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

4. Summary and recommendations

Summary of what worked well

It is important to acknowledge up front that Public Health Agency of Canada and Health Canada staff worked extremely hard during the pandemic. They demonstrated profound professionalism and commitment. Their dedication to anticipating and responding to the needs of Canadians was admirable.

Overall, the response of the Health Portfolio to the H1N1 pandemic is considered to have been effective. Critical federal building blocks for the response had been established prior to the pandemic, including the creation of the Public Health Agency of Canada, the appointment of a Chief Public Health Officer, the existence of the National Microbiology Laboratory, the establishment of a Pandemic Contingency reserve, as well as development of the Federal Emergency Response Plan, the Health Portfolio Emergency Response Plan and a Health Portfolio Emergency Operations Centre. Key situational awareness tools such as the Global Public Health Intelligence Network were also up and running. Mechanisms for provincial/territorial collaboration were also in place, such as the Conference of Deputy Ministers of Health, the Pan-Canadian Public Health Network, the Council of Chief Medical Officers of Health, the Canadian Public Health Laboratory Network, and the Canadian Pandemic Influenza Plan for the Health Sector. Collaboration with other countries was aided by relationships and plans already in place, such as the North American Plan for Avian and Pandemic Influenza.

In addition to these key structures, resources, relationships, plans and tools already in place, many important successes were identified in all aspects of the Health Portfolio’s pandemic response.

On the science side, pandemic influenza is difficult to predict. Responses must be tailored as knowledge evolves about the characteristics of the virus. 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 during the early stages of the pandemic and five Public Health Agency scientists assisted 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.

In terms of regulation, Health Canada expedited the approval of the H1N1 vaccine, working closely with the manufacturer in advance of the pandemic to identify safety information and data. Science, policy and regulatory experts adjusted scientific and regulatory processes to address the uniqueness of the H1N1 pandemic situation. Although processes were expedited, no shortcuts were taken that would compromise the safety of Canadians.

As key players on the international scene, Health Canada and the Public Health Agency of Canada held ongoing exchanges with Canada’s main partners including the United States and Mexico. Throughout the H1N1 pandemic, there was also close collaboration with the World Health Organization, the Pan American Health Organization, the Global Health Security Initiative and other international organizations.

The Health Portfolio worked closely with provinces and territories and established a response structure for managing the H1N1 pandemic, building on existing mechanisms and adding new structures to respond to emerging issues as understanding of the pandemic, and the required response, evolved. For the most part, federal and provincial/territorial governments created a transparent, cooperative working environment. A significant collaborative activity was the development of guidance documents on various topics for various audiences (e.g. clinicians, surveillance specialists, laboratory scientists, public event organizers, schools, daycares, post-secondary institutions and camps).

Great benefits were derived from advance pandemic planning. Establishing a 10-year contract with a domestic manufacturer in 2001 helped to ensure timely access to a safe and effective vaccine during the pandemic. Canada’s immunization rate was the second highest in the world, with almost half of our population vaccinated. Having the National Emergency Stockpile System and National Antiviral Stockpile in place enabled the provinces and territories to distribute antivirals and medical supplies quickly.

In terms of addressing the needs of on-reserve First Nation communities, many communities had pandemic plans in place and vaccination clinics on reserves resulted in high rates of immunization. Following some initial challenges, there was good cooperation among Health Canada, the provinces and First Nations leadership.

The Public Health Agency of Canada and Health Canada also understood the importance of timely, clear communication with the Canadian public during the pandemic. Key spokespeople, like the Minister of Health and the Chief Public Health Officer, were visible throughout the pandemic. Coordinated communication activities were encouraged among federal and provincial/territorial governments. Infection control practices instilled during this time generated the added benefit of reducing the impact of all infectious diseases.

The involvement of all stakeholders was crucial. Information about the pandemic was provided using a variety of engagement mechanisms with health professional associations, national Aboriginal organizations, the private sector, emergency response organizations, organizations representing at-risk populations and organized labour. Members of Canada’s influenza academic research community were engaged through a Science Advisory Committee.

Cross-cutting recommendations for action required

Notwithstanding these strengths of the Health Portfolio response, lessons were learned and improvements are required. This Review identified 34 areas for action across the nine elements of pandemic response examined. The areas of action can be clustered into three overarching recommendations for improvements (see Figure 4.1). The first recommendation is specific to pandemic preparedness and response capacity; it demands federal and provincial/territorial collaboration. The second recommendation is federally oriented and deals with 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.

Pandemic preparedness and response capacity

The federal government, along with provincial/territorial partners, has made significant investments in building pandemic preparedness and response capacity over many years. In 2006, after extensive dialogue and collaboration, the federal, provincial and territorial governments approved the Canadian Pandemic Influenza Plan for the Health Sector. The Plan provides a broad, national-level framework for a collaborative response to pandemic influenza in Canada and aims to establish the roles and responsibilities of the Public Health Agency of Canada, Health Canada, the provinces and territories during a pandemic.

