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Responding to an Infectious Disease Outbreak: Progress Between SARS and Pandemic Influenza H1N1

 

  1. INTRODUCTION
  2. THE PUBLIC HEALTH SYSTEM IN CANADA
    Local and Provincial/Territorial Roles
    Federal Role
  3. THE IMPACT OF SARS: RESTRUCTURING PUBLIC HEALTH IN CANADA
    Public Health Agency of Canada
    Pan-Canadian Public Health Network
    International Health Regulations
  4. IMPROVEMENTS IN DETECTION AND RESPONSE SINCE SARS
    Detection
    Risk Assessment
    Response
    International Response
  5. MOVING FORWARD
  6. CONCLUSION

 

Editor’s Note

Since its creation in 2004, the Public Health Agency of Canada (the Agency) has taken important steps toward making Canada less vulnerable to the impacts of infectious disease outbreaks. While the challenge is ongoing and work remains, Canada has improved its capacity to prepare for, and respond to, an infectious disease threat of national concern.

The following report gives an historical overview of the progress made by the Agency in effectively addressing infectious disease outbreaks of national concern between 2004 and 2009.  The progress made during this time was informed by the lessons learned from the 2003 SARS outbreak, and contributed greatly to the Agency’s response to the H1N1 influenza pandemic. A lessons-learned review of the H1N1 pandemic response was undertaken and separately documents the Agency’s actions to this outbreak. This review will help inform the Agency’s response to any future pandemic.

Introduction

In 2003, the world was taken off guard by the sudden emergence of an infectious respiratory disease that spread rapidly around the globe. The disease soon became widely known as severe acute respiratory syndrome (SARS), resulting in thousands of cases worldwide, and causing 44 deaths in Canada. SARS was a wake-up call for the international community, demonstrating just how quickly diseases can emerge and spread around the world. 

Since SARS, Canada has worked to augment efforts to rapidly detect and protect Canadians from the public health impact of infectious disease outbreaks. This is an ongoing challenge. According to the World Health Organization (WHO), infectious diseases are emerging more quickly than ever, with the discovery of nearly 40 new diseases that were unknown a generation ago.

Disease epidemics that spread globally and affect populations worldwide, referred to as pandemics, are a cause for great concern among public health professionals and the public alike. Although SARS was not a pandemic, the outbreak demonstrated that events starting abroad can swiftly appear in Canada. The threat of imported diseases has increased, owing to several factors, including increased opportunities for disease emergence due to the effects of globalization, international spread through human migration and international travel and health vulnerabilities related to the aging population in North America.   

Canadians can, and should, take measures to protect themselves against diseases and other public health threats.  Public health officials continue to take steps to further safeguard the population and respond to emerging and ongoing health threats. Local, provincial and territorial public health authorities have all worked to enhance their ability to detect and respond to outbreaks. The Public Health Agency of Canada (the Agency) was created in September 2004 as a key federal initiative to enhance Canada’s ability to mount a coordinated and effective response to infectious disease outbreaks. While local, provincial and territorial authorities have done a lot of work since SARS in strengthening public health preparedness and response including pandemic preparedness, this report focuses on the Agency’s activities that improved Canada’s readiness for a large-scale infectious disease outbreak. It also provides an overview of areas where more work still remains to be done as the Agency moves forward.  

The Public Health System in Canada

Public health is a shared responsibility in Canada. To detect and monitor emerging disease threats, all levels of the public health system (local, provincial, territorial, federal) collect information to track changes in disease trends (surveillance).  Disease trends are also used to monitor the impact of public health prevention and control measures (e.g. immunization, health promotion).  Information collected locally is shared with the province or territory and the Agency as appropriate.  Public health authorities analyze this information to assess the risk to Canadians and issue alerts when there is a threat.

Often described as a “bottom up” system, the initial and ongoing responsibility for investigation and response to public health events, including infectious disease outbreaks, occurs at the local/municipal level. As needed, depending on the severity, complexity, extent and nature of the public health issue, provincial, territorial and federal systems may be engaged to provide assistance and resources as requested and/or required by local authorities and facilities managing the situation.  All levels of government have their own legislation in order to protect their populations.  For example, provincial or territorial Chief Medical Officers of Health can quarantine people within their jurisdiction to limit spread of disease.  Partnerships among all levels of government allow Canada to increase its capacity to prepare and respond to public health events. 

Local and Provincial/Territorial Roles

Local authorities are responsible for providing public health services in Canada.  During a domestic infectious disease outbreak, local public health officials are the front-line public health responders, working with other health care providers.  Their role includes monitoring and detection of health events and carrying out outbreak investigation to identify the source, including laboratory testing if available, isolation and treatment of the sick, and follow-up with close contacts of the sick.  

