Public health measures: Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector

Public Health Measures Annex

Table of Contents

• List of Abbreviations and Acroynms
• Preamble
• 1.0 Introduction
  • 1.1 Background
  • 1.2 Purpose
  • 1.3 Changes in This Version
• 2.0 Context for Planning
  • 2.1 Role of Public Health Measures in the Prevention of Pandemic Influenza
    • 2.1.1 Factors Influencing Public Health Measures in a Pandemic
  • 2.2 Uncertainties and Unpredictability
  • 2.3 Lessons Learned from the 2009 H1N1 Pandemic
    • 2.3.1 Programmatic Lessons Learned
    • 2.3.2 Scientific Findings
  • 2.4 Program Delivery in the Canadian Context
    • 2.4.1 Understanding Canada's Diversity
  • 2.5 Ethical Considerations
  • 2.6 Legal Considerations
• 3.0 Canada's Pandemic Public Health Measures Strategy
  • 3.1 Objectives
  • 3.2 Guiding Principles and Approaches
  • 3.3 Public Health Measures – Specific Assumptions
  • 3.4 Pandemic Roles and Responsibilities
  • 3.5 Key Elements of the Response
    • 3.5.1 Individual Measures
    • 3.5.2 Community-Based Measures
    • 3.5.3 Border and Travel Measures
    • 3.5.4 Case and Contact Management Measures
    • 3.5.5 Public Education
  • 3.6 Risk Management Approach
    • 3.6.1 Overview
    • 3.6.2 Risk Management Considerations for the Public Health Measures Strategy
  • 3.7 Triggers for Action and Key Decisions and Activities
• 4.0 Integration with Other Response Components
  • 4.1 Surveillance
  • 4.2 Communications and Stakeholder Liaison
• 5.0 Research Needs
  • 5.1 Individual Measures
  • 5.2 Community-Based Measures
  • 5.3 Special Considerations
• 6.0 Assessment and Evaluation of Public Health Measures Preparedeness and Response
• Appendix A: Recommened Public Health Measures, by Settings and Severity
• Appendix B: Guidance for Remote and Isolated (RI) Communities

List of Abbreviations and Acroynms

CDC

(US) Centers for Disease Control and Prevention

CNPHI

Canadian Network for Public Health Intelligence

CPIP

Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector

CPIP-TG

Canadian Pandemic Influenza Preparedness Task Group

ECDC

European Centre for Disease Prevention and Control

FNIHB

First Nations and Inuit Health Branch

FPT

federal/provincial/territorial

FP

family physician

GC

Government of Canada

GPHIN

Global Public Health Intelligence Network

HC

Health Canada

HCW

health care workers

ILI

influenza-like illness

NGO

non-governmental organization

NPI

non-pharmaceutical interventions

OBTH

Office of Border and Travel Health

PEP

post-exposure prophylaxis

PHAC

Public Health Agency of Canada

PHEIC

public health emergency of international concern

PHM

public health measures

PT

provincial and territorial

SARS

severe acute respiratory syndrome

WHO

World Health Organization

Preamble

The Public Health Measures Annex of the Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) is a federal, provincial and territorial (FPT) guidance document that outlines how jurisdictions will work together to ensure a coordinated and consistent health sector approach to Canada's public health measures strategy. The CPIP main body and annexes are intended to be used together.

While it is anticipated that CPIP's strategic direction and guidance will inform FPT planning to support a consistent and coordinated response across jurisdictions, the provinces and territories (PTs) have ultimate responsibility for planning and decision-making within their respective jurisdictions.

It is important to note that CPIP is not an actual response plan. Rather, it is a guidance document for pandemic influenza that can be used to support jurisdictional pandemic plans. While CPIP is specific to pandemic influenza, much of its guidance is also applicable to other public health emergencies, such as outbreaks of other communicable diseases.

1.0 Introduction

1.1 Background

Public health is defined as an "organized activity of society to promote, protect, improve, and, when necessary, restore the health of individuals, specific groups or the entire population."^{Footnote 1} Perhaps nowhere is this definition more evident than in the implementation of public health measures in an influenza pandemic. Public health measures are also known as non-pharmaceutical interventions (NPI) – which are used to slow the spread of a communicable disease, such as seasonal and pandemic influenza, in communities.

Canada's public health measures strategy includes actions:

• taken by individuals, such as hand hygiene and self-isolation;
• taken in community settings and workplaces, such as increased cleaning of common surfaces and public education;
• that require extensive community planning and have considerable impact, such as closure of schools, cancellation of mass gatherings, and travel and border restrictions.

This Annex describes the many factors to consider when planning public health measures aimed at preventing, controlling and mitigating pandemic influenza. It is meant to facilitate a common approach to community-based disease control strategies across jurisdictions during an influenza pandemic.

1.2 Purpose

The purpose of this Annex is to outline Canada's approach to public health measures in an influenza pandemic and offer specific operational and technical guidance for the health sector in provinces, territories and locations where the federal government provides health care services. It is one of a series of annexes that support CPIP.

The primary audiences for this Annex are the FPT ministries of health, along with other government departments that have responsibilities for the health care of specific populations, such as Indigenous Services Canada, Department of National Defence and Correctional Services Canada. The Annex also serves as a reference document for other government departments, non-governmental organizations (NGOs), and for other stakeholders interested in Canada's strategy for public health measures in an influenza pandemic.

