ARCHIVED - The Health Portfolio: Framework for Action on the 2014 Ebola Virus Disease Outbreak

• Foreword
• Purpose
• Part I: Building on Strengths: The Health Portfolio's EVD Strategy
  • Strategic Considerations Informing the Health Portfolio's Approach to EVD
  • Goals and Objectives
• Part II: Protecting the Health and Safety of Canadians
  • Coordination/Governance
  • Detection
  • Response
  • Research on Vaccines and Therapeutics
• Part III: Supporting International Response and Containment Efforts
• Appendix: Inventory of Resources, Guidelines and Agreements for EVD Preparedness and Response

Foreword

Developing strategies, protocols and guidance for preventing and responding to infectious disease outbreaks in Canada is not new. For example, the federal Quarantine Act first came into force in 1872, Canada supported the World Health Organization's original International Health Regulations (2005) in 1969, Canada's first Contingency Plan for Viral Hemorrhagic Fevers was published in 1978 and the precursor to the current federal-provincial-territorial pandemic preparedness plan for the health sector was agreed to in 1988. These are just a few examples of the various plans and collaborative arrangements in place to protect the health and safety of Canadians from known and emerging infectious disease outbreaks.

Each of these plans and arrangements has evolved to reflect advances in science and medicine, new insights into public health management, lessons-learned from outbreak management and progression in our understanding of individual and institutional accountability. They also take into account that responsibility for public health in Canada is shared between the federal, provincial and territorial governments.

Since the first description of Ebola virus disease (EVD) in 1976, these plans and arrangements have been supplemented through targeted investments in research and surveillance to take account of EVD's unique characteristics and risks.

In March 2014, global surveillance systems detected a new EVD outbreak in West Africa. As the focal point of accountability within the Health Portfolio for infectious disease preparedness and response, the Public Health Agency of Canada (Agency) immediately stepped up its surveillance activities and began reviewing and updating outbreak response protocols. This included coordinating the Health Portfolio's overall preparedness to respond to a potential outbreak.

Health Portfolio partners that play an important role in Canada's EVD response, include Health Canada and the Canadian Institutes of Health Research:

• Health Canada:
  • Health Products and Food Branch (HPFB) by virtue of its regulatory role in regard to drug and vaccine testing, safety and approval;
  • First Nations and Inuit Health Branch (FNIHB), which supports the delivery of public health and health promotion services on-reserve and in Inuit communities;
  • Communications and Public Affairs Branch (CPAB), which provides communication support to the Health Portfolio; and,
• Canadian Institutes of Health Research (CIHR), which supports health-related research and knowledge transfer and exchange that improves the health of Canadians.

The Health Portfolio's response focuses on two complementary tracks of activity:

• working collaboratively with federal partners and agencies; other levels of government; and the health community and emergency response professionals to protect the health and safety of Canadians; and
• working collaboratively with the international community and with the Department of Foreign Affairs, Trade and Development (DFATD) to contain the outbreak at its source.

On August 8, 2014 the World Health Organization (WHO) declared that the West Africa Ebola outbreak was a "Public Health Emergency of International Concern" under the International Health Regulations (2005) and accelerated global coordinated efforts already underway to test, validate, refine and enhance our surveillance systems, response plans and operational readiness to address this potential public health threat.

Purpose

The purpose of the Health Portfolio Framework for Action on the 2014 Ebola Virus Disease Outbreak is to:

• articulate Canada's health response to the EVD outbreak and explain the underpinning principles and considerations;
• outline the Health Portfolio's collaborative engagement with other federal partners, provinces and territories (PTs), and public health stakeholders to ensure an effective and coordinated health sector response to the EVD outbreak; and
• collate existing key guidance documents and reference materials relevant to the EVD response to support emergency planners and front-line responders and evidence-informed decision making.

The primary target audiences for this document are federal, provincial and territorial (FPT) officials responsible for public health and health emergency planning. Understanding that PTs have lead responsibility for planning and decision-making within their respective jurisdictions, this document aims to inform and support coordinated FPT planning and response efforts. The document may also serve as a reference tool for health professionals, emergency planners, first responders and others individuals and organizations with an interest in EVD planning and response efforts.

