ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic
3.1 Surveillance, science and research
The Public Health Agency of Canada and Health Canada are recognized as science-based organizations. In addition to using established science, both organizations conduct and support research to increase knowledge on a range of health topics. To understand health threats that require the intervention of the federal government, these organizations rely on their specialized staff, external experts and global/domestic surveillance systems to track the spread of new or existing infectious diseases that could have an impact on the health of Canadians. During significant public health events such as an influenza pandemic, collecting data about the behaviour of a virus and developing scientific knowledge about infection prevention and control are key factors that support decision making.Footnote 26
What worked well?
Through surveillance, health authorities around the world realized in mid-April 2009 that an H1N1 influenza virus had the potential to become a pandemic. The situation reported from Mexico City showed that an unrecognized source of infection was hitting groups of the local population, that symptoms were those of a severe respiratory illness, and that the contagion was spreading quickly through contact with an ill person. This information triggered a flurry of Public Health Agency of Canada and Health Canada scientific activities that involved surveillance and research at the international, national, provincial/territorial and local levels.
From that point onward, scientific activities sought to identify the virus, study its evolution for possible mutations and analyze how transmission occurred. In addition, researchers continued to work to identify the factors that made some groups more vulnerable to infection and to assess the evidence-based literature and expert opinion on the best prevention and clinical treatment approaches. The goal was to inform the government response to:
- test for the H1N1 influenza virus strain
- assess the response of the virus to known antivirals and a vaccine
- understand how the pandemic was developing
- support the development of guidance on prevention and treatment
- identify and fund areas of research.
The knowledge, expertise and experience of both the Public Health Agency of Canada and Health Canada employees proved to be essential for the international response to the pandemic.
Existing networks, systems and tools facilitated the prompt exchange of science, surveillance and research information
In the detection of disease outbreaks, the Public Health Agency of Canada plays a key role by linking information between geographically dispersed but related cases. Before the H1N1 outbreak, the Public Health Agency of Canada had worked with the provinces and territories to develop and maintain systems and tools to detect and report respiratory illnesses. For example, FluWatch, Canada’s national influenza surveillance system, provided a surveillance protocol and case report form for the rapid identification and reporting of severe respiratory illnesses of unknown cause. In response to the dynamics of H1N1 and the increased rates of severe disease, the Public Health Agency of Canada was able to quickly expand FluWatch surveillance activities to include the collection of epidemiological data on H1N1 hospitalizations, intensive care unit admissions, and deaths.
In advance of the H1N1 pandemic, the Public Health Agency of Canada had also developed electronic information systems to support the investigation, monitoring and reporting of public health events across the country. For instance, the Canadian Network for Public Health Intelligence is a secure, web-based system used by local health authorities, provinces, territories and the Public Health Agency of Canada to communicate with each other, including posting public health alerts about emerging or evolving public health events. To track confirmed cases of the H1N1 influenza virus, the Public Health Agency of Canada’s National Microbiology Laboratory established a national database using the Canadian Network for Public Health Intelligence platform. The Public Health Agency of Canada also used the Canadian Adverse Events Following Immunization Surveillance System. This System is supported by health care professionals who report adverse events to their provincial or territorial public health offices, which is then shared with the Public Health Agency of Canada.
During the H1N1 pandemic, the Public Health Agency of Canada monitored information from unofficial international sources, such as the media and newswires, to detect H1N1 and other health issues in other countries that could affect the health of Canadians. To support this function, the Public Health Agency of Canada maintains the Global Public Health Intelligence Network to gather preliminary reports of disease outbreaks or other public health events of concern from around the world, 24 hours a day, seven days a week and in seven languages: Arabic, simplified and traditional Chinese, English, French, Russian, and Spanish. Footnote 27 The Public Health Agency of Canada then works with the World Health Organization and other countries’ health authorities to verify this unofficial information to assess the risk to Canada. In the spring of 2009, the Global Public Health Intelligence Network played a critical role in identifying and communicating the outbreak of H1N1 2009 while it was still an unknown respiratory disease.