Outbreaks are also often detected by provincial and territorial public health authorities.  If an outbreak spreads beyond local boundaries or has serious human health implications, the province or territory will assume leadership in coordinating the management of the response.  Provincial and territorial public health authorities also establish standards and guidelines and provide assistance to local authorities, including laboratory services. 

Federal Role

Before an outbreak even occurs, the Agency is involved in the routine detection, monitoring and analysis of national and international trends and spread of infectious disease threats. As diseases and patterns can change, ongoing review is critical.  In 2005, the Agency together with provinces and territories assessed and ranked the top 60 infectious disease threats in Canada according to a set of criteria, including how common, severe, and easily spread the disease is and whether public health interventions are available and needed.   The Agency led the development of national standards for detection and reporting of these infectious diseases, including case definitions and protocols for reporting to allow Canada-wide comparison.  When there is an international effort to control or eliminate a disease (e.g. polio, measles), the Agency is responsible for ensuring that domestic reporting and control measures align with international standards.

While local public health authorities may detect unusual clusters of disease or illness in their communities, the linkage of information at the national level may detect geographically dispersed but related cases (e.g. outbreaks due to a contaminated food item that has been widely distributed). The Agency has also developed mechanisms to monitor other information sources, such as global media and newswires, which can help detect health issues abroad that may potentially have an impact on the health of Canadians. When the Agency detects a potential threat abroad through unofficial information sources, it verifies the information with the WHO and other official government channels. Likewise, Canada contributes to the global picture of disease. For example, we are part of an extensive network that monitors the ever-evolving influenza viruses and their spread around the world.

In managing domestic outbreaks, the federal government may take on an advisory role in addition to monitoring and communicating with provinces and territories.  For example, the federal government may link with national and international experts to provide advice to health care providers on public health measures, laboratory testing and clinical management as well as providing information to the general public and at-risk groups.  When outbreaks involve more than one province or territory, the federal government takes on a leadership role to coordinate the response. At times, outbreaks that are geographically localised can be large (i.e. affect many people) and may overwhelm provincial or territorial resources.  Provinces and territories may then request federal assistance to support or lead the investigation and response. The federal government is also involved when there is potential for spread of the disease into or out of Canada.   

Infectious disease outbreaks are only one type of event that can have an impact on the health of Canadians. That is why the federal government has been working to strengthen Canada’s overall capacity to prepare for and respond to any emergency where the health of the population may be affected, including floods, fire, and other natural or human-caused disasters.  Similar to outbreak response, emergency management uses a “bottom up” approach.  Local authorities prepare and respond to emergencies using local resources and emergency management systems.  When an emergency exceeds local capacity or if it becomes larger in scope, provinces and territories, as well as the federal government may become involved to coordinate and assist, as needed. 

The Impact of SARS: Restructuring Public Health in Canada

The SARS outbreak, while comparatively small in terms of total number of cases, presented a formidable challenge to public health in Canada. In a few short months the global community combined efforts to identify, contain and eradicate a newly emerged virus in human populations. Federal response was required due to the need for coordination and collaboration with multiple Canadian and international partners from diverse disciplines in dealing with this novel disease. The situation was especially challenging given that knowledge was initially limited and constantly evolving, there was no specific treatment and public health measures had to be adjusted based on knowledge collected over time.

Public Health Agency of Canada

Following the SARS outbreak, the federal government convened the National Advisory Committee on SARS and Public Health. In keeping with the recommendations of this committee chaired by Dr. David Naylor, the federal government created the Public Health Agency of Canada in 2004 to provide leadership and action on public health matters such as national disease outbreaks and emergencies. The government also appointed Canada’s first ever Chief Public Health Officer, Dr. David Butler Jones, to be the leading federal voice for public health in Canada. The Public Health Agency of Canada Act External site, which came into force in 2006, gave the Agency the statutory footing required to fulfill its role on behalf of the Minister of Health.

The Agency’s mission is to promote and protect the health of Canadians through leadership, partnership, innovation, and action in public health. To accomplish this, the Agency is focused on promoting health, preventing chronic diseases and injuries, and responding to public health emergencies and infectious disease outbreaks. These activities occur across Canada through the Agency’s headquarters, laboratories, regional offices and deployed staff. 

Since SARS, the Agency has been working to strengthen Canada’s public health capacity including the establishment of the Canadian Public Health Service, which places qualified public health officers where they are most needed (e.g. a local health department, a provincial ministry) to assist with response to both routine and emerging public health needs.  Laboratory liaison technical officers have been placed in several provincial laboratories to increase their capacity. The Agency has also bolstered the number of training positions across Canada, including field epidemiologists (disease investigators) and other scientists. In partnership with the Canadian Institute for Health Research, the Agency is funding 14 academic leaders/champions (Academic Chairs) to help develop the next generation of public health practitioners and researchers.

The Agency has further developed the Skills Online program, based on a defined set of essential public health skills (core competencies) which has helped over 4,600 public health practitioners nationwide increase their skills, knowledge and abilities in public health since its creation in 2002 by Health Canada. The program consists of 10 internet-based modules aimed at public health practitioners at all levels, including modules on surveillance, epidemiology and outbreak management.  Applying the knowledge and skills from these modules helps to achieve sound, evidence-based public health decision-making and planning. 

The Agency is also involved in the design and development of electronic information systems to support the investigation, monitoring and reporting of public health events across the country. One such system, the Canadian Network for Public Health Intelligence External site (CNPHI), is a secure, web-based system now utilised by one hundred percent of local health authorities, all provinces and territories, and the Agency. This system enables communication across public health jurisdictions, including timely dissemination of information about emerging or evolving public health events such as the posting of public health alerts. In addition, the Agency has provided technical input for the development of a pan-Canadian electronic tool (Panorama) that allows health authorities to collect, share and analyze a wide range of health information to manage public health issues, including outbreaks and vaccine coverage. 

An informed and engaged public is important in managing public health threats. 
Since SARS, the Agency and Health Canada developed and adopted a Strategic Risk Communications Framework to guide their work in developing effective communications for the general public and specific groups such as health professionals and vulnerable populations.  This framework advocates facilitating dialogue to enable authorities and stakeholders to make well-informed decisions for effective, responsible and ethical risk management (i.e. activities involved in addressing health and safety risks). This approach to communicating risk issues has already been extensively applied to areas including pandemic influenza planning and response. 

The Agency is also working with risk communication networks, both nationally and internationally, to provide training and produce consistent approaches and messages. This collaborative work helps to build a common understanding of the guiding principles of effective risk communications essential to a coherent approach in a federal/provincial/territorial and international environment.

Many organizations are involved in managing public health events. On a federal level, the Agency is part of the Health Portfolio. Health Canada, another key component of the Health Portfolio, has a special role in managing events such as outbreaks involving First Nation and Inuit communities.  Health Canada also regulates pharmaceuticals, vaccines and other health products.  The Agency collaborates with several other federal partners including the Canadian Food Inspection Agency (CFIA) to manage foodborne and select animal disease outbreaks such as avian influenza.  Finally, Public Safety Canada coordinates multi-department response to emergencies including counter-terrorism issues.

Avian influenza in humans and poultry 

In 2004, an avian influenza A(H7N3) outbreak was identified in a commercial poultry farm in British Columbia (BC).  In the ensuing weeks, a large scale depopulation of poultry in the BC lower mainland was carried out by the Canadian Food Inspection Agency as a standard measure to stop the spread of the virus to other birds and prevent the infection from entering the human population. Local, provincial and federal health authorities put in place measures to further reduce the risk of human infection with the avian virus and to prevent possible double infection of humans with both the avian virus and human seasonal influenza viruses (mixing of animal and human virus infections) which has the potential to generate a new pandemic virus. These measures included providing workers involved in poultry depopulation with personal protective equipment (e.g. gowns, masks, eye protection), seasonal influenza vaccine, and antiviral medication.  In addition, health authorities actively monitored for illness among workers involved in poultry depopulation, farm workers and their household contacts.  Two individuals with exposure to infected poultry were identified as having mild avian influenza A(H7N3) virus infection.  Both individuals received treatment with antiviral medication and their symptoms resolved fully.

This avian influenza A(H7N3) outbreak in Canada, and the avian influenza A(H5N1) outbreak in other regions of the world, further led to the development of a collaborative federal, provincial, territorial and non-governmental organization project to survey influenza A infections in wild birds across Canada. This survey provides a better understanding of the character, presence and relevance of these viruses in bird populations and will aid in more rapid diagnosis of virus strains in the event of an outbreak. Likewise the survey's multi-agency collaborative effort is building and maintaining important linkages between field, laboratory, regulatory and communications partners within Canada to better enable a rapid and integrated response to avian influenza virus outbreaks and related emerging disease issues.

Canada's experience in responding to domestic avian influenza outbreaks has provided us a greater understanding of the risks and challenges of early intervention and effective measures for animal and human disease prevention and control.

As part of Canada’s preparation for an influenza pandemic, the Agency coordinated and collaborated with diverse groups including public health professionals, non-governmental organizations, and industry associations. As well, since SARS, there has been increasing recognition of the important roles played by the voluntary sector’s networks, providing experience and expertise in assisting communities to prepare for and respond to emergencies. 

Pan-Canadian Public Health Network

To improve collaboration in public health response to outbreaks and other public health events across Canada, including the development of agreements and protocols, the Agency supported the formation of the Pan-Canadian Public Health Network External site. Headed by the Public Health Network Council (co-chaired by the federal Chief Public Health Officer and a provincial or territorial Chief Medical Officer of Health), this federal, provincial and territorial network is a mechanism for providing technical advice and evidence-based best practice protocols to Deputy Ministers upon request in order to improve the daily operations of public health in Canada.  Canadian public health and other experts support the work of the Pan-Canadian Public Health Network in the areas of communicable disease control, emergency preparedness and response, public health laboratories, surveillance and information, chronic disease and injury prevention and control, and health promotion. In September 2008, federal, provincial and territorial Ministers of Health approved two key agreements (memoranda of understanding) developed via the network on information sharing and on mutual aid during public health emergencies.  

To facilitate consistent and coordinated approaches to health emergency management, the Pan-Canadian Public Health Network is developing the Pan-Canadian Health Emergency Management System. This system sets out how jurisdictions and organizations connect and interact effectively with each other before, during and after a public health event or emergency. General approaches to emergency management are adopted by governments to prepare for and respond to any natural and man-made hazards. Broadly speaking, these approaches address pre-event activities which aim to prepare for and mitigate a hazard, activities during an event to respond to the emergency and post-event activities which aim to facilitate recovery and evaluate lessons-learned learnt.

A key example of the Pan-Canadian Health Emergency Management System approach is the Canadian Pandemic Influenza Plan for the Health Sector.  First published in 2004 and updated in 2006, the plan is designed to coordinate federal, provincial, territorial, and local jurisdictions in their preparation and response to an influenza pandemic in Canada.

Before a pandemic occurs, the pre-event stage involves monitoring public health intelligence to detect potential threats such as avian influenza viruses and other novel influenza viruses which may cause illness in human. Depopulation of infected birds has been used as one measure to prevent the spread of new influenza viruses (potentially capable of infecting humans), thereby reducing the risk of a pandemic.  Preparedness includes developing plans, training responders and testing these plans through exercises, securing vaccine supply, building medical stockpiles (e.g. anti-influenza medication, personal protective equipment), planning for additional health system capacity, and public education.  Prior to an event, it is also important to clarify and formalize roles and responsibilities amongst governments and stakeholders.

During a pandemic, public health response activities are aimed at mitigating impact on the population by minimizing severe health outcomes, including death, and secondly, by reducing social disruption and economic impact. These activities may include isolation of the sick, treatment with anti-influenza medication, conducting immunization programs, laboratory analyses, triage and provision of additional medical capacity (e.g. setting up alternative sites for providing care), provision of social service and psychosocial support, and coordination and communication across jurisdictions in Canada and internationally.  After the event, recovery involves organizing activities to restore community life and health services (e.g. dismantling alternative care sites).  Evaluating the effectiveness of the public health response is a key after-event activity to inform planning and preparedness activities. 

International Health Regulations

After SARS, recognizing the rapid and serious global impact of infectious disease and other public health hazards, there was international impetus to strengthen disease detection and reporting capabilities. The WHO sped up the revision of the International Health Regulations (IHR), a legally binding international agreement, which came into force in June 2007. The regulations are a framework for detecting, reporting and managing public health risks in the international context. The regulations require signatory countries, including Canada, to report to the WHO public health events that have the potential to cross borders and threaten people worldwide, and to strengthen their core capacity for public health surveillance and response. The Agency acts as the focal point for coordinating the implementation of the IHR in Canada.

Improvements in Detection and Response Between SARS and H1N1

As described above, managing a public health threat involves a series of activities that starts with detection of the threat, followed by an assessment of the associated risks and the implementation of appropriate response or management activities.

Detection

Detecting Diseases and Outbreaks within Canada

Another novel SARS-like or pandemic disease outbreak will likely occur again. When that happens, it is likely that informed front-line health care providers will be the first to detect the disease in Canada. The Agency is collaborating with public health partners to implement measures such as rapid communication to the front-line, training tools and guidelines to ensure that emergency room physicians and other front-line health providers are advised of what to look for when a patient presents to their clinic and know what to do in terms of infection control, testing and notifying appropriate authorities. The Agency has worked closely with provinces and territories to develop and maintain systems and tools to detect and report respiratory diseases and unusual activity. This includes FluWatch, Canada’s national influenza surveillance program which has been in place for over 12 years. Following SARS, the Agency worked with provinces and territories to develop a surveillance protocol and case report form to rapidly identify and report severe respiratory illnesses of unknown cause.  In addition, a Respiratory Illness Outbreak Response Plan was developed and implemented to assist in coordinating the investigation and control of severe respiratory illness outbreaks. 

Outbreaks may also be detected through laboratory testing and analyses. The Agency coordinates PulseNet Canada External site, a network of microbiologists who conduct genetic fingerprinting of disease-causing bacteria such as E. coli and listeria.  A web-based database and discussion board enables the laboratories to compare information from cases that may be geographically far apart but share the same genetic pattern, allowing the Agency to investigate and respond to an outbreak before it becomes a wider problem. 

