Pan-canadian public health network council report and policy recommendations on the use of antivirals for prophylaxis during an influenza pandemic

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Key Considerations and Expert Reviews

7. Citizen and Stakeholder Deliberative Dialogues

In response to TGAP’s mandate to consult with the Canadian public, a professionally-managed series of dialogue sessions was held during 2006 and early 2007, to assess the views of Canadians on whether governments should stockpile antivirals for prophylaxis and, if so, under what conditions and specifically to for whom. Eleven one-and-a-half day sessions were held in six cities across Canada - seven were with citizens (including a First Nations session), two with stakeholders, and two with those in occupations that could be targeted for prophylactic antivirals.

A deliberative dialogue approach was used. It offers a deeper insight into the values and common ground of participants regarding particular issues and alternative courses of action and provides a sound reference framework for assessing complex policy choices that involve fundamental ethical considerations. The session began with a detailed information session, covering topics such as pandemic influenza, antivirals and their uses, current scientific knowledge and uncertainties, and pandemic planning at federal and provincial/territorial levels. Medical experts were present throughout the dialogue to respond to questions and ensure that participants had the best information available to inform their choices. Following the education sessions, participants were asked to reflect on the pros and cons of three different approaches to the use of prophylactic antivirals, (which had been developed based on a rigorous issue framing process and input from TGAP and PHNC). Participants engaged in dialogue and open discussion on these approaches and on priority group rankings. They were also specifically asked whether governments should in fact proceed with stockpiling antivirals for prophylaxis. Individual participant views were assessed before and after the Dialogues.

A more detailed report on this process can be found in Annex 3.7. The Final Findings Report is available upon request or can be found at http://www.phac-aspc.gc.ca/influenza/antiviralprev_e.html#ekos.

Key Findings

Of the three approaches presented, participants rated “Keep Society Functioning” highest, with “Minimize Serious Illness and Death” close behind. “Minimize Governments’ Role” rated lowest. While there were some discernible differences across the sessions, from a public policy perspective these differences are not significant enough to require variation in the policy recommendation.

There was an overall consensus that governments should create an additional national stockpile of antivirals for prophylaxis. However, this support was nuanced, and given the unknowns, including safety, effectiveness, equity considerations, and opportunity costs, was based more on prudence/insurance principles than on a deep conviction thate prophylactic antivirals made sense. Erring on the side of caution, there was also a general consensus that the use of prophylactic antivirals be limited to as few people as necessary to obtain results.

In terms of the core values that participants feel should guide decision-making, pragmatism rated highest. Participants therefore felt it important to focus scarce resources on health and emergency workers who would play an important role in keeping society functioning and containing spread of the virus. However, this was coupled with the notion of reciprocity – that those receiving prophylactic antivirals need to show up for work to be able to keep society functioning and need to take the drugs as directed. Other strong sentiments included the values of fairness and equity, compassion for the vulnerable, knowledge-sharing, and the need for strong government leadership.

There was considerable discussion and divided views about priority recipients. However, given the core values, it is not surprising that health care workers were rated highest, particularly those with close patient contact. Emergency workers rated slightly lower, and vulnerable groups last, with children highest in this category. It was felt that society had an obligation to protect the health and safety of those likely to be on the front-lines of a pandemic response and that the provision of antivirals for prevention for these workers was reasonable, fair and necessary. Further, once the needs of health care and emergency workers had been addressed, society had a duty to do right for the most vulnerable segments of society, particularly children.

Participants indicated a need for strong government leadership, and for knowledge to be widely shared and transparent. Governments were expected to be proactive in keeping the public informed about an outbreak and plans for dealing with it, and for reassuring them that these plans had been objectively developed and would be applied fairly. Governments were clearly the first choice to oversee a stockpile of antivirals for prevention due to economies of scale and the ability to ensure a fair and sensible distribution process.

One central theme that was discussed in most sessions was the need for consistency. People wanted the decisions regarding prophylactic antivirals to be the same across the country, with a recognition that the way the service might be provided may need to vary (e.g., in more remote areas).

Participants emphasized the need for early and sustained public education, both in relation to pandemic preparedness generally, and in the event of a positive decision on stockpiling. Participants also strongly recommended additional research to address significant current knowledge gaps, and considered that availability of new information in regard to risks/benefits might yield different results.

First Nations on Reserve participants spoke of the need for decision-makers to recognize the potential contribution of traditional medicine to pandemic planning and response efforts.

Conclusions

Participants key considerations indicated that they supported antivirals for prevention, but limited to those required to keep society functioning, based on a duty to protect those on the front lines. This advice aligned with the highly rated core value of pragmatism in terms of protecting those needed to keep society functioning, the need for prevention and containment, and flexibility to adapt to new information. It was also closely coupled with participant’s strong support for the concept of reciprocity that those receiving antivirals for prophylaxis because of their critical role have a duty to show up for work and take the drug as directed.

Other core values included fairness and equity, both important in offering equal access to protection, regardless of factors such as income or geography, as well as compassion for the vulnerable, not only as the right thing to do, but also to ease the burden on the health care system.

Three other findings stand out:

• the imperative for public education as a form of prevention;
• the need for additional research on the use of prophylactic antivirals;
• the need for strong, transparent and consistent government leadership .

Given the struggle many participants had in determining priority recipients, the concern about the unknowns of prophylactic antivirals in a pandemic and the potential opportunity cost of investing in public education (as a prevention measure) rather than prophylactic antivirals as opposed to public education, for example, there was considerable discussion as to whether the benefits of antivirals outweighed the potential costs – both economic and societal. It can be concluded that many participants would be open to governments taking a decision not to provide prophylactic antivirals as long as:

• the health (and therefore functioning) of front-line workers, particularly those with close patient contact, could be protected in other ways;
• the decision is transparent, consistent across governments and is communicated clearly along with a sound rationale;
• any decision taken will be revisited as new evidence becomes available; and
• there is early and sustained public education, both as a prevention measure and to minimize panic by keeping people well-informed.

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