1.3 Changes in this Version

This version of the CPIP Public Health Measures Annex is considerably changed from the 2006 edition in both format and content. Content has been updated based on post-H1N1 pandemic reviews conducted at the FPT and international levels and by key Canadian stakeholder groups.

The underlying principles and approaches outlined in the CPIP are highlighted throughout this annex, and the CPIP's pandemic risk management approach has been incorporated. The CPIP's planning scenarios are used to identify specific risk management considerations related to public health measures in pandemics of varying impact, along with potential mitigation approaches. The key elements of the public health measures strategy are described, and triggers for key activities are identified.

Guidance documents that were produced for the 2009 influenza pandemic continue to serve as useful tools for a future pandemic, and concepts from these guidance documents have been incorporated into this Annex.

2.0 Context for Planning

2.1 Role of Public Health Measures in the Prevention of Pandemic Influenza

Public health measures are the most basic actions that can be taken to reduce community transmission of a pandemic influenza virus. In the context of pandemic influenza, public health measures seek to reduce both the occurrence and duration of human infections so as to delay the peak of pandemic influenza activity. They are commonly used across Canada for seasonal influenza and other communicable disease outbreaks and will play an important role throughout a pandemic. During the period before an effective pandemic vaccine becomes available, antiviral drugs, primarily for treatment of cases, and non-pharmaceutical public health measures will be the only tools available early on to mitigate the effects of the pandemic. According to the CPIP Vaccine Annex, using the current egg-based pandemic vaccine production technology, it will take four to six months for vaccine to become available. Thus, a pandemic vaccine may not be available during the first pandemic wave in Canada.

The defining features of public health measures are that they can be implemented early and involve multidisciplinary collaboration, between and across health and non-health sector settings, including homes, workplaces, public and educational settings, ports of entry, various community-based service organizations and correctional facilities.

Public health measures include:

• Personal protective measures (also referred to as individual measures), such as respiratory etiquette, hand hygiene and environmental cleaning of surfaces to protect uninfected individuals against influenza, and staying home when ill (self-isolation) to prevent the spreading of infection.
• Community-based measures to reduce transmission of infection within community settings such as workplaces, schools, and communal living facilities. Social distancing measures (e.g., minimizing close contact with others) include proactive school closures, public gathering cancellations and alternative workplace approaches (e.g., teleworking). Since these actions may require extensive community preparation and may have significant secondary consequences, they are most applicable in pandemics of moderate to high impact.
• Case management of individuals with pandemic influenza in the early stage of a pandemic. Associated measures may include educating and advising individuals to self-isolate; reporting cases to appropriate public health authorities; and managing contacts of suspected or confirmed cases, which may include educating exposed individuals and advising voluntary home quarantine (i.e., in an individual's home or other setting where they reside).
• Travel and border-related actions, such as providing disease information to travellers and measures taken with suspected cases and their contacts (under the Quarantine Act) to prevent the spread of a communicable disease across Canada's international borders. These actions depend on various factors, such as the extent of pandemic influenza virus activity in Canada at the time of detection, the pandemic's epidemiology, and feasibility considerations.
• Public education to promote and to support the implementation and adoption of measures at the individual and community levels, based in a risk communications approach. It will also be important to provide educational materials to health professionals that reinforce existing recommendations for public health measures for individuals presenting with influenza-like illness (ILI).

The guidance contained in this Annex is designed to be adaptable to different situations, as well as regional and jurisdictional contexts. Many of the recommended measures are contingent upon local triggers; therefore, the timing of their implementation depends on local circumstances that may not occur simultaneously across Canadian jurisdictions. However, a consistent approach to the application of public health measures and the messaging that accompanies them will improve public perception, trust and compliance with guidance.

2.1.1 Factors Influencing Public Health Measures in a Pandemic

When planning public health measures, decision-makers must weigh not just the costs of implementation but also any secondary impacts. Social and economic impacts on individuals, families, communities and businesses due to, for example, closing schools or cancellation of public events, should be considered with any intervention and weighed against its potential benefit. Individual behavioural measures, such as practicing hand hygiene, respiratory etiquette and self-isolation when ill, are promoted during seasonal influenza and should be encouraged in any pandemic scenario. Other measures, such as school closures and border restrictions, are complex, costly to sustain and likely to have unintended societal and economic consequences.

The success of any public health measure depends on a variety of factors, such as:

• Epidemiology: This factor includes the use of epidemiological tools and methods to collect, analyze and interpret data (e.g., clinical cases, hospitalizations, deaths, severe clinical outcomes and associated risk factors). Such data will help detect a pandemic, identify populations at risk, and estimate the population health burden of the pandemic, all of which will ultimately inform the planning of public health measures.
• Timing of public health measures: Implementing interventions early on is generally seen to be more effective than waiting until a pandemic is well under way.^{Footnote 2},^{Footnote 3} For example, early communication to the public of a potential influenza outbreak and the personal protective measures that can be taken will give health authorities more time to control viral spread and impact. However, some measures may be difficult to sustain because of their secondary impacts.
  • Given the geographic breadth of the country and the specifics of the pandemic epidemiology, it is likely that public health authorities will implement measures at different times across Canada. Overall pandemic severity and local conditions will inform the choice and timing of measures^{Footnote 4}; however, the triggers for such actions, the rationale(s) for their implementation, and clear communication to the public should remain consistent.
  • For case and contact management to be most effective, follow-up of suspected or confirmed cases is recommended when the first few hundred cases occur in Canada. When data are collected from investigation and follow-up of these initial cases, the focus should shift away from individual management towards public education in order to reinforce individual and community measures.
  • Decisions around when and if to initiate or discontinue a specific public health measure should consider such factors as the need to prevent case resurgence, the economic costs or social disruption, and intervention fatigue among the public.
• Public compliance with the measures: Previous pandemic influenza experience indicates that individuals generally comply with personal protective measures (e.g., handwashing and self-isolation) and to a lesser degree with social distancing, particularly at the early stage of a pandemic. However, as more individuals become ill, compliance wanes.^{Footnote 5},^{Footnote 6},^{Footnote 7},^{Footnote 8} Therefore, maintaining public engagement in and compliance with public health measures as the pandemic evolves is an important consideration. See Section 3.5 regarding specific public health measures.
• Layering of public health measures: No single public health measure is adequate to prevent virus transmission. It is more effective to use combinations of measures in a layered approach to reduce virus transmission. Data analysis of the 1918 influenza pandemic shows that early and sustained public health measures over several weeks may have helped to limit mortality, although no single measure could be identified as responsible.^{Footnote 9},^{Footnote 10},^{Footnote 11} In addition to layering of measures, evidence from more recent pandemic events and modelling exercises suggests that combining public health measures with vaccination and targeted antiviral use delays and flattens the pandemic peak stage (see Figure 1).^{Footnote 12},^{Footnote 13}
• Scalability, flexibility and proportionality: Lessons learned from the 2009 influenza pandemic included the importance of scaling the public health measures response to the associated risk of disease. In addition, public health measures need to be flexible to accommodate different settings, potentially over many months. Finally, the choice of measures should be proportionate to the pandemic's severity and the transmissibility of the novel virus. To help guide decisions about the scale of the local public health measures response, public health jurisdictions would ideally have access to epidemiological data so that they can calculate attack rates, hospital and intensive care unit admission, and mortality associated with the novel virus. However, it is important to note that, during the 2009 pandemic, it was difficult to obtain such data at the initial and early stages; and this may not be an atypical experience for jurisdictions trying to contain the virus at the source in any future pandemic.^{Footnote 14} The Surveillance Annex describes an approach to collecting additional information that may be required during the pandemic, built on existing surveillance systems for seasonal influenza.

2.2 Uncertainties and Unpredictability

Public health measures will play a significant role during a pandemic, especially before a vaccine becomes available. Aligned with the CPIP's risk management approach is the need for planners to be aware of the uncertainties associated with the use of public health measures during a pandemic.

In addition to the areas of uncertainty outlined in the CPIP main body (i.e., when and where a pandemic will occur, nature of spread, the virus's characteristics), specific uncertainties are associated with the selection and timing of the implementation of public health measures. They include:

• Effectiveness of measures – In general, public health measures for communicable disease control are now studied and reported in the scientific literature more regularly. However, many of the studies are not of high quality, making it difficult to draw conclusions; therefore, expert opinion continues to inform recommendations about public health measures where there is a lack of scientific efficacy and effectiveness data.
• Selection of appropriate measures – Public health authorities will have to judge what measures are most appropriate when working under the condition of scientific uncertainty and public pressure to "do something."
• Public acceptance and adoption of measures – Key to the success of public health measures is public adherence to them. To comply with a measure, the public needs to understand not only how to perform the measure properly, but also the rationale behind the measure's implementation. Therefore, comprehensive public messaging about how and why specific measures are being implemented is critical to their adoption during an evolving pandemic. The Communication and Stakeholder Liaison Annex provides a strategic approach to risk communications during a pandemic.
• Assessment of potential societal and economic consequences of selected measures – Public health measures do not take place in a vacuum. When choosing and implementing measures, public health authorities will have to account for a variety of societal and economic realities within their communities, realities that may be adversely affected by any given measure. For example, closing schools may delay the transmission of a novel influenza virus but will have significant consequences for certain groups, such as single parents and caregivers, children who participate in school-based nutrition programs, families who cannot afford increased child care costs, and parents without flexible work arrangements or paid leave benefits.

2.3 Lessons Learned from the 2009 H1N1 Pandemic

Following the 2009 pandemic, FPT governments and other expert stakeholder groups reviewed Canada's H1N1 response efforts, including guidance documents that were produced by the health portfolio on a variety of public health measures, such as hand hygiene and respiratory etiquette for various settings (e.g., home, schools, summer camps, daycares). Those reviews produced valuable lessons learned about the type, use and impacts of public health measures and will be used to inform future pandemic planning.

2.3.1 Programmatic Lessons Learned

Many of the lessons learned that were related to planning and implementation of public health measures have been incorporated into this Annex, such as:

• Public health measures should be chosen according to the pandemic's anticipated impact and should be implemented early in a targeted and layered manner to be most effective.
• The public health benefits of any given measure must be weighed against the economic and social costs of its implementation.
• General public health measures and principles applicable to any pandemic influenza event (e.g., hand hygiene, self-monitoring, staying home when ill, environmental cleaning) are key, and the rationales for implementing them must be clear and consistently communicated to the public and updated as the situation evolves.
• Local public health authorities must provide specific, in-depth guidance to non-health sectors on when and if they need to take specific actions to reduce the spread of the virus (e.g., closing schools, delaying mass gatherings) and when to stop or scale back these actions.
• Preparedness and response activities must be tailored for remote and isolated communities to address issues such as: their limited access to health care workers and supplies; the distance required to travel to hospital for acute care; the overall difficulty in gaining timely access to a full complement of health care services; high rates of pregnancy; overcrowding; and, in some communities, limited access to running water for hand hygiene.^{Footnote 15}
• Widespread restrictions of movement to contain or slow an emerging pandemic are impractical, if not impossible, to implement.
• To achieve a flexible response that will serve a variety of settings and populations, public health measures must be implemented at the right time and tailored to the specific setting and population.
  • Specific settings that may require unique considerations or guidance include:
    • workplaces;
    • residential facilities (retirement homes, group homes);
    • correctional facilities;
    • schools, daycares, post-secondary institutions and camps (e.g., children's summer camps, work camps);
    • shelters, drop-in centres and other settings with transient populations;
    • mass gatherings (concerts, sporting events, large meetings and conferences);
    • conveyances (aircraft, passenger trains, ferries, buses, cruise ships) and transit terminals; and
    • remote and isolated communities.
  • Populations that may require unique considerations, guidance or tailored approaches include:
    • populations with vulnerabilities such as isolation, poverty, etc. (see CPIP, Section 2.4);
    • essential service workers (e.g., police, firefighters, paramedics); and
    • employees involved in pandemic response activities.

  Following the H1N1 pandemic, detailed influenza-specific pandemic planning guidance was developed to address vulnerabilities of populations in Canada. Some of the challenges related to implementation of public health measures included implementing social distancing due to lack of space, and difficulty in accessing sufficient supplies of masks and gloves.^{Footnote 16},^{Footnote 17},^{Footnote 18}

  2.3.2 Scientific Findings

  Public health measures studies conducted during and after the 2009 influenza pandemic produced many key findings that have informed Canada's public health measures strategy and are further discussed in Section 3.5. The key findings include:

  • Masks worn by ill individuals may protect uninfected individuals from virus transmission, but little evidence exists that mask use by well individuals avoids infection.^{Footnote 19},^{Footnote 20}
  • The combination of good hand hygiene and early initiation of mask use by ill individuals reduced influenza transmission within households^{Footnote 21},^{Footnote 22} and among university students in residence.^{Footnote 23},^{Footnote 24}
  • A growing body of evidence indicates that pre-emptive school closures can help prevent or reduce the spread of influenza,^{Footnote 25},^{Footnote 26},^{Footnote 27},^{Footnote 28},^{Footnote 29} but the extent of the social and economic impacts of school closures in a pandemic of mild to moderate severity is not yet known.^{Footnote 30},^{Footnote 31}
  • International border entry screening is ineffective, largely because of limited sensitivity in detecting all cases. At best, it can delay local epidemics by only a few weeks.^{Footnote 32},^{Footnote 33Footnote 34},^{Footnote 35},^{Footnote 36} Border departure screening has a higher reported effectiveness, which seems to be related to the reduced numbers of infected passengers on board the conveyance and the consequent decreased transmission.^{Footnote 37},^{Footnote 38}

  More details on Canada's lessons learned from the 2009 influenza pandemic can be found in the reports from the Government of Canada and the Standing Senate Committee on Social Affairs, Science and Technology (PDF: 464.67, 70 pages).^{Footnote 39},^{Footnote 40}

  2.4 Program Delivery in the Canadian Context

  The responsibility and legislative authority for implementing the majority of public health measures belong to the relevant PTs and local public health authorities, with the exception of international border and travel-related issues, for which the federal government is responsible.

  The Canadian Armed Forces Health Services is responsible for implementing public health measures on all Canadian Forces establishments, bases, wings and stations across Canada and for Canadian Armed Forces personnel deployed abroad. Indigenous Services Canada provides health services to Indigenous communities and develops context-specific guidance for them while also encouraging the inclusion of Indigenous considerations in on-reserve First Nations communities to align and to be integrated with the provincial public health authority planning. In addition, there is ongoing federal responsibility for the provision of health services and advice on any public health measures aligned to other specific federal populations (e.g., Global Affairs Canada to missions abroad, Correctional Services Canada to federal inmates). The planning guidance for the health sector provided in the CPIP main body (Section 3.4.2) and throughout this Annex also applies to these federal departments or agencies.

  2.4.1 Understanding Canada's Diversity

  Canada is diverse in terms of language, religious beliefs, ethnicity, culture and lifestyle. Many public health measures used during a pandemic will be modifications of existing practices for seasonal influenza and will therefore be familiar to public health jurisdictions and the public. Nevertheless, there may be individuals in any community whose needs are not being fully addressed by standard services, or these individuals may not be able to access and use resources, making them more vulnerable to infection or complications of influenza during a pandemic (e.g., those who are physically or mentally disabled, homeless or street involved, housebound or frail seniors, socially isolated, new immigrants, refugees, and persons who do not speak English or French). These groups will need special consideration to support their adoption of recommended public health measures.

