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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Annex 3.5–F/P/T Considerations in the Use of Antivirals for Prophylaxis

Submitted by:
Horacio Arruda
Directeur de la protection de la santé publique
Ministère de la santé et des services sociaux

Sylvie Poirier
Chargée de projet pandémie d’influenza
Direction de la protection de la santé publique
Ministère de la santé et des services sociaux

Intended for: Task Group on Antivirals for Prophylaxis

Context

In order to properly respond to pandemic influenza, governments must adopt a multi-faceted strategy made up of many components, such as surveillance, public health measures, immunization with a pandemic vaccine, public communications, care of the sick and the use of antivirals for treatment. The mandate of the Task Group on Antiviral for Prophylaxis (TGAP) is to consider whether antivirals for prophylaxis should be a further component of this population-based approach, to attain the goals of the Canadian Pandemic Influenza Plan for the Health Sector (CPIP). There has been and there will continue to be pressures to fund multiple aspects of pandemic preparedness. The allocation of the resources required to acquire and implement antivirals for prophylaxis may occur to the detriment of other important aspects of a comprehensive pandemic preparedness response strategy.

Opportunity costs will be considered differently by each jurisdiction. The ability of jurisdictions to pay for their share of a recommended prophylaxis stockpile may vary. Coming to an agreement regarding a federal/provincial/territorial (F/P/T) cost-sharing formula is a determining factor for some provinces/territories (P/Ts) on their ability/willingness to pay.

The decision to establish the National Antiviral Stockpile (NAS) in the fall of 2004 was the first step towards securing a supply of antiviral drugs that could be used at the time of a pandemic. One of the objectives of establishing the NAS was to facilitate equitable distribution and use of a limited resource across jurisdictions during a pandemic. The initial size of the NAS was 16M doses. The contract to purchase Tamiflu^® for the national stockpile was awarded in spring 2005. The cost of the 16M doses was shared between the federal and P/T governments using a 60:40 funding formula.

The initial investment (16M doses) was derived from calculations which estimated antiviral needs on a priority basis using a number of assumptions. In the fall of 2005, the Pandemic Influenza Committee (PIC) Antiviral Working Group (AVWG) reviewed its initial assumptions and concluded that the NAS should be increased. The AVWG then recommended to PIC that the NAS be substantially increased.

While the NAS was being established, P/T and federal government departments were purchasing their own stockpile of antivirals (outside NAS) and as of February 2006, it was estimated that the amount of antiviral doses which had been ordered or acquired by P/T and federal government departments outside the NAS was 21M doses. The variation across jurisdictions opened up the scenario of disparate access across Canada.

At their February 27-28, 2006, joint-meeting, the PHN Council and CCMOH recommended that the National Antiviral Stockpile be increased to 55M doses (48M oseltamivir, 5M zanamivir, 2M oseltamivir oral suspension). At their May 12-13, 2006, Conference, the FPT Ministers of Health agreed to “seek authority as necessary to increase the joint National Antiviral Stockpile from 16 million to 55 million doses”. The same cost sharing formula was considered, and ultimately agreed to, for the purchase of the additional doses to be included in the national stockpile. The national stockpile was shared on a per capita basis. All P/Ts purchased their share of the national stockpile. Some jurisdictions may have made the decision to purchase on their own additional doses. If so, they have paid 100% of the cost for the exceeding doses.

Size of the F/P/T Stockpile Ordered or Acquired

Currently, the total amount of doses purchased by P/Ts and federal government departments outside the NAS is not known.

Transparency across jurisdictions regarding the intent and current status of each jurisdiction’s stockpile of antivirals for prophylaxis is important because it may help a certain level of uniformity of decisions and it allows for a more informed decision-making process regarding whether or not antivirals for prophylaxis should be included in the national antiviral stockpile.

The current size of the NAS for each P/T government is indicated in the table below.⁷¹

F/P/T Considerations

The CPIP was developed using a joint federal, provincial and territorial process. The actual NAS was also created with an F/P/T process. Considering the potential negative impacts of different strategies across Canada, an F/P/T process was also chosen in order to consider whether or not antivirals for prophylaxis should be a component of our publicly funded population base program. Consensus in the overall scope and application of policies made at the F/P/T level is a desired goal.

A decision to stockpile antivirals for prophylaxis will likely result in the need to expand the size of the national antiviral stockpile beyond the 55 million doses. Other decisions with F/P/T implications regarding the antiviral strategy need to be taken regarding the treatment stockpile (how the treatment strategy will be implemented across Canada) and the possible use of antivirals in the early phases of the pandemic (avian flu, phases 4 and 5 and for containment).

1. Financial considerations

Ideally, each jurisdiction has the ability to pay for its share of the stockpile. Prior to making any decision, each jurisdiction will have to consider the opportunity costs—in other words the financial repercussion (what else would not be funded)—of such a decision. The fiscal flexibility of each P/T to pay for their share of a recommended prophylaxis stockpile may vary. A greater likelihood of interjurisdictional equity in ability to purchase antivirals and consequently provide access to their citizens would be possible if a cost-sharing agreement, in which federal, provincial and territorial responsibilities are described, is agreed upon.

Although each jurisdiction has autonomy regarding its health care spending, one cannot deny the fact that each jurisdiction’s decision may impact on others. For example, workers in different jurisdictions fulfilling similar roles and responsibilities may have the expectation that they will all be treated in the same way (e.g., nurses in hospital settings). In addition, there may be employees with similar labour requirements working side by side but being treated differently depending on their employers (e.g., RCMP and provincial and local police).

2. Policy considerations

The global and Canadian experience with SARS has demonstrated the tremendous impact of emerging infectious disease outbreaks and other biological threats on the healthcare system and on society as a whole. Recommendations from numerous inquiries related to the SARS outbreak have led to legislative changes and structural modifications, and have emphasized the importance of a robust public health capacity as well as clear roles and responsibilities. Another F/P/T Task Group is currently working on a memorandum of understanding (MOU) that will better define the roles and responsibilities of the federal government and of the provincial and territorial governments in pandemic management.

Interjurisdictional policy differences may pose communication challenges with regard to the F/P/T strategy on antivirals for prophylaxis. Legal considerations would need to be examined if there were significant interjurisdictional policy differences.

The amount of control that provinces and territories have over their local/regional health authorities and institutions varies. Therefore, the ability of local /regional health authorities and institutions to stockpile antivirals outside of the NAS also varies. For these reasons, the amount of antivirals within each P/T available for its population may be different from one P/T to another even if a consensus is reached by all jurisdictions regarding the size of the national stockpile.

Other ministries (e.g., labor) are directly involved in pandemic management. Any decision regarding the use of antivirals for prophylaxis during a pandemic will require significant engagement of all parties involved in pandemic management. The variation of private sector stockpiles between jurisdictions may also contribute to a different access to antivirals.

3. Operational considerations

The implementation of the recommendation will involve numerous operational and implementation considerations. