# Presentation: 526706

## Pandemic Influenza Preparedness in Canada

- Arlene King, MD, MHSc, FRCPC
- Director, Immunization and Respiratory Infections Division, Federal Chair, Pandemic Influenza Committee

## Outline

- Evolution of Canadian Pandemic Influenza Plan
- How the Plan was used during the H5N1 (2003) and SARS responses
- How the Plan has been modified
- Key challenges, successes and general lessons learned from SARS
- Current status of the Plan and next steps

## Pandemic Planning in Canada

- 1988:  First draft plan (planning began in 1983)
- 1996:  Second draft plan
- 1997:  Lessons from Hong Kong “bird flu” incident
- 1998-2000:  Federal-provincial-territorial (F/P/T)				planning process began
- 2000/2001:  Two national planning meetings and working groups 	established
- 2001:  F/P/T Working Agreement accepted
- 			by all provinces and territories

## Pandemic Planning in Canada - II

- 2001:  Multiyear vaccine contracts and pandemic 	contract signed
- 2002:  Pandemic Influenza Committee (PIC) 	established
- 07/2003-01/2004:  Lessons from SARS incorporated
- 2003 Dec 12:  Canadian Pandemic Influenza Plan 	approved by Deputy Ministers of Health
- 2004 Feb 12:  Public release of the Plan

**www.hc-sc.gc.ca/pphb-dgspsp/cpip-pclcpi/**

## Slide 5

## Slide 6

## Pandemic Influenza Committee (PIC)

- Established under F/P/T working agreement
- Federal and provincial co-chairs
- 18 voting members, including all provinces/territories
- Provides technical advice for annual and pandemic influenza prevention and control
- Provides overall guidance on the Plan

## PIC - II 

- First meeting, March 2002, followed by regular teleconferences and face-to-face meetings in Nov 2002 and Sept 2003
- November 2002 PIC Meeting
- Discussion/reformulation of goal and objectives
- Review of Preparedness Section and Annexes
- Review of draft Response Section

## PIC - III

- January/February 2003
- Preparedness Section and Annexes updated based on meeting and consultation feedback
- Plan re-structured to include:
- Introduction
- Background
- Preparedness Section
- Response Section
- Plan posted on password protected website ...

## March to July 2003...

## PIC          “F/P/T SARS”

- “F/P/T SARS:”  PIC, Council of Chief Medical Officers of Health, Canadian Medical Association, Canadian Public Health Laboratory Network
- Working Groups
- Surveillance
- Laboratory Issues
- Clinical Issues
- Infection Control
- Public Health Measures
- F/P/T Communications Network

## www.sars.gc.ca

- Single reference for information, tools and guidelines
- for health professionals
- for public and media

## Key Challenges

- Public health infrastructure:  Human resources, data management capacity, policies, procedures and legislation to support public health action at all levels
- Information generation (real time epidemiology and rapid implementation of applied research)
- Information sharing (competing priorities, academic versus public health)
- Evidence-based decision making

## Key Successes

- Pandemic influenza structures and processes as template for the SARS response
- Early phases of the national pandemic influenza response have been tested and applied to another emerging infectious disease
- Lessons learned incorporated into the Plan
- Disease control measures, despite uncertainties, were effective

## Key Successes - II

- F/P/T communications network
- International and national laboratory networks (etiologic and genomic work and diagnostic test development)
- Other permanent partnerships in disease control, both nationally and internationally

## Lessons Learned: General

- Team work is essential
- Plan for **dedicated leadership** that will not be pulled away to deal with other issues
- Plan staffing to allow time off but for continuity of response activities (eg, rotating shifts)
- Plan to support your staff/responders (provide meals, off hours transportation, child care, etc)

## Lessons Learned: General - II

- Develop generic communicable disease emergency plans
- Need a “think tank” team that is not directly involved in the response
- Response team components should include:
- Coordination and operations (with int’l liaison);  Technical (surv, epi, etc);  Logistics;  Communications;  Think Tank

## Additional Lessons Learned from  Human and Avian Influenza

- Every new emergency provides an opportunity to strengthen pandemic influenza (and emerging infectious disease preparedness) ... eg, Fujian (H3N2), Avian influenza (H5N1), Asia ... and now, Avian influenza (H7N3), Canada ...
- Strengthen real time surveillance of morbidity and mortality due to influenza
- Develop capacity to do vaccine effectiveness studies

## Additional Lessons Learned from Human and Avian Influenza - II

- Zoonotic diseases can and will cross the species barrier and cause illness in humans
- Forge ties with those responsible for non-human animal disease surveillance and response
- Those managing epizootics may be the index cases of the next emerging infectious disease
- Occupational health and safety personnel are allies in your public health response

## Canadian Pandemic Influenza Plan

- Based on nationally agreed upon goal
- Organized into components (framework for national working group activities)
- Uses WHO Pandemic Phases
*National* plan, outlines roles and responsibilities of all levels of government
- Model for national emergency response plans
- Contains checklists and technical annexes
- Dynamic or “evergreen” document

## Goal of Influenza Pandemic Planning 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*

## Overview of the Plan

- Executive Summary
- Overview
- List of Annexes

_**I. INTRODUCTION**_
- Goal of Influenza Pandemic Preparedness and Response
- Overview of the Canadian Pandemic Influenza Plan
- Roles and Responsibilities
- The Pandemic Influenza Committee
- The Pre-Pandemic Period
- The Pandemic Period
- The Post-Pandemic Period

_**II. BACKGROUND**_
- Epidemiology of Pandemic Influenza
- Estimated Impact of an Influenza Pandemic on Canadians
- Terminology
- Pandemic Phases
- List of Abbreviations
- Legal Issues
- Ethical Issues

_**III. PREPAREDNESS SECTION**_
- Introduction  (to Preparedness Section)
- Components of the Preparedness Section
- Surveillance
- Vaccine Programs
- Antivirals
- Health Services Emergency Planning
- Emergency Services
- Public Health Measures
- Communications
- Planning Activities by Components
- Pandemic Planning Checklists

_**IV. RESPONSE SECTION**_
- Introduction (to Response Section)
- Phased Approach
- Experience to Date
- Key Response Activities by Pandemic Phase

_**V. RECOVERY SECTION**_
*Currently in development*

_**ANNEXES**_
- See “List of Annexes”

**Each section for FPT audience**
**Consistent terminology/approach**
**  ****throughout**
**Tools: checklists, technical annexes**

**Released **
**February 12, 2004**

## II. BACKGROUND

- Epidemiology of Pandemic Influenza
- Estimated Impact of an Influenza Pandemic on Canadians
- Terminology
- Pandemic Phases
- List of Abbreviations
- Legal Issues
- Ethical Issues

- NEW!

- NEW!

- Refer to consultant’s documents

## III. PREPAREDNESS SECTION

- Introduction  (to Preparedness Section)
- Components of the Preparedness Section
- Surveillance
- Vaccine Programs
- Antivirals
- Health Services Emergency Planning
- Emergency Services
- Public Health Measures
- Communications
- Planning Activities by Components
- Pandemic Planning Checklists

- NEW!

- Includes:
-  Description
- Objectives
- Current Status
- Outstanding issues
- Planning principles & assumptions

## IV. RESPONSE SECTION

- Introduction (to Response Section)
- Phased Approach
- Experience to Date
- Key Response Activities by Pandemic Phase

- NEW!

- Includes:
-  series of tables (one table per Pandemic Phase/Level)
-  “Focus”, “Actions”, “Response Level” for each component

- Including SARS

**Notes:**
Geared toward an FPT audience

## The Plan:  Current Activities

- Using pandemic influenza structures and processes to define Canada’s response to Avian Influenza (Phase 0.2)
- “Management of Human Health Issues related to Domestic Avian Influenza Outbreaks”

## The Plan: Current Activities - II

- Finalize and post new Annexes (2004)
- First Nations
- Public Health Measures
- Surveillance
- Completion of antiviral drug strategy (2004)
- Testing domestic vaccine production infrastructure, regulatory processes and clinical trial protocols (2004-2005)
- Influenza research agenda (2004)
- Further “exercising” of the Plan
- Completing the Recovery Section

## “The only thing more 		difficult than planning for 	an emergency is having to 	explain why you didn’t.”

## Feuille d’érable et globe

**Feuille d’érable et globe**
- Cette feuille d’érable stylisée nous rappelle qu’il s’agit d’une initiative nationale du Canada. La forme de la feuille fait penser à l’art autochtone — un rappelle de l’impact de la maladie sur le monde autochtone.
- Le mouvement de balayage vers l’avant suggère l’élan donné au projet.  Le globe au centre du design place l’initiative dans un contexte international la pandémie ne connaît pas de frontières. Les trois bandes encerclant le globe représentent les trois étapes de l’initiative : avant, pendant et après la pandémie.

**Maple leaf and globe**
- The stylized maple leaf reminds us that this is a national Canadian initiative. The shape of the leaf is reminiscent of aboriginal art—a reminder of the impact of the disease on native peoples.
- The forward, sweeping motion of the leaf suggests the momentum of the project. The globe in the center of the design places the initiative in an international context—pandemics have no boundaries. The three bands on the globe represent the three stages of the initiative: pre-, during, and post-pandemic.

## Vaccine Strategy

- Goal:  to provide sufficient infrastructure and capacity to produce 100% of domestic supply needs in the event of a pandemic (enough vaccine for all Canadians)
- 32 million doses in 16 weeks
- Current capacity 6 million doses per month
- Sufficient egg supply to maintain constant pandemic readiness

## Use of Vaccines in Short Supply

- 1.	Health care workers, including paramedics and public health
- Essential service providers / government leaders
- 3.	Persons at high risk of severe or fatal outcomes
- 		a)	persons in nursing homes and long-term care
- 			facilities
- 	    b)	persons with high-risk medical conditions
- 		c)	persons >65 years
- 		d)	children 6 to 23 months of age
- 		e)	pregnant women
- Healthy adults
- Children 24 months to 18 years old

## Antiviral Strategy

- Options for use and stockpiling
- All available drugs in an emergency
- Neuraminidase inhibitors for stockpile
- Guidelines on use of antivirals in short supply
- Strategies for delivery, administration
- Monitoring of distribution, uptake, wastage
- Monitoring for adverse events and resistance
- Clinical use guidelines

## Planning Guidance forUse of Antivirals in Short Supply

- Treatment of persons hospitalized for influenza
- Treatment of ill health care and emergency services workers
- Treatment of ill high-risk persons in the community
- 4.	Prophylaxis of health care workers
- 5.	Control outbreaks in high-risk residents of institutions (nursing homes and other chronic care facilities)
- 6.	Prophylaxis of essential service workers
- Prophylaxis of high-risk persons hospitalized for illnesses other than influenza
- 8.	Prophylaxis of high-risk persons in the community