The Agency has the only high-level containment “Level 4” laboratory in Canada to safely store and study the most deadly infectious organisms. Since SARS, this National Microbiology Laboratory External site (NML) has further developed state-of-the-art technology to rapidly analyze genetic sequences of viruses and enhanced vaccine research capacity.

Listeriosis

On July 29, 2008, the Ontario Ministry of Health notified the Agency of a listeriosis outbreak in the province.  The source of the listeria was unknown at that time. On August 13, the National Microbiology Laboratory notified laboratories across Canada using PulseNet, an electronic communication tool, that genetic fingerprinting showed a clustering of cases with a similar strain in more than one province. The Agency issued a public health alert to inform local, provincial and territorial public health officials of the potential multi-provincial foodborne illness outbreak and to request information on cases. Additional cases of listeriosis were identified in British Columbia, Quebec and Saskatchewan. The Agency took the lead in coordinating the investigation, as per the Foodborne Illness Outbreak Response Protocol (FIORP), a national reference to guide the provincial, territorial and federal response to outbreaks involving more than one jurisdiction. Most of the ill individuals were residents of long-term care facilities or were hospitalized during their likely exposure period and reported consumption of ready-to-eat meat.  The Agency and its provincial, territorial, and federal partners collaborated to determine that Maple Leaf Foods ready-to-eat meat was the cause of the outbreak. The Canadian Food Inspection Agency (CFIA) began issuing recalls of some Maple Leaf Foods products.  After additional food testing, genetic fingerprinting results and a Health Canada risk assessment, CFIA expanded its recall to include all Maple Leaf Foods Establishment 97B ready-to-eat meat products. This was the first multi-provincial outbreak of listeriosis associated with ready-to-eat meat in Canada and the investigation represents a solid example of collaboration among all levels of government. Canada’s system of health surveillance and response identified the problem and took appropriate action.  The opportunity to review the response and identify areas for improvement accompanies all foodborne outbreaks. The Agency has conducted a review of the listeriosis outbreak and is using the findings to guide its planning and decision-making to strengthen the Agency’s ability to respond to future outbreaks.

One of the most challenging situations in any outbreak is ensuring appropriate specimen collection, identifying the priority specimens to test and specimen transportation. To facilitate the most effective and efficient use of limited laboratory resources during an outbreak, the NML has worked to support provincial laboratories through the Canadian Public Health Laboratory Network External site (CPHLN), and in partnership with CPHLN has developed a number of guidelines to assist front-line providers and laboratories. To increase readiness to detect the arrival and spread of any future pandemic influenza virus, most provinces have laboratories that are now able to identify novel strains of influenza using standardized molecular technology.

Once a public health risk is identified, rapid communication among public health authorities is key to increase awareness and understanding of the character of the event and recommend critical measures that can be implemented to mitigate the impact and prevent further spread.  Since SARS, the web-based system for alerting public health authorities, Canadian Network for Public Health Intelligence External site (CNPHI), has expanded in scope from being limited to foodborne outbreaks to all public health issues, including respiratory outbreaks.

Multi-drug resistant tuberculosis

In the spring of 2007, a United States (U.S.) citizen with active tuberculosis (TB) disease traveled by air from the U.S. to Europe against the advice of local public health officials. While he was in Europe, the U.S. Centers for Disease Control and Prevention (CDC) informed him that his TB bacteria were resistant to multiple types of TB medications.  Fearing that he wouldn’t receive proper treatment in Europe, he boarded a flight that landed in Canada. After landing, he drove across the border into the U.S., where American officials identified him and informed Canadian officials for the first time. When the Agency learned of this event, it worked with the involved provinces and international public health partners to contact all the passengers sitting in close proximity to this traveler on the plane from Europe to Canada and have them medically assessed. Fortunately, there was no evidence of TB transmission from this exposure.  This is an example of strong international partnerships supporting a public health response.

Detecting Diseases and Outbreaks Abroad

The Agency may become aware of diseases and outbreaks abroad through the WHO and other international networks (e.g. North American partners, Global Health Security Action Group).

Detecting Diseases at the International Border

Following SARS, the federal government updated and expanded the Quarantine Act to adapt it to the modern reality of rapid and widespread international travel.  While retaining the government's legislative authority to screen, examine and detain arriving and departing travellers, conveyances (e.g., airplanes, cruise ships) and their goods and cargo, contemporary public health measures were added, such as ordering treatments.  New powers also included the ability to divert aircraft to an alternate landing site when necessary, to establish quarantine facilities at any location in Canada, and to prohibit entry of travellers or importation of goods from certain countries or regions of the world to prevent the introduction or spread of a disease.