  It will also be important to consider the circumstances of individuals living in remote and isolated communities in Canada because such circumstances may make them more susceptible to infection and complications of influenza in an influenza pandemic. These include social, environmental and economic factors, including the state of their housing, water, food security, personal health, education and income, in addition to limited access to health care services due to lack of health care professionals and geographical considerations. It will be important for planners to take these circumstances into account when planning for the implementation of public health measures in a pandemic.^{Footnote 41} Appendix B provides more pandemic planning considerations for remote and isolated communities.

  It was anecdotally reported that, during the 1918-19 Spanish influenza pandemic, small villages in Alaska that stringently restricted movement in and out of the village remained free of influenza. During the 2009 pandemic, some remote and isolated communities experienced early and intense outbreaks. In response, a task group was formed to provide technical advice on the public health pandemic response and delivery of health services in remote and isolated communities. Local planners should consider ways to leverage the potential for pandemic delay in isolated communities, for example by engaging the residents in the planning process to explore their potential support for early measures. These measures must be evaluated carefully in the context of the pandemic impact, potential benefit and social acceptability.

  The main body of the CPIP (Section 2.4) further discusses the planning considerations related to the Canadian context.

  2.5 Ethical Considerations

  The ethical principles set out in the main body of the CPIP (Section 2.5) – trust and solidarity, reciprocity, stewardship, equity and fairness – inform decision-making for implementing the public health measures strategy. Ethical decision-making also involves openness and transparency, accountability, inclusiveness and reasonableness.

  These principles should guide all decision-making around the selection and implementation of public health measures in an influenza pandemic, including those situations in which information is limited. As noted in the CPIP Communications and Stakeholder Liaison Annex, jurisdictions need to communicate proactively with the public, even when gaps in scientific evidence exist or information is limited, to help ensure the public's trust in those managing the pandemic response.

  Several aspects of the public health measures strategy have specific ethical considerations, including the need to:

  • Balance respect for individual freedoms with the duty to protect the population's health, especially when deploying more restrictive measures (i.e., adhere to the guiding principles of proportionality and flexibility as well as the ethical concept of reciprocity).
  • Aim for an equitable distribution of public health resources, benefits and burdens for all groups, including remote and isolated communities and other individuals identified in Section 2.4, whose circumstances require special consideration to support the adoption of recommended public health measures. If these circumstances result in a distribution of resources that is not equitable, a clear and transparent rationale should be provided to explain the decision-making process.
  • Inform the public about the rationale for implementing individual and community-based restrictions to mitigate influenza transmission.

  2.6 Legal Considerations

  The authority to implement public health measures in a pandemic may lie at the federal, provincial/territorial or local public health level, depending on the particular setting and measure. For example, the federal government has authority under the Quarantine Act (2005) to take public health measures to prevent the introduction and spread of communicable disease at Canada's international borders. PT and local governments also have authority for certain public health measures and health emergency management activities under their respective legislation.

  In addition, the International Health Regulations (IHR), which aim to prevent the international spread of disease while limiting interference with international traffic and trade, establish processes to be followed by Member States, including Canada, when responding to a public health emergency of international concern. Therefore, a collaborative and co-ordinated approach that includes all levels of government and awareness of obligations under the IHR is essential, both when identifying gaps in the ability to undertake certain public health measures and when measures are actually implemented during a pandemic.

  3.0 Canada's Pandemic Public Health Measures Strategy

  3.1 Objectives

  The public health measures strategy supports Canada's goals for pandemic preparedness and response:

  First, to minimize serious illness and overall deaths, and second, to minimize societal disruption among Canadians as a result of an influenza pandemic

  The specific objectives of the public health measures strategy are:

  • To reduce the overall transmission and slow the rate of transmission of the novel or pandemic virus, thus lowering the total number of severely ill cases and deaths and delaying the accumulation of cases.

  • To reduce peak demands on health care institutions, thereby protecting to the greatest extent possible against societal disruption and the overwhelming of community services, and buying time before an effective vaccine is produced.

  The epidemiologic curve below illustrates the goal of flattening and delaying the peak of the epidemic by implementing public health measures to reduce and slow transmission of a novel influenza virus.

3.2 Guiding Principles and Approaches

All principles underpinning Canadian pandemic preparedness and response activities and decision-making (see CPIP main body, Section 3.2) apply to the public health measures strategy, especially:

• Collaboration – All levels of government as well as health care stakeholders need to work together to help ensure that individuals and communities understand and adopt public health measures.
• Evidence-informed decision-making – Decisions related to public health measures should be based on the best available evidence.
• A precautionary or protective approach – Public health measures are implemented in a timely manner and include reasonable preventive actions that are proportional to the threat. This principle is particularly important in the pandemic's early stage, when evidence-informed decision-making is challenged by a lack of data.
• Proportionality – Public health measures should be appropriate to the level of the threat and tailored to the anticipated pandemic impact and local situation.
• Flexibility – Public health measures are local by nature and subject to change as new information arises. Thus, flexibility will likely be needed when scaling and timing interventions to reflect local conditions.
• Use of established practices and systems to the extent possible – Effective seasonal influenza activities support a strong pandemic response, as these well-practiced public health measures can be rapidly ramped up to manage the pandemic.
• Ethical decision-making– When implementing, communicating and managing public health measures, decision-makers must always balance collective versus individual rights, interests and values. This aspect of decision-making is discussed in more detail in Section 2.5.