Given the dynamic nature of the current EVD outbreak, this will remain an "evergreen" document that will be periodically updated on the Agency website. For ease of use, the document has been organized into three parts:

• Part I outlines the strategic considerations that inform the Health Portfolio's EVD strategy as well as the strategy's goals and objectives.
• Part II outlines the nature, emphasis and scope of the Health Portfolio's efforts to protect the health and safety of Canadians from EVD.
• Part III provides a high level summary of some of the Health Portfolio's contributions to the international response to EVD.
• Appendix: Inventory of Resources, Guidelines and Agreements for EVD Preparedness and Response provides an up-to-date inventory of relevant protocols, clinical guidance and planning tools- some new and some revised- that are helping ensure a consistent and coordinated response to the current EVD outbreak.

Part I: Building on Strengths: The Health Portfolio's EVD Strategy

Health emergency management planning in Canada is predicated on the existence of a series of established and approved frameworks, systems, and plans. As required by legislation, all jurisdictions have plans that set out the steps to be taken in the event of an emergency or disaster. These plans are designed to identify linkages and channels of communication to international and national level health organizations and other ministries, programs and agencies of the Government. They can be used as stand-alone documents or linked together to allow for a coordinated, system-wide approach to emergency management.

These health emergency management plans are further reinforced through intergovernmental agreements and memoranda of understanding (MOU). For example, in 2009, FPT Ministers of Health signed an MOU on Mutual Aid in the event that a jurisdiction's health care system is overwhelmed during an emergency or public health crisis. To support the implementation of the MOU on Mutual Aid, the Public Health Network has developed complementary operational agreements that outline processes, procedures and tools/templates. Jurisdictions can use those to facilitate a timely and coordinated pan-Canadian approach to making or managing requests for inter-jurisdictional health care professional mutual aid resources in health crises and/or emergencies. Another example is the Multilateral Information Sharing Agreement (MLISA), which came into force in October 2014. MLISA establishes standards for why, how, what and when public health information can be shared among various jurisdictions in Canada, and also supports collaborative health emergency management planning.

These and other existing plans, arrangements and agreements provide a strong foundation for developing effective strategies to anticipate, contain, mitigate and successfully control threats to public health and safety, including those from outbreaks of viral hemorrhagic fevers such as EVD. Several have been actively updated in response to the specific characteristics of the current EVD outbreak, the effectiveness of containment efforts and uncertainties with respect to potential medical countermeasures. All other documents are being reviewed with the aim of revision as new knowledge emerges and circumstances require.

Strategic Considerations Informing the Health Portfolio's Approach to EVD

Canada's strategic approach to EVD incorporates many of the same factors that have been adopted to guide inter-governmental pandemic preparedness and response planning. These evidence-informed approaches take into account the following considerations:

• The clinical severity of the disease, how effectively the infection can be contained and its likely impact on different regions and populations (given Canada's geographic, cultural and economic diversity).
• Public health ethics, consistent with domestic law, policy and international norms, including: the importance of informed consent; balancing individual risks and harms versus those of society; society's duty to medical and other first responders and front-line care-providers; equitable access to treatment and vaccines; and, open, transparent and inclusive decision-making processes.
• Legal considerations, including: FPT commitments and obligations under the International Health Regulations (IHR) (2005); relevant legislation at the federal (e.g. the Emergency Management Act and the Quarantine Act) and provincial/territorial levels (e.g. emergency management powers and requirements to have comprehensive emergency plans); and, the role of professional associations, unions, expert advisory groups and licensing bodies.
• Jurisdictional roles and accountabilities, including emergency management frameworks (e.g. All-Hazards Response Planning), collaborative agreements (e.g. Multilateral Information Sharing Agreement) and fiduciary responsibilities for First Nations.
• Existing inter-governmental mechanisms and expert and advisory groups that support collaboration on public health issues, including the Public Health Network Council (PHNC) and the Canadian Council of Chief Medical Officers of Health (CCMOH).
• Risk Management planning principles, including: evidence- based decision-making, proportionality and flexibility; and, a precautionary/protective approach proportionate to the possible magnitude of harm when there is uncertainty early in an event.
• Risk communications principles including factoring public reaction and risk perceptions into communications and providing Canadians with the information they need to make well-informed decisions about their health.

Goals and Objectives

Based on these factors, collectively, the Health Portfolio's goals and objectives for EVD are:

1. To contain EVD at its source; limit its negative impacts; and conduct research on therapeutic modalities for treatment and improve health systems responses to future outbreaks through contributing to international collaborative efforts.
2. To mitigate the risk to health through enhancing surveillance and quarantine capacity at international border points of entry until the WHO declares an end to the EVD crisis.
3. To minimize serious illness, death and social disruption through supporting a coordinated, collaborative response to EVD with PTs, other federal partners, international organizations and stakeholders. Further, the Health Portfolio will:
   1. Minimize serious illness and death, by:
      • Reducing the spread of infection through promotion of individual and community actions.
      • Protecting the population through public health measures.
      • Providing Canadians with the information they need to make informed decisions about their health.
   2. Minimize social disruption, by:
      • Maintaining trust and confidence through support for evidence-informed decision-making via the collection, analysis and sharing of surveillance and scientific information.
      • Communicating appropriate and timely advice to decision-makers, health professionals and the public.
4. To support efforts to accelerate the testing and development of effective, efficient and affordable Ebola vaccines and treatments.

Part II: Protecting the Health and Safety of Canadians

This section briefly summarizes the strategic approach underpinning the Health Portfolio's EVD response efforts, including some of the actions being taken (in coordination with other federal partners) to prevent Ebola from reaching our borders, for containing it at border points of entry if it does arrive, and for ensuring an effective, coordinated pan-Canadian health sector response in the event an infected person is identified in Canada.

From an FPT governance perspective, key actors in Canada's overall health system response to infectious disease outbreaks, including EVD, include:

• Ministers of Health: who are ultimately accountable for the health sector response to infectious disease outbreaks within their respective jurisdictions and collectively accountable for the overall effectiveness of the pan-Canadian response in this area of shared constitutional responsibility.
• Deputy Ministers of Health: who provide comprehensive policy advice to their respective Ministers of Health in regard to health-related issues, including planning for and responding to, infectious disease outbreaks.
• The Conference of Deputy Minsters of Health (CCDMH): an inter-governmental consensus-building forum that supports coordinated inter-governmental action on health related issues, including outbreak readiness and responses.
• The Pan-Canadian Public Health Network (PHN): a network of individuals across Canada from many sectors and levels of government, who effectively work together to strengthen public health in Canada. The PHN has strong links to senior government decision-makers and other key players in the public health system, which supports horizontal linkages across public health policy issues in a sustainable and integrated manner.
• The Pan-Canadian Public Health Network Council (PHNC): a 17-member Council composed of FPT officials, including the Chief Public Health Officer of Canada and senior government officials from all jurisdictions responsible for public health, governs the PHN. The work of the PHN is managed by three F/P/T Steering Committees, including one on the Communicable and Infectious Disease.
• The Council of Chief Medical Officers of Health (CCMOH): a forum for FPT Chief Medical Officers of Health focused on promoting excellence in population and public health practice through communication, and collaboration and exchange of ideas, knowledge, experience and best practices. CCMOH may provide direction, guidance and recommendations on technical issues relating to PHN work to PHN Council and Steering Committees, as appropriate. CCMOH reports to the CCDMH through the PHN Council.