Measles Outbreak

In May of 2007, the Agency investigated a potential measles outbreak when a Japanese student was hospitalized for the disease shortly after arriving in Vancouver, British Columbia, as part of a tour group. The rest of the tour group went on to visit Alberta.  As this incident involved international visitors and two provinces, the Agency took the lead in the federal government’s response, in cooperation with provincial health authorities and the Japanese government. In coordination with Alberta provincial authorities, the rest of the tour group was tested for immunity to measles and it was determined that a number of the other students who had been exposed to the individual who developed measles were susceptible. These individuals were subsequently given immune globulin by health officials in Alberta. When the group returned to Vancouver in order to board a flight back to Japan, one of the students complained of illness and had a fever at the time of pre-departure screening by Quarantine Officers. In accordance with the Quarantine Act, the entire group was subsequently quarantined, and the ill student was medically assessed.  After the laboratory samples tested negative for measles and the student improved clinically, the entire group was reassessed and medically cleared to return to Japan.  The public health response, which included information sharing, quarantine measures, laboratory work, and international consultations, was a successful demonstration of the Agency’s leadership and collaborative efforts with the provinces and territories.

Quarantine stations staffed with nurses and supported by physicians are currently located in international airports in Calgary, Montreal, Ottawa, Toronto, Vancouver and Halifax. These airports account for 95% of all international air travel in and out of the country and provide services 24/7. Quarantine officers also respond to ill persons presenting at international marine ports and land borders.

To manage screening and events at the international border and points of entry, the Agency also works closely with the Canadian Border Services Agency (CBSA), Royal Canadian Mounted Police (RCMP), Citizenship and Immigration Canada, Health Canada’s Environmental Health Officers, airport authorities and provincial, territorial and local public health authorities.

Risk Assessment

Once a potential outbreak has been reported, the Agency, along with relevant stakeholders (e.g. provinces, territories, other federal departments such as the Canadian Food Inspection Agency) reviews the available information to assess the risk to Canadians. The Agency also considers the potential for international spread and may consult the WHO to develop a common risk assessment. Since SARS, international consultations resulted in the development of a more formalized framework for risk assessment which is included in the IHR. The Agency now applies the IHR decision instrument for assessing and notifying events that may constitute a public health emergency of international concern which includes the following key questions:

  • Is the public health impact of the event serious?
  • Is the event unusual or unexpected?
  • Is there a risk it could spread across provincial, territorial or international borders?
  • Are there travel or trade implications?

 

For some diseases such as SARS or human influenza due to a novel virus, a single reported case would be considered immediately to be a potential public health event of international concern and would be reportable to the WHO. 

Response

To coordinate an outbreak response, the Health Portfolio Emergency Operations Centre (HPEOC), a central command and coordination platform for emergency response in Ottawa, can be activated to support the Agency and Health Canada’s program areas and provincial, territorial and other federal partners. The HPEOC provides 24/7 event management capabilities and can utilize its telecommunication network, equipment and specialized software to coordinate information sharing and response across the various partners involved in outbreak response.  The HPEOC also includes a duty officer program to ensure that contact points are available for provinces and territories 24/7. The National Microbiology Laboratory also has an EOC that coordinates laboratory response to outbreaks and serves as a back-up to the Ottawa HPEOC. Regional Offices also have emergency plans and Regional Emergency Coordination Centres to coordinate a response.

 

Train Incident

On a spring morning in 2008, the Agency was contacted by Health Canada to coordinate the communication aspect of the federal response to an incident involving passengers on a train in northern Ontario. Health Canada had been contacted by Via Rail, indicating that one death, one medical evacuation and influenza-like illnesses had occurred on board the train. The train had stopped in the small town of Foleyet and local health authorities were called in. The situation was a rapidly evolving event as the media had already found out about it and were reporting the event live on television. The Agency activated the Health Portfolio Emergency Operations Centre, and ascertained that the train had traveled through various provinces.  The Agency made links with local health authorities so that real-time information could be exchanged.  The Agency also managed international requests for information, in particular fielding questions regarding the possibility of an infectious disease outbreak. As it turned out, three unrelated health events had occurred, none of which posed an active public health threat. The Agency, in cooperation with other agencies and jurisdictions, had quickly and efficiently determined the facts of the event and quelled concerns that a disease outbreak of international concern was occurring.

 

Deployable Resources

The Agency has epidemiological, laboratory and other public health experts, together with equipment and supplies that can be deployed for responding to outbreaks.  Based on the risk assessment and provincial/territorial requirements, the Agency can draw from the available response teams to ensure that the needed and requested expertise as well as equipment and supplies can be deployed to support an outbreak response. 

Field Epidemiologists
Field epidemiologists, outbreak investigators trained by the Agency through an apprenticeship program (established in 1975), can be deployed upon request to assist local public health. Their role is to work with the investigative team to find the cause of an outbreak and determine how to control it. Since SARS, the Agency has doubled its capacity to train field epidemiologists to ten per year. The Agency’s epidemiologists have also been deployed overseas to assist with humanitarian response to natural disasters and outbreaks including the earthquake in Pakistan (2005), avian influenza outbreaks in Asia (2004) and numerous international “Stop the Transmission of Polio” (STOP) missions.