The Public Health Agency of Canada worked with the provinces and territories to facilitate the most effective and efficient use of laboratory resources during the H1N1 outbreak. The National Microbiology Laboratory supported provincial laboratories through the Canadian Public Health Laboratory Network to increase Canada’s readiness to detect the arrival and spread of the H1N1 pandemic influenza virus. In partnership with this Network, most provinces now have laboratories that are able to identify new strains of influenza using standardized molecular technology.
The Public Health Agency of Canada helped identify, understand and monitor the H1N1 virus
From the very beginning of the pandemic, the Public Health Agency of Canada’s National Microbiology Laboratory, internationally recognized as a state-of-the-art facility, was a leader and helped guide the global response. The Laboratory was asked to assist with testing specimens from people in Mexico City who showed symptoms of a severe respiratory illness. Five Public Health Agency scientists assisted with testing in Mexico over the course of six weeks. After identifying the virus in mid-April, the National Microbiology Laboratory developed and supported the implementation of a test that allowed researchers and provincial/territorial laboratories to determine whether the strain of influenza tested was the H1N1 influenza virus. The National Microbiology Laboratory sequenced the Mexican and Canadian strains to better understand the virus and its impact on populations around the world. 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.
Health Canada’s review of the H1N1 vaccine’s safety was conducted promptly
The review by Health Canada’s Biologics and Genetic Therapies Directorate respected the highest standards for an expedited approval of a vaccine in Canada and no shortcuts were taken in the examination of the evidence available. The benefits of international collaboration were demonstrated in the vaccine review process as many discussions with international regulators were held to analyze concerns about some of the vaccine’s components. More details on the vaccine review are found in section 3.8, Vaccine.
The Public Health Agency of Canada and Health Canada were leaders in the international response to H1N1
Canada’s National Microbiology Laboratory played a leadership role in supporting domestic and international efforts to identify, better understand and monitor the novel H1N1 influenza virus. Canada’s successful domestic response to the H1N1 pandemic was in part a result of the strong pre-established relationships with key international partners at the policy, technical and senior official levels. For example, the need for a strong liaison network between Canada, the United States and Mexico for a pandemic response was anticipated and planned before the onset of the pandemic.
During the pandemic, the Public Health Agency of Canada and Health Canada led and participated fully in international consultations and exchanges, which included senior-level participation in World Health Organization science conferences and in teleconferences and exchanges with Canada’s main partners. In addition to the Global Public Health Intelligence Network,Footnote 28, many communication and exchange vehicles were used during that period, including:
- the World Health Organization Developing Countries’ Vaccine Regulators Network, which was established in the pre-pandemic period among Health Canada and other international regulatory partners, had biweekly teleconferences during the pandemic to discuss regulatory issues and to share clinical and safety data on H1N1 vaccines in real time
- the Global Health Security Initiative, a network of countries that came together shortly after September 11, 2001 to ensure exchange and coordination of practices in confronting new risks such as pandemic influenza, facilitated Canada’s ability to receive information on the epidemiology of H1N1 globally and the mitigation strategies employed by other countries, which helped inform Canada’s domestic response
- a trilateral group of regulators formed between Health Canada, the United States Food and Drug Administration, and the European Medicines Agency, which coordinated clinical development and pharmacovigilance plans for the H1N1 vaccines
- the pilot exchange of public health liaison officers between the United States Department of Health and Human Services and Canada’s Public Health Agency, which facilitated information sharing between the two countries.
The Public Health Agency of Canada hosted “Severe H1N1 Disease: Preventing Cases, Reducing Mortality,” a September 2009 conference. Its purpose was to bring together national and international critical care and public health experts to discuss the clinical care and management of severe H1N1 disease, as well as to prepare for an expected fall pandemic wave.
The conference offered public health officials and critical care specialists an opportunity to:
- gain insights into the epidemiology of severe H1N1 disease
- discuss strategies for prevention and early recognition of severe disease
- share best practices for clinical care, disease management and resource utilization.
A key outcome was a guidance document on the epidemiology and clinical management of severe H1N1 disease to help prepare physicians, as well as intensive care and emergency health specialists, for the expected fall pandemic wave.
Areas for action
Overall, surveillance, science and research activities were effective in supporting the Public Health Agency of Canada and Health Canada in their response to the H1N1 pandemic. This Review, however, also identifies areas for action to increase readiness for a future public health event.