Coordination/Governance

Coordinated Planning: Working with Decision-Makers, Partners and Stakeholders

• Since the earliest stages of the outbreak, the Agency has been working collaboratively with the PTs through the Public Health Network Council (PHNC) and the Council of Chief Medical Officers of Health (CCMOH) to improve operational readiness and ensure a coordinated health sector response to an EVD case in Canada.
• A joint PHNC-CCMOH Special Advisory Committee (SAC) has been convened and is meeting regularly to refine current EVD plans and strategies and where necessary, accelerate preparedness and planning efforts. This collaborative approach, which has been used successfully in previous infectious disease outbreaks (e.g. H1N1), allows for more robust, timely and integrated advice from PHNC to the Conference of Deputy Ministers of Health. FPT and pan-Canadian issues that have been reviewed by SAC, include: EVD surveillance; enhancing laboratory diagnostic capacity for EVD; triggers for implementing Mutual Support Agreements for sharing health human resources between jurisdictions; the composition of the National Emergency Strategic Stockpile; and, access to personal protective equipment for health professionals.
• The Health Portfolio's Operations Centre (HPOC) has been activated to monitor EVD developments at home and internationally and to share information with FPT and other stakeholders. The HPOC activation level will be adjusted as required based on the outbreak status.
• The Agency is working with Transport Canada (TC) to review protocols and standard operating procedures for the safe transport of potential EVD specimens.
• The Agency's Centre for Biosecurity, jointly with the National Microbiology Laboratory (NML), has also reviewed laboratory biosafety and biosecurity procedures for handling EVD specimens and has issued updated diagnostic protocols for EVD that are being shared via the Canadian Public Health Laboratory Network (CPHLN), a forum for public health laboratory leaders to share and exchange knowledge.
• CPAB is engaging with several stakeholders to share approved messaging and coordinate the public response including: other government departments, such as the Department of Foreign Affairs, Trade and Development, the Canada Border Services Agency and the Treasury Board Secretariat; international organizations such as World Health Organization and the United States Centers for Disease Control; non-governmental organizations; and research organizations.
• The PHN Working Group on Communications is meeting regularly to ensure timely, consistent and complete information on EVD, pursuant to established risk communications principles, is shared with Canadians as well as forward planning in the event if a case of Ebola.
• FPT Health Ministers have also discussed their level of Ebola readiness, including training and access to personal protective gear for frontline healthcare workers. The frequency of these meetings will be increased based on ongoing EVD risk assessments.

Working with Health Care Workers

• Canada's Chief Public Health Officer is meeting regularly with key Canadian healthcare professional organizations to discuss how the Government of Canada can further assist frontline healthcare workers in the event of a first confirmed case of Ebola in Canada. These discussions include topics such as planning and clinical guidance documents; updated infection protection and control measures; the information needs of frontline health professionals responding to EVD; and, ensuring that appropriate protective gear and training is available to frontline health professionals. The Agency's website also features information targeted specifically to health professionals that includes an inventory of current and updated planning and clinical guidance documents and other technical information.

Working with Stakeholders

• The Agency is supporting industry in developing appropriate measures for preventing and responding to suspected EVD cases on airports, airplanes, trains, ferries and cruise ships. Engagement and dialogue with partners and stakeholders will remain ongoing.

Communicating with Canadians

• The Agency's Communications and Public Affairs Branch is fully engaged in supporting the Ebola response. Activities include providing strategic communications advice and message development; coordinating Ministerial announcements, monitoring and analysis of media and social media; media relations; emergency communication planning and surge support; internal communications to employees; liaising with communications counterparts at other government departments, provinces and territories, non-governmental organizations, etc.; development of creative services products including videos and infographics; developing and managing web content; and the creation of a public awareness social media campaign. The Agency's website, which is being regularly updated, is a central repository for the Health Portfolio's background information, notices, guidance and advice to Canadians on EVD. The Agency's website also features information targeted specifically to health professionals that includes an inventory of current and updated planning and clinical guidance documents and other technical information.

Detection

Enhanced Surveillance and Capacity at Points of Entry

• On August 8, 2014, the World Health Organization (WHO) declared that the 2014 Ebola outbreak in Guinea, Liberia and Sierra Leone constitutes a Public Health Emergency of International Concern under the International Health Regulations (2005). Accordingly, Canada has further enhanced its border measures at points of entry. Under the Quarantine Act, which is administered 24 hours a day at all points of entry into Canada, airlines are required to report any travelers arriving on international flights that are exhibiting symptoms of a communicable disease (e.g., fever, diarrhea) to a Quarantine Officer. Pursuant to the Quarantine Act additional measures have been implemented that now require all persons with a history of travel to Guinea, Liberia and Sierra Leone in any of the 21 days prior to arrival in Canada to disclose this to a Screening Officer, who will refer them to a Quarantine Officer for a detailed health screening, including a temperature check. The Agency has also increased its presence at Canadian airports to deliver public health education to all travelers.

