were often slow to be completed and made available on the web limited the ability of expert advisors to share draft documents and agree on key messages, resulting in inconsistent messaging and duplication of work. One interviewee suggested,
There was confusion jurisdictionally around who are the priority groups, who should come forward. Another example, based on unpublished research, was that some provinces decided not to go forward with the seasonal flu campaign. That decision was not communicated in a coordinated way.
There seems to be agreement that federal, provincial and territorial authorities and health care professionals should work together in the interpandemic period to develop a pan-Canadian strategy to be used during health emergencies, with particular consideration of the following processes:
- development: establish mechanisms to undertake timely development and communication of clinical management guidelines for clinicians during a public health emergency
- approval: define who needs to be involved and specify roles and responsibilities for each level of authority
- language translation and release: plan for translation and determine when it is appropriate to release guidance documents.
Fill gaps in existing guidance
Review guidelines and address areas not currently covered
Research indicates that some issues were not addressed in the guidance material and there was not always sufficient evidence to make informed decisions. For example, timely, national-level data on the health of pregnant women, their fetuses and newborns was not available in an ongoing and systematic way. Other areas include protocols for monitoring drug resistance during a pandemic and for determining the appropriate treatment dose and duration for a novel virus.
While Health Canada currently receives adverse drug reaction reports from health care providers, further discussions are required regarding the unique needs of monitoring the extensive use of antivirals during a pandemic.
Research the needs and resources required for pandemic response in remote and isolated communities and develop guidance
The H1N1 experience highlighted the importance of having preparedness and response activities tailored for remote and isolated communities. By virtue of being isolated, these populations have special public health needs, requiring an approach that is different from that of the general public.Footnote 34
While a number of guidance documents were generated for remote and isolated communities (see Figure 3.3.1), more research may be required on the needs of persons residing in remote and isolated communities during a mass immunization to provide the necessary evidence for developing mitigation strategies. Existing national guidelines on antivirals, surveillance and public health measures may not fully address the particular needs of these populations, including their limited access to health care workers, physicians and supplies.
Use appropriate language and formats for guidance documents
Finally, some stakeholders mentioned that language used in guidance was not appropriate for lay people or even those working in front-line health care positions. Some stakeholders described guidelines as ‘confusing’ and that what was needed were ‘plain-language’ documents that were easy to access and understand. Guidance documents were also noted to be difficult to follow because of the use of abbrs, abbreviations and complex tables. Further consultations with front-line health professionals may be warranted when producing health-related guidelines. There should also be continuing attention to formats or media used to ensure accessibility and cultural appropriateness for all Canadians.
- Pandemic H1N1: Fast Facts for Front-line Clinicians
- Use of Pandemic Influenza A (H1N1) 2009 Inactivated Monovalent Vaccine
- Addendum – Guidance for Use of Panvax™ H1N1 Vaccine (Unadjuvanted)
- Recommendations for pH1N1 Vaccine in Pregnancy
- Guidance on H1N1 Vaccine Sequencing
- Questions and Answers on Influenza A (H1N1) 2009 Pandemic Vaccine Arepanrix™ H1N1
Infection Prevention and Control
- Infection Prevention and Control Measures for Occupational Health Management for all Health Care Settings
- Additional Infection and Prevention Control Guidance
- Infection Prevention and Control Measures for Health Care Workers in Long-term Care Facilities
- Infection Prevention and Control Measures for Health Care Workers Providing Care of Service in the Home
- Infection Prevention and Control Measures for Health Care Workers in Acute Care Facilities
- Appendix B: Visitors/Accommodation