Microbiological Emergency Response Team (MERT)
The Microbiological Emergency Response Team (MERT), staffed by National Microbiology Lab personnel, is equipped with a mobile laboratory that can be set up on-site to identify biological agents.  The MERT has provided laboratory testing support during domestic outbreaks and has also been deployed internationally enhancing laboratory capacity for emerging infectious diseases for the 2008 Beijing Olympics in China and supporting the testing of Ebola, Marburg and other lethal emerging viruses in Africa.  Since SARS, MERT has continued to develop new diagnostic tests that can detect emerging infectious agents rapidly and efficiently. 

Health Emergency Response Team (HERT)
The Agency continues to work with our federal, provincial and territorial partners to improve our capacity in promoting and protecting the health of Canadians in the event of a public health emergency.  The pilot HERT team was designed to augment provincial and territorial capacity during health emergencies or for special events.  

The Agency is currently reviewing a number of operational components to determine how to best move forward in providing health emergency surge capacity and support to our provincial/territorial counterparts.

Technical Liaison Officers
A number of Agency staff have been deployed as liaison officers to China, U.S. and the WHO headquarters in Geneva, Switzerland. In addition to providing technical support, these liaison officers provide a strategic link between the Agency and its partner organizations, to facilitate communications in key locations of public health importance to Canada.

National Emergency Stockpile System (NESS)
The Public Health Agency of Canada maintains the National Emergency
Stockpile System (NESS), on a 24-hour basis to provide emergency supplies quickly to provinces and territories when requested.

The types of equipment and supplies in the NESS are varied and can include items such as:

  • Pharmaceuticals (e.g., antivirals);
  • Casualty collection unit (CCU) (general first aid supplies);
  • Mini-clinics (for basic assessment, triage and treatment, simple wound management, etc.);
  • Other supplies including beds and blankets.

Other NESS supplies include personal protective equipment for front-line health providers, such as masks, gloves and gowns.  For chemical, biological, radiological, and nuclear events, the Agency manages stockpiles of specific vaccines (e.g. smallpox), antibiotics and antidotes (e.g. potassium iodide).

This stockpile has been used to support a number of special events, as well as provide assistance in emergency situations (e.g., forest fires, flooding) to provinces and territories when needed.  With evolving public health threats, the Agency is continually working to enhance and adapt the NESS to meet the needs of the provinces and territories. 

In addition to stockpiling general emergency supplies in the NESS, the Agency has also established other supplies for specific public health events.  In 2001, to prepare for a pandemic, the Agency put in place a contract with a domestic manufacturer to produce sufficient vaccine to immunize the entire Canadian population. As a pandemic vaccine takes months to manufacture, the Agency worked with the provinces and territories to establish the National Antiviral Stockpile of antiviral drugs to treat ill Canadians during the early stages of viral-based illness.  To increase preparedness for the risk presented by the H5N1 avian influenza strain currently circulating in other areas of the world, the Agency purchased sufficient materials for the manufacture of an H5N1 vaccine. 

International response

The prevention and control of infectious diseases and other public health emergencies require international efforts. The Agency is participating in a number of international networks to facilitate information sharing and collaboration including risk communication networks. The development of the North American Pandemic and Avian Influenza Plan is an example of a successful collaboration with the United States and Mexico through the Security and Prosperity Partnership (SPP). The Agency has also established agreements and work plans with countries and international organizations on public health collaboration including the Global Health Security Action Group, Brazil, China, as well as the European Centre for Disease Prevention and Control, and the WHO. 

Moving Forward

While the Agency has made significant progress since SARS to enhance Canada’s ability to respond to a pandemic, a SARS-like outbreak or other emergency, there is still much to do.  Here are some of the Agency’s next steps for moving forward. 