Updating Clinical Care and Patient Management Guidance for EVD

• In response to the WHO declaration of the Ebola outbreak as a Public Health Emergency of International Concern, the Agency invited the Canadian Critical Care Society, the Association of Medical Microbiology and Infectious Disease Canada and the Canadian Association of Emergency Physicians to develop specific clinical care guidelines for clinicians in Canada who may be engaged in the treatment of EVD patients. These recently published clinical guidelines, which are posted on the Agency website, focus on clinical care and patient management as well as on the inter-facility transfer of suspected patients. Both directly and through PHN, the Agency will enhance its collaboration with these and other professional associations, licensing bodies and colleges.

Response

Reviewing and Validating Existing Infection Control Systems and Procedures

• Hospitals in Canada have established infection control systems and procedures designed to prevent nosocomial transmission of EVD and to provide the best possible care for the patient. The Agency publishes and actively supports expert groups to develop infection control guidelines used by health care institutions across the country. As new evidence of EVD has become available, current infection control procedures have been reviewed and where necessary, new updated guidelines have been published. Examples of interim EVD clinical guidelines are listed in the Appendix of this document.

New EVD Laboratory Diagnostic Protocols

• EVD diagnostic protocols for lab testing and specimen transfer have been updated and are being widely shared. The Agency's National Microbiology Laboratory is closely connected to all of the public health laboratories in Canada through the Canadian Public Health Laboratory Network (CPHLN) and is thus ideally poised to help detect and respond quickly in the event an EVD case arrives in Canada. The CPHLN, which also supports a rapid and coordinated nationwide laboratory response to emerging and re-emerging communicable disease threats, has reviewed the updated EVD procedures. Laboratory biosafety procedures for managing EVD specimens have been reviewed and the Agency is working with Transport Canada to confirm standards operating procedures for the safe transport of specimens.

Establishment of Ebola Rapid Response Teams

• The Public Health Agency of Canada (Agency) has established Ebola virus disease Rapid Response Teams (EVD RRTs) to mobilize to any PT, upon request, in the event of a laboratory confirmed EVD case in Canada. The EVD RRTs are intended to provide surge capacity support to complement PT efforts to address the public health aspects of an EVD case.
• RRTs are comprised of experts in public health, epidemiology/surveillance (i.e. contact tracing), communications, emergency coordination/logistics, biosafety, infection prevention and control, and laboratory support.
• At the request of PTs, RRTs will collaborate with PT to undertake advance planning activities to prepare RRTs to provide operational support customized for each P/T jurisdiction. This includes site visits, joint exercises, and preliminary capacity and preparedness assessments, which would enable the RRTs to support best practices and training that respond to specific community needs depending on the context on the ground.

Protecting Canadians Overseas

• The Agency has issued travel health notices to advise Canadians of the risks of travelling to countries that are dealing with Ebola outbreaks. These travel health notices- which are regularly updated- are posted on the Government of Canada's travel.gc.ca website, partner websites and widely disseminated to travel agencies and travel medicine clinics across the country.
• The Agency is also working with other governmental and non-governmental bodies, to identify safe medical evacuation strategies in the event that a Canadian abroad becomes ill with suspected EVD.

Meeting the Needs of First Nations

• Health Canada's First Nations and Inuit Health Branch (FNIHB) is working closely with the Agency, provinces and other partners to ensure that the response to the EVD outbreak includes consideration of the needs of First Nations communities.
• To ensure that First Nations communities and those who provide health care on reserve are fully informed and prepared, FNIHB has been disseminating key information to First Nations leadership and community health staff as well as developing First Nations specific protocols on containment, isolation, transportation and contact tracing that is based on provincial guidelines.
• FNIHB has medical transportation protocols in place in all regions and will work with provinces and the Agency to immediately transfer any possible case of EVD to the nearest designated hospital equipped to manage a case of Ebola.
• In collaboration with the Agency's National Emergency Strategic Stockpile program, FNIHB is working on enhanced PPE needs for front-line staff working in First Nations health facilities.

In addition, FNIHB has begun training over 1300 designated front line health care professionals working in First Nations communities in the proper use of enhanced PPE relevant for EVD. Training that is being provided aligns with the Agency's National Infection Prevention and Control Guidance for Ebola and complements existing evidence based protocols and recommendations being provided to health care workers across Canada.