There is no doubt that this advance planning paid off, allowing a collaborative approach for the response to H1N1. However, challenges arose when implementing the national Plan. The Plan should be updated to address these challenges.

When assessing the Plan in light of H1N1, it is apparent that it was based on, minimally, a moderately severe scenario where “in the absence of a pandemic vaccine and antivirals, it is estimated that between 15 and 35 percent of Canadians could become ill, 34,000 to 138,000 individuals may need to be hospitalized, and between 11,000 and 58,000 deaths could occur.”^{Footnote 70} This scenario did not reflect what happened on the ground during the H1N1 pandemic. Federal/provincial/territorial partners need to examine the foundation of the Plan to ensure that all potential scenarios have been considered, including one potential scenario where the virus spreads quickly but the levels of morbidity and mortality are below moderately severe. Therefore, activities and responsibilities for all partners can be adjusted accordingly.

Success hinges on confidence in the Plan itself and the process used to develop it. Consultations with all relevant parties should be an integral component of this review. Within the federal sphere, this includes corporate support services within the Health Portfolio as well as staff in central agencies.

Clearer governance structures and decision-making processes should be communicated to advisory groups. Governance structures should be agreed to and in place so they can be implemented immediately in any future pandemic. This would provide clarity in roles and responsibilities and a more streamlined decision-making and approvals process.

Some provinces and territories appear to have high expectations of public health leadership for the Public Health Agency of Canada, specifically regarding the provision of guidance documents, including clinical guidance to front-line workers. Collaborating with all partners that have a role in the development of guidance is crucial for these documents to be available when needed by their target audiences in a format that is accessible, understandable and available. Enhanced collaboration will also lead to a reduction in varying messaging, often deemed confusing to Canadians and specific stakeholders, such as front-line health care workers.

Another very important consideration is the finalization and implementation of data-sharing agreements with provinces and territories. It is also important to clarify, in advance of a communicable disease emergency, roles and responsibilities at all levels of government pertaining to services provided to First Nations people living on a reserve.

 

Emergency management

Under the Emergency Management Act (2007), section 6(1), all Ministers accountable to Parliament for a government institution are responsible for identifying the risks that are within or related to their area of responsibility, including those linked to critical infrastructure, and to do the following in accordance with the policies, programs and other measures established by the Minister of Public Safety:

• prepare emergency management plans
• maintain, test and implement those plans
• conduct exercises and training in relation to those plans.

The Health Portfolio prepared a Health Portfolio Emergency Response Plan that describes the high-level roles and responsibilities of the Public Health Agency of Canada and Health Canada. A draft of this Plan was revised and approved in the midst of the pandemic in September 2009 (although certain annexes still require completion). The Health Portfolio should update the Plan, taking into account lessons learned from the entire H1N1 experience, as well as recent guidance on emergency management planning from Public Safety Canada.

The Health Portfolio did prepare a draft Health Portfolio Emergency Response Policy in 2007, which identifies the emergency response roles and responsibilities of organizational units and regions within the Public Health Agency of Canada and Health Canada. The Policy has not yet been finalized and approved.

It should be noted that a Public Health Agency lessons learned review in December 2008 following the listeriosis outbreak also recommended that the Health Portfolio Emergency Response Plan and related Policy be finalized and approved.^{Footnote 71}

The Health Portfolio Emergency Response Plan needs to reflect the reality of the governance and operational management structures. More specifically, it should ensure the linkages are clear between Health Portfolio management of a public health event and Public Safety Canada’s government-wide emergency coordination. Furthermore, it should include a description of the roles and responsibilities of the Minister’s Office, central agencies and members of Parliament, and attempt to anticipate their briefing requirements.

The Health Portfolio Emergency Response Policy should describe the specific roles of strategic policy, communications, operational/program groups and regional offices, as well as outline the type of support expected from corporate services. The sustainability of emergency response services and business continuity are dependent on the support of corporate services.

More work should also be done in the Health Portfolio Emergency Response Plan on activation and escalation standards to ensure that they are commensurate with the severity of an event.

Once the science of the H1N1 virus emerged, the implications for the Health Portfolio’s human resources demands became increasingly clear and “the response morphed into a marathon, rather than a sprint.” It is critical that the Health Portfolio Emergency Response Plan contain principles and procedures for ensuring the sustainability of response with sufficient surge capacity.

Regular orientation and training on the Emergency Response Plan and related Policy should take place with Health Portfolio employees, as well as staff from the Minister’s Office and central agencies (as appropriate), to ensure a shared understanding of structures, roles and responsibilities, and decision-making and approval processes.