  • The Agency is working to streamline its many surveillance activities into a coherent and integrated system. 
  • The Agency is dependent upon timely and accurate data from the provinces and territories to carry out national-level outbreak investigations and disseminate information for context and comparison.  Arrangements for information sharing tend to be based on good networking and relationships, rather than formal protocols or procedures around data sharing. There is a need for clearer protocols on the level of information that can be shared for various purposes in different situations. There is a great deal of work currently underway within the Agency regarding broader government-to-government information sharing agreements consistent with the Auditor General’s 2008 Report on the Surveillance of Infectious Diseases.  A Memorandum of Understanding has been signed with one province in Canada for routine data sharing and others are underway.
  • The clarification of roles and responsibilities is a fundamental need for a coordinated and effective response to a public health emergency. While outbreak response protocols and emergency preparedness plans set out roles and responsibilities of key players, there is still a need to formalize these relationships. For pandemic preparedness, the Agency is working to complete a Memorandum of Understanding/agreement with provinces and territories on roles and responsibilities.
  • The Canadian Pandemic Influenza Plan for the Health Sectorrequires ongoing updating as science, technology and policy decisions evolve.
  • Work has begun to formalize and test fail-safe telecommunication mechanisms and 24/7 contact points between the Agency and the provinces and territories so that we can rapidly communicate and coordinate our efforts to deal with pandemics and other health hazards. Work continues to establish standard operating procedures.
  • Strengthening Canada’s public health capacity, including laboratory capabilities, is a key Agency priority. Further work on existing and new training resources for front-line health care providers and public health professionals (e.g. e-learning modules and tools) are underway to ensure that Canada has the ability to detect and respond to outbreaks in a timely, effective manner. 
  • Work is underway to ensure that available people and resources can be mobilized between jurisdictions, including guidelines and operational protocols on requesting and receiving aid, and addressing licensure issues for health professionals.
  • The Agency is looking forward to a strategic renewal of the National Emergency Stockpile System to ensure that supplies and equipment are available to respond to today’s health risks including pandemics. There is ongoing work in dealing with expiring anti-influenza drugs and diversifying the stockpile with a number of different drugs so that we can respond to a pandemic influenza virus that develops resistance.
  • The Agency also prepares for large scale events that may have human health impacts, such as the 2010 Winter Olympics and Paralympics: preparing public health emergency plans, coordinating and participating in emergency exercises and developing on-site capacities.  
  • Canada has been a key signatory promoting compliance to the IHR globally. To fully comply with the obligations of the IHR, Canada has just completed an assessment of its current capacity to detect, assess, notify and respond to public health threats. Following the assessment, Canada is implementing the necessary measures to ensure that Canada’s surveillance and response capacities meet the IHR requirements by 2012. 
  • Recent outbreaks, and the emergence and establishment of diseases new to human populations including West Nile Virus, Ebola Hemorrhagic Fever, SARS, Mad Cow Disease, and novel influenza viruses with pandemic potential (such ash H5N1 avian influenza), illustrate how intimately connected human health is with the health and welfare of animals. In fact, approximately 75% of emerging infectious diseases now originate in animals. The Agency is working with national and international organizations to discuss how the intersection between animal, human and ecosystem health can be better understood and integrated into Canada’s public health prevention and control efforts.  This concept is termed ‘One Health’ and recognizes the need to take a more holistic approach to disease control – one that predicts and prevents diseases from crossing the divide between humans, their livestock and wildlife. 

Conclusion

In its first five years, the Agency took important steps toward making Canada less vulnerable to the impacts of infectious disease outbreaks. While the challenge is ongoing and work remains, Canada has improved its capacity to prepare for and respond to an infectious disease threat of national importance. The Agency’s rapid and effective response to a number of outbreaks and other emergencies over the years, in collaboration with provinces, territories and other stakeholders demonstrates, the country’s capacity and commitment to responding to potential threats to the health of Canadians.

Canadians can never be certain they are completely safe from infectious diseases.  But we can prepare. We can establish mechanisms to monitor outbreaks and ensure that we have the necessary resources and structures in place to respond to them in a coordinated and effective manner. The Agency, in cooperation with the provinces, territories, and international partners, is making every effort to help fulfill one of the most primary tasks of government: keeping Canadians safe from illness, and allowing the population to pursue its daily activities with confidence and determination.

Appendix: Checklist of Completed Actions to Increase Public Health Capacity in Canada

  • Establish a new federal agency, the Public Health Agency of Canada, with a Chief Public Health Officer, to provide leadership and action on public health matters

  • Create a Pan-Canadian Public Health Network to integrate federal, provincial and territorial activities in infectious disease surveillance, prevention and management

  • Approved agreements (Memoranda of Understanding) on information sharing during a public health emergency. 

  • Enhance public health and laboratory capacity in provincial, territorial and local public health organizations and provincial laboratories (Canadian Public Health Service, Laboratory Technical Officers, Canadian Field Epidemiology Program)

  • Develop on-line and other public health training tools

  • Strengthen the Quarantine Act and Quarantine Service to improve disease detection at borders

  • Expand web-based communication systems to ensure timely sharing of information with public health professionals

  • Strengthen pandemic preparedness by enhancing domestic vaccine capacity, antiviral stockpile and other pandemic supplies and revising the Canadian Pandemic Influenza Plan for the Health Sector

  • Establish national surveillance and reporting for Severe Respiratory Illness and a national Respiratory Illness Outbreak Response Protocol

  • Enhance deployable resources to assist in outbreak response, including the Microbiology Emergency Response Team and National Emergency Stockpile System

  • Create and adopt a framework to guide the development of effective risk communications