Research on Vaccines and Therapeutics

Scientists at the Agency's National Microbiology Laboratory (NML) have spent over 10 years developing an Ebola vaccine and advancing research on therapies to treat Ebola. Canada's vaccine has shown great promise in animal research and if established as safe and effective in humans, could become an important tool in helping to control the ongoing Ebola outbreak in West Africa. Accordingly, Canada is an active participant in WHO consultations on potential Ebola therapies and vaccines that brings together government representatives from Ebola-affected countries and development partners, civil society, regulatory agencies, vaccine manufacturers and funding agencies.

• With respect to vaccines: Pharmaceutical companies and regulatory authorities have committed to ramp up production and review processes to make millions of doses available in 2015.

  Canada donated a large number of doses of its Ebola vaccine to the WHO and the Agency is actively engaged in clinical trials and in accelerating the research and development, production and access to Ebola vaccines.

• With respect to therapeutics: There are no specific treatments for EVD approved by national regulatory authorities for use in humans. The NML plays an important role in advancing research in this area and is exploring options for sharing its expertise and prototypes with a view to supporting or conducting clinical trials. The Agency has also made arrangements with the CIHR as the primary federal funding organization for health research in Canada, the National Research Council and the Canadian Immunization Research Network to draw on their expertise to enhance surge capacity for rapid research response.
• With respect to research ethics: Canada is engaged in an ongoing dialogue with international partners, including the WHO, about research ethics with respect to the development and approval of Ebola medical countermeasures. Canada's positions is that ethical criteria should guide the provision of such interventions and that there is a moral obligation to collect and share all data generated, including from treatments provided for compassionate use.

Part III: Supporting International Response and Containment Efforts

The Government of Canada has adopted a whole-of-government approach to addressing the challenges posed by the EVD crisis, with the Health Portfolio, the Department of Foreign Affairs, Trade and Development, National Defence, Citizenship and Immigration, and Transport Canada each contributing in complementary areas.

Appendix: Inventory of Resources, Guidelines and Agreements for EVD Preparedness and Response

Pathogen Safety Data

• Ebola virus: Pathogen Safety Data Sheet - Infectious substances

Case Identification

• National Case Definition: Ebola Virus Diseases (EVD)

Reporting

• Ebola Virus Disease (EVD) Case Report Form

Ebola Specimen Testing

• Interim biosafety guidelines for laboratories handling specimens from patients under investigation for Ebola virus disease

Clinical Care

• Ebola Clinical Care Guidelines (PDF document) - Developed by Canadian Association of Emergency Physicians, Association of Medical Microbiology and Infectious Disease Canada, Canadian Critical Care Society

Infection Prevention and Control

• Interim Guidance - Ebola Virus Disease: Infection Prevention and Control Measures for Borders, Healthcare Settings and Self-Monitoring at Home (updated)
• Environmental Sanitation Practices to Control the Spread of Communicable Disease in Passenger Conveyances and Terminals
• Interim Guidance for Airline Cabin Crews, Cleaning Personnel and Cargo Personnel: How to Protect Yourself and Others from Ebola Virus Disease (New)

Laboratory Biosafety

• Interim Biosafety Guidelines for Laboratories Handling Specimens from Patients Under Investigation for Ebola Virus Disease

Public Health Management

• Public Health Management of Cases and Contacts of Human Illness Associated with Ebola Virus Disease (EVD)

FPT Collaborative Agreements: Mutual Aid, Information Sharing and Emergency Supplies

• Operational Framework for Mutual Aid Surge Requests for Health Care Professionals
• F/P/T Memorandum of Understanding on the Provision of Mutual Aid In Relation To Health Resources During an Emergency Affecting the Health of the Public
• The Multi-lateral Information Sharing Agreement (MILSA)
• FPT MOU on the Sharing of Information during a Public Health Emergency
• National Emergency Strategic Stockpile

Federal Emergency Response Plans

• Federal Emergency Response Plan (FERP)
• Health Portfolio Emergency Response Plan (HP ERP)
• Research Ethics TCPS 2-Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans
• WHO Ethical considerations for use of unregistered interventions for Ebola virus disease