3.3 Public Health Measures – Specific Assumptions

Identifying assumptions is a way to deal with uncertainty and provide a useful framework for planning. However, while rooted in evidence as much as possible, assumptions should not be regarded aspredictions. As the pandemic unfolds, new and emerging evidence will be incorporated to guide the response.

Informing the planning assumptions identified below are the WHO's Pandemic Influenza Risk Management guidance^{Footnote 42}, the UK's Scientific Summary of Pandemic Influenza & Its Mitigation ^{Footnote 43} and discussions from the Canadian Pandemic Influenza Preparedness Planning Assumptions Workshop held in 2011. The CPIP main body contains a number of assumptions related to a pandemic that are particularly relevant to the public health measures context:

• The pandemic virus will behave like seasonal influenza viruses in significant ways:
  • incubation period – expected to last from 1-3 days;
  • period of communicability – adults are infectious from 24 hours before and up to 5 days from the onset of symptoms, and children may be infectious for up to 7 days. Longer periods have been found, especially in persons with immune compromising conditions;
  • methods of transmission – mainly by large droplet and contact (direct and indirect) routes; the role of airborne transmission is unclear and unproven.
• Most communities will experience two or more pandemic waves of different magnitudes. In any locality, the length of each wave will be from several weeks to a few months but may vary by community.
• There will be geographic variability with regard to the timing and intensity of waves, although some jurisdictions will be affected simultaneously.
• The pandemic impact will vary across communities, and some members of the public may be affected more severely than others.
• In addition to workers' illness, workplace absenteeism may be higher than the estimated clinical attack rate because of caregiving or concern about personal safety in the workplace.
• Vaccine is expected to be available in time to have an impact on the overall pandemic but is unlikely to be available for the first wave. Given current technology, it will take four to six months for vaccine to become available. The earlier the vaccine is available, the greater its impact on the pandemic.
• Individual personal protective measures are expected to help reduce transmission between individuals and within households and other settings.
• Impact will vary across communities, and vulnerable populations are expected to be affected more severely.

There are additional assumptions specific to the public health measures response:

• Public health measures will be the primary means for slowing down transmission in the early stages of a pandemic. Should resistance to antivirals occur, public health measures will become even more important.
• The pandemic will evolve over time, requiring flexibility and scalability in terms of public health measure responses (see Section 3.6).
• Decision-makers will need to establish triggers to indicate when to scale up and scale down public health measures within their response strategy, and these may vary across the country.
• Canadians will seek information or public health advice, requiring effective communications strategies.
• Public acceptance of restrictive control measures will correlate with the process used to arrive at these decisions, the transparency and inclusiveness of the process, the articulation of explicit and transparent rationales for measures, and the public's perception of risk.

3.4 Pandemic Roles and Responsibilities

The public health measures strategy requires a collaborative approach with clearly defined roles and responsibilities. This section focuses on FPT government responsibilities, although it is recognized that local public health authorities may have a role in the activities listed under PT responsibilities.

The roles and responsibilities for the pandemic public health measures strategy (Table 1) are adapted from those set out in the CPIP main body, Section 3.4.2. Note that some roles and responsibilities, such as FPT decision-making processes, are beyond the scope of this annex.

It is also acknowledged that other partners play important roles in a pandemic with respect to public health measures, such as sharing credible information, supporting new and flexible policies and in the area of communications. These partners include the private sector (e.g., workplaces), NGOs, municipalities and international organizations.

4.0 Integration with other Response Components

This section demonstrates the way in which certain response elements (Surveillance and Communications) are essential to the effective implementation of public health measures in a pandemic. Other response components, such as Vaccines and Antivirals, play a complementary role, as indicated where relevant in this Annex.

4.1 Surveillance

Timely surveillance information is needed for public health measures decision-making. PHAC collates and analyzes surveillance information from across Canada and other countries to produce risk assessments and provide decision-makers with timely and relevant surveillance data.
Surveillance information required for public health measures decision-making includes the following:

• indicators of transmissibility and severity of clinical disease;
• rates of illness, severe disease and death by age and risk groups and risk of severe disease in those affected;
• risk factors for severe illness, hospitalization and death (including settings with increased risk); and
• proportion of severe disease in persons with and without underlying health conditions.

For further details on surveillance during a pandemic, see the CPIP Surveillance Annex.

4.2 Communications and Stakeholder Liaison

The imperative for effective communications and the strategic engagement of key stakeholders is an integral element of all CPIP annexes and the planning guidance they provide. Communications must build and maintain the trust and confidence of the public and other stakeholders by providing clear, concise, consistent, realistic and timely information.

Key goals of public health measure communication include:

• Informing the public of the disease (symptoms and signs, how it is transmitted);
• Providing guidance on appropriate responses, including:
  • hand hygiene and respiratory etiquette;
  • what to do should people become ill (e.g., when to present to health care providers); and
  • when to defer travel if unwell.
• Addressing public concerns (giving an accurate assessment of risk while acknowledging uncertainty and reassuring the public).