- Infection Prevention and Control Measures for Pre-hospital Care
- Additional Infection Prevention and Control Guidance for Pregnant Women, Newborns, and the Postpartum Period
- Requirements for Efficacy Claims for Hard Surface Disinfectants
Treatment and Clinical Care
- Clinical Recommendations for Patients Presenting with Respiratory Symptoms During the 2009-2010 Influenza Season
- Clinical Guidance for the Management of Influenza-like Illness in the Context of Pandemic H1N1 Influenza Virus in Adult Intensive Care Units
- Clinical Management Considerations: Timing and Mode of Delivery of Pregnant Women Requiring Hospitalization for H1N1 Influenza-like Illness
- Use of Antivirals to Treat H1N1 Flu Virus (Human Swine Flu)
- Clinical Guidance for Pregnant and Breastfeeding Women with Influenza-like Illness in the Context of the Pandemic H1N1 2009 Virus
- Important Notice: Expiry of the Interim Order That Permitted the Sale of Oseltamivir (Tamiflu®) for Use in Children Under One Year of Age in the Context of Pandemic H1N1 2009
- Information Update: Potential Medication Errors with Liquid Tamiflu®
- Guidance for Ambulatory Care of Influenza-like Illness in the Context of H1N1 Influenza Virus
- Guidance for the Management of Pandemic H1N1 2009 Outbreaks in Closed Facilities
Remote and Isolated Communities
- Guidance for Remote and Isolated Communities in the Context of the Pandemic (H1N1) 2009 Outbreak
- Looking After Someone at Home with H1N1 Flu Virus in a Remote or Isolated Community
- Guidance for Clinical Management of Patients with Influenza-like Illness in the Context of Pandemic (H1N1) 2009 in Remote and Isolated Communities
- Guidance for the Preparedness and Management of Influenza-like Illness, Including Pandemic (H1N1) 2009, in Residential Facilities in Remote and Isolated Communities
- Mass Immunization Clinics in Remote and Isolated Communities
- Hand Hygiene Recommendations for Remote and Isolated Community Settings
- Considerations for Definitions of “Remote” and “Isolated” in the Context of Pandemic (H1N1) 2009
- Guidance for Health Services Planning in Remote and Isolated Communities in the Context of Pandemic (H1N1) 2009
Continuing Medical Education
- Infectious Disease Outbreaks: Tools and Strategies for Front-line Clinicians
- A Practical Guide to the H1N1 Vaccine
- Interim Guidance for Laboratory Testing for Detection and Characterization of Pandemic H1N1 (2009)
- Novel H1N1 Flu Virus (Human Swine Flu): Guidelines – Biosafety Advisor
Public and Event Organizers
- How to Look After Someone at Home with H1N1 Flu Virus
- Individual and Community-based Measures to Help Prevent Transmission of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus, Related to Mass Gatherings
Schools, Daycares, Post-secondary Institutions and Camps
- Public Health Guidance for Post Secondary and Boarding Schools Regarding the Prevention and Management of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus
- Public Health Guidance for Child Care Programs and Schools (K to Grade 12) Regarding the Prevention and Management of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus
- Prevention and Management of Cases of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus, in Summer and Other Children’s Camp Settings
- Surveillance Protocol for Severe Respiratory Illness – Surveillance for Influenza in Hospitalized Adults 2009-2010
- Adverse Events Following Immunization Reporting Form
- Health Canada: Reporting Adverse Reactions to Antiviral Drugs During an Influenza Pandemic – Guidelines for Health Professionals and Consumers
- Case Definitions for National Surveillance H1N1 Flu Virus (Human Swine Flu)
- H1N1 Flu Virus (Human Swine Flu) Case Report Form for Initial 100 Canadian Cases
Managing H1N1 Flu Virus in Various Settings
- Public Health Guidance for the Prevention and Management of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus, Related to Communal Living Settings
- Recommended Disinfection Procedures for Conveyance (Aircraft, Passenger Trains, Ferries, Buses and Cruise Ships) and Terminal (Airport, Cruise Ship, Bus, Ferry and Train) Operators and Their Staff
- Recommended Safe Work Practices for Flight Catering Operators and Their Staff
- Prevention and Management of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus, on Conveyances including Airplanes, Trains, Ferries and Buses
- Prevention and Management of Influenza-like Illness, Including the Pandemic (H1N1) 2009 Influenza Virus, on Cruise Ships
- Guidance for the Management of Pandemic H1N1 2009 Outbreaks in Closed Facilities
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