One type of required training is emergency simulations. The Health Portfolio has never experienced a “no notice” test and should consider the feasibility of an unanticipated simulation to test for preparedness and to practise various types of response scenarios. These types of simulations, however, are resource intensive and logistically challenging. Therefore, the Health Portfolio should continue to leverage real-life events as training opportunities. ‘Tabletop’ exercises with Health Portfolio management, as well as staff from the Minister’s Office and central agencies, should also be considered.

Finally, the Health Portfolio should consider a more integrated approach to lessons learned exercises as noted in the June 2010 Public Health Agency of Canada’s Audit Report on Emergency Preparedness and Response.^{Footnote 72} There was a great deal of disciplined reflection by many organizational units throughout and following the H1N1 experience. This was in the form of after-action/after-event reports, ‘hotwashes’, post mortems, and other types of formal and informal studies and assessments. Organizational units should be commended for this important work. However, it would be beneficial to have mechanisms in place for:

• taking a more standardized approach to completing these reviews
• sharing reviews across organizational units
• synthesizing patterns of lessons learned to brief senior management and to ensure that lessons learned are also applied at a corporate level
• monitoring the implementation of recommended improvements
• archiving all reviews in a central repository so they are easily accessible for future reference.

 

Communicating science

The Public Health Agency of Canada and Health Canada are both organizations whose business is based on scientific knowledge. In a period of health crisis such as a pandemic, scientific knowledge should be the key factor in decision making. But communicating science-based suggestions to decision makers and then the science-based decisions to a variety of audiences (such as other federal government departments and central agencies, provinces and territories, stakeholders, the Canadian public, as well as the media) is a challenge that requires preparation prior to activating and escalating a pandemic response.

Communicating uncertainty

The Public Health Agency of Canada and Health Canada need to work on how to describe uncertainty, clearly state options and provide justification for decisions taken. As science-based organizations, there are a number of times when communication will have to focus on not knowing the response but at the same time instilling confidence in the general population that the government is capable of responding.

People think you don’t know what you are doing and you’re changing your mind when in fact you knew full well at the start that the data will dictate, in the end, what the recommendations are… (it’s) having people sensitized to that certain level of uncertainty and risk’ — maintaining confidence while in the face of uncertainty.

Communicating risk

The Science Advisory Committee believes that the pandemic’s risk may have been overstated and suggests that, in the future, science and research may want to focus more on firmly determining a pandemic’s virulence before communicating it to the public. However, it is important to state that any future pandemic will take place in a multisource environment and therefore a wait-and-see approach may not be the best one to take with the general public. They will get their information from another government source, be it within Canada or externally — such as the United States or from the World Health Organization — or from social media sources, which may not provide accurate information or assessments of the situation.

Instead, there is a need to plan for different scales of pandemic response, dependent on the severity of the virus but recognizing that, even when there is a lower risk of morbidity and mortality with certain strains of a pandemic influenza, there will always be tragic cases that may move public opinion and therefore must be accounted for in a low-risk pandemic situation. As one interviewee said, “If you were more brutal in your assessment of who was at risk, more Canadians would have seen themselves NOT at risk.”

The majority of communication activities targeted the general population with guidance for specific populations coming later in the process. While a broad communications strategy is essential in keeping Canadians informed, a more targeted approach may also be necessary to ensure higher-risk populations receive timely and specific information necessary to respond to the pandemic. This approach should examine both message and mode of transmission (social media as well as traditional sources of information such as television, print or from trusted sources such as health professionals).

Communicating shifts in scientific knowledge

The Public Health Agency of Canada needs to continue to be mindful that decisions may change as the science evolves. As discussed earlier, initial communications were based on a different type of virus. As the science evolved, communications were adjusted. One senior manager stated:

You could give them your best educated — more than a guess — prognosis, but that science was shifting as the pandemic was unfolding and, if science shifted, that didn’t mean there had been a mistake at the front end. They saw a change in the context as either a mistake or a failure to predict. As distinct from a molecular — literally — shift.

The problem of communicating uncertainty, risk and shifts in scientific thinking is not limited to the Canadian public or other external stakeholders. It is also problematic when communicating findings, evidence and processes to decision makers and decision influencers (such as central agencies within the federal government) to ensure approval of messages to be communicated to the general public.

Making health science and the uncertainty linked to the basic scientific process easy to understand for the general public should be an important task for both organizations. Audience-specific learning tools should be available and disseminated prior to any emergency to accelerate decision making and to ensure that the rationale behind decisions about public health measures is understood.

 

Next steps

Planning is a continuous process. The lessons learned from the experiences with the Severe Acute Respiratory Syndrome (SARS) outbreak and other public health significant events, such as the 2008 listeriosis outbreak, laid the groundwork for improvements in 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 significant public health events.

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

Figure 4.1 Areas for action and cross-cutting recommendations