The planners of public health measures response strategies should consult the CPIP Communications and Stakeholder Liaison Annex in conjunction with this Annex, especially for the public education aspects of public health measures. It provides planning guidance on how to address the information needs of the public; describes factors that support public acceptability and compliance; and contains information about educating key stakeholders and intermediaries whose perceptions of the pandemic response may influence public opinion. Of special note is the guidance provided on communicating to the public about risks, the evolving nature of the pandemic and the subsequent need for public health measures to change over the course of the event.

5.0 Research Needs

Research plays a key role in pandemic preparedness and response. Although additional research has been undertaken since the 2009 pandemic to build an evidence base for a public health measures response to pandemic influenza, more research is needed on the effectiveness of public health measures, the choice and timing of implementation and the potential for unintended secondary consequences. While some research questions can be carried out during the interpandemic period, others will need to be conducted during a pandemic; therefore, it is important to plan in advance for a rapid research response. Putting in place and sustaining an infrastructure during the interpandemic period is the best way to ensure that timely research can be conducted during a pandemic.

As research resources are limited across jurisdictions, it is critical that research topics related to pandemic public health measures be periodically reviewed and prioritized. In addition, periodic review has the potential to reduce duplication of research efforts and to find means to collaborate on a given initiative. If possible, consideration should be given to sharing pre-publication research results of importance with other jurisdictions (i.e., results that may impact the efficacy of public health measures). The research needs outlined below have been identified as interpandemic (I) or pandemic (P), depending on when the research is required. They include:

5.1 Individual Measures

• How do increased frequency and quality of hand hygiene affect influenza virus transmission in the community setting? (I) (P)
  • Are hand sanitizers as effective as hand washing with soap and water?
  • What is the effect of the combined use of respiratory etiquette and hand hygiene?
• What educational activities are most effective for changing behaviours and improving compliance for hand hygiene and respiratory etiquette across population groups? (I) (P)
• What social media tools are most effective for disseminating public education messages about individual and community-based measures to prevent influenza transmission? (I)
• What situations call for increased surface cleaning in various settings (e.g., households or schools with confirmed influenza cases)? (I)
• What is the effectiveness of individual measures (e.g., hand hygiene, respiratory etiquette, use of masks) in preventing transmission of the pandemic influenza virus? (P)

5.2 Community-Based Measures

• How do school policies for hand hygiene and availability of soap and water influence hand-washing behaviours in school-aged children? (I)
• How do various types of face masks, weather conditions (e.g., humidity and temperature) and social or behavioural factors influence the effectiveness of face masks in preventing influenza transmission? (I)
• What are the optimal triggers (e.g., number of cases, transmissibility of the virus, severity of influenza) for recommending mask use among ill individuals and well individuals in community settings? (I) (P)
• What are the effectiveness, timing and optimal implementation of school closures, other social distancing measures and environmental control methods in specific settings? (P)
• What are the secondary consequences (e.g., missed work) of community-level measures (e.g., school closures, cancellation of mass gathering events) that have direct economic effects for families and communities? What is the magnitude of the impact, and does it make these measures unfeasible? What is the impact of these secondary consequences on community living settings (e.g., group homes and retirement homes)? (P)
• How can the transmission be slowed in circumstances that need to be continued during waves, such as public transportation and other essential services? (I) (P)
• What factors influence the public acceptability of, and adherence to, community-based measures? (P)
• What is the level of compliance with public health measures in a pandemic and the impact of intervention fatigue? (P) What is the effectiveness of public health measures in mitigating pandemic impact (e.g., effect on virus transmission, hospitalizations, deaths)? (P)

5.3 Special Considerations

• How is viral transmission affected by social structures and behaviours (e.g., population density, living conditions, social interactions)? (P)
• What are the transmission dynamics among populations whose circumstances (e.g., low income, homelessness, remote and isolated communities) may increase their susceptibility to infection and/or complications of pandemic influenza? (P)
• Are there additional factors besides universal susceptibility that allow the rapid spread of the virus in the first wave? (P)

6.0 Assessment and Evaluation of Public Health Measures Preparedness and Response

An evolving pandemic can be volatile as, for example, disease characteristics shift or resulting social disruptions complicate efforts to implement and manage public health measures. Planners need to design an evaluation program that is flexible enough to work under conditions of considerably greater uncertainty than other contexts that require evaluation.

This task poses considerable challenges. Public health measures planners must develop an agile strategy for evaluating such measures, both during and after a pandemic response. There is a duty to collect data that can be used to conduct an evaluation for purposes of identifying optimal public health measure implementation, maintenance and discontinuation. Therefore, PTs and local public health authorities need to work together to identify upfront what data to collect during a pandemic.

Forward planning for evaluation will establish the protocols and priorities that can facilitate any needed changes in direction during the pandemic, as well as facilitate an overall after-action evaluation of the response in order to identify lessons learned and best practices. In addition, evaluation activities should be identified for different pandemic scenarios.

Evaluation activities may be more successful if they are co-ordinated to ensure that selected sites examine specific issues, thus potentially reducing duplication of effort and the need for all sites to participate. This approach may improve the acceptability of evaluation activities among health authorities in jurisdictions that are still recovering from the pandemic.