Effective and timely surveillance is critical to the ability of the federal government and the provinces and territories to accurately track, plan for and respond to diseases. Strengthening national surveillance capacity has been consistently recognized as a challenge for the Public Health Agency of Canada. The 2003 report by the National Advisory Committee on Severe Acute Respiratory Syndrome (SARS) and Public Health (Naylor Report) identified the need for several measures to strengthen surveillance. More recently, Chapter 5 of the 2008 May Report of the Auditor General of Canada, entitled Surveillance of Infectious Diseases – Public Health Agency of Canada, called for a national integrated surveillance system with the capacity to effectively support both routine and emergency response efforts in the future. Since the federal Budget 2006, the Public Health Agency of Canada has received funds to develop a comprehensive national influenza and response strategy as part of the Avian and Pandemic Influenza Preparedness Program.
During the H1N1 pandemic, the Public Health Agency of Canada experienced challenges with respect to its surveillance capacity including both a lack of real time data on key epidemiological variables and epidemiological resources to review surveillance data.
At the onset of the H1N1 outbreak, the lack of a comprehensive public health surveillance system was specifically evident in First Nation communities and represented a complex challenge for the Health Portfolio. This situation resulted in an incomplete and inconsistent national picture and therefore did not support timely decision making. To respond to this issue, Health Canada developed and implemented an adhoc regional surveillance system to track H1N1 activity in First Nation communities, as well as surveillance mechanisms for reporting on vaccine uptake.
Finalize agreements on sharing surveillance information across jurisdictions
As outlined in the Canadian Pandemic Influenza Plan for the Health Sector, the responsibility for surveillance is shared among federal, provincial/territorial and local governments.Footnote 29 While it provides a framework for this type of information sharing, the Plan does not include the operational details essential for an efficient cross-jurisdictional surveillance system.
Provinces and territories share data with the federal government as part of routine and ongoing health surveillance activities. During the pandemic, an agreement was developed that included an annex on surveillance information sharing (epidemiologic data and laboratory data). This annex was approved by most jurisdictions. However, there are currently no commitments to share information in the event of a future pandemic.
The surveillance challenges experienced during H1N1 underline the importance of effective national reporting and data-sharing infrastructures and approaches. Integrated surveillance for immunization is discussed in section 3.8, Vaccine. Improved national coordination of surveillance activities would also allow federal and provincial stakeholders to better leverage existing capacity and expertise across public health agencies and other federal/provincial centres.
Consider options to ensure that appropriate mechanisms exist to facilitate the rapid conduct of critical research
The experiences associated with the H1N1 pandemic highlighted that existing mechanisms are not sufficiently agile to rapidly initiate strategic planning, funding and coordination of a national research response to novel and urgent public health threats, such as a pandemic influenza virus. Specifically, the Public Health Agency of Canada encountered the following challenges:
- absence of a standardized process to rapidly set research priorities during a pandemic and to critically evaluate proposals for research funding against priorities
- lack of available contingency funds to initiate rapid research projects
- lack of human resources capacity to coordinate and administer rapid research projects
- absence of a mechanism to rapidly provide funding for project proposals (in emergencies, the timelines associated with standard procurement processes, as well grants and contributions processes, are not sufficiently responsive).
It is suggested that the Public Health Agency of Canada, in collaboration with the Canadian Institutes of Health Research, consider options for the development of standardized mechanisms to facilitate the rapid conduct of critical research so that the Public Health Agency of Canada has the necessary information for decision making during a public health event. This could be considered in the context of the Public Health Agency of Canada’s science and research strategic plan. The development of options should consider the following:
- standardized processes to rapidly identify research opportunities, set research priorities and critically review internal and external proposals for funding
- contingency funds to initiate rapid research projects
- human resources capacity to coordinate and administer rapid research projects
- rapid funding mechanisms.
Refine approaches for translating scientific knowledge into information useful for planning, decision-making and communications
In a crisis, the availability of scientific knowledge is critical. But it is also important that policy and communication officers, senior managers and central agencies can use that information for planning and decision making, as well as for communication with stakeholders and Canadians. Enhancing the Health Portfolio’s capacity to convey complex scientific information is essential. More details on this topic are provided in section 4, Summary and recommendations (see Recommendation 3).
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