Areas to evaluate include:

• Type and degree of public health measures implementation;
• Differences in approaches to implementation of public health measures within and between PTs;
• Resource availability (e.g., personnel, masks);
• Impact of pandemic on provision of other public health services;
• Secondary or unintended consequences of public health measures and the effectiveness of strategies to mitigate them, including impact on community living settings, such as group homes and retirement homes;
• Accuracy and timeliness of guidance provided; and
• Information gaps.

Appendix B: Guidance for Remote and Isolated (RI) Communities^{Footnote 134}

Considerations for people living in RI communities

The overall health of Canadians living in remote and isolated communities can be affected by social, environmental and economic factors, including housing, water, food security, personal health, education and income. These factors, in addition to limited access to health care, are important to take into account when planning for, and responding to, pandemic influenza in remote and isolated communities.

The social circumstances and needs of people living in RI communities may differ when compared to the general Canadian population in the following ways:

• Housing: There are typically higher rates of overcrowding, and housing standards are often below adequacy and suitability standards. This is of concern because overcrowded and inadequate housing conditions contribute to increased likelihood of transmission of communicable diseases (e.g., influenza, TB).
• Water: There is frequently a lack of adequate quantity and quality of water. This is of concern because of the importance of effective hand washing for infection prevention and control.
• Food Security: Access to affordable, nutritious food is often a challenge, especially because of the increased costs associated with the logistics of transporting fresh produce. This is of concern because food insecurity compromises the overall health and resiliency of affected people.
• Personal Health: The proportion of people with pre-existing chronic health conditions, such as asthma and diabetes, is significantly higher. This is of concern because of the evidence of increased severity of influenza in groups with chronic medical conditions.
• Education: The proportion of people with high school or post-secondary education tends to be significantly lower. This is of concern in designing public communications/education campaigns (e.g., literacy, use of pictorial or visual messaging) that people will understand.
• Income: The overall unemployment rate is significantly higher, and the annual income is significantly lower. This is of concern because health, morbidity and mortality follow a social and economic gradient, and availability of income is a practical consideration with respect to stockpiling food and supplies, access to transportation options, etc.
• Access to health care: Communities may have challenges in accessing health care due to a lack of health care workers and extreme weather conditions. This is of concern because prompt access to health care will be essential in a pandemic.
• Culture: Cultural practices include a community and family-centred approach to health (e.g., multiple family members attending medical appointments or providing care for sick household members, high respect for elders). These practices will need to be considered when planning health care services for communities.

Public Health Measures in RI Communities

RI communities are at risk of influenza outbreaks due to multiple predisposing factors for transmission. In these settings, it is important to minimize the impact of possible rapid spread. It is recommended that early outbreak investigation and management be considered in consultation with the local public health unit.

Challenges and potential strategies for implementing community-based public health measures are listed below:

RI Challenge: Lack of availability of non-medical supplies

Delivery and transportation of non-medical supplies (e.g., soap, food, household items) in RI communities can be challenging due to limited transportation, possible illness in the household and other factors, such as inclement weather.
Strategies for public health planners to consider:

• Encourage and increase the awareness of individuals, families and communities of the need to have a surge of essential supplies (e.g., soap, household cleaning products, non-perishable food and fluids, tissues) in order to meet their needs.

RI Challenge: Limited access to running water

Some RI communities have limited access to running water or clean running water for hand hygiene.
Strategies for public health planners to consider:

• Increase the awareness of individuals and families in RI communities vis-à-vis alternative means for effective hand hygiene if they lack clean running water. Consider treating available water (e.g., boiling for one minute with chemicals, such as chlorine bleach), using two separate containers for their water (e.g., pail, bowl) and moving hands around to mimic running water Alternatively, alcohol-based hand sanitizer may be used for hand hygiene. However, if hands are visibly soiled, hand wipes should be used to remove any such soil or organic material; this should then be followed by the use of hand sanitizer.

RI Challenge: Public gatherings

The potential for spread of infection during public gatherings may put undue strain on already limited resources in RI communities.
Strategies for public health planners to consider:

• Consider the presence of ILI activity as well as the availability of health care providers, basic medical supplies, medications, isolation beds or rooms, etc. when considering the postponement of public gatherings.

RI Challenge: Impact of school closures

School closures in RI areas may have a significant impact on a community. Given limited qualified substitute staff in the community, the school may not be able to implement a business continuity cycle if there is a high attack rate. Hence, the school closure may be longer than in urban communities.

Strategies for public health planners to consider:

• Communities considering school closures should consult with local public health authorities and follow various school guidelines.
• Actively involve schools in surveillance to identify cases before an outbreak occurs.
• Communities develop a business continuity plan for each school which would include a list of human resources.

RI Challenge: Potential lack of tailored public health awareness campaigns

RI communities may be less exposed to public health awareness campaigns than urban communities. In addition, the messaging that RI communities receive is often not suited or tailored to the circumstances (e.g., limited water, limited accessibility to supplies) in these communities, or consideration may not be given to health literacy, language barriers and limited access to telecommunications, including basic phone and internet).

Strategies for public health planners to consider:

• Identify communities where tailored communication strategies are required given the local circumstances. Tailored strategies could include: mail-outs, community radio, posters, door-to-door messaging and community meetings. Tailoring may also include messaging from people who are familiar or trusted (e.g., Indigenous elders or physicians).
• Develop and communicate campaigns that are specifically tailored to the circumstances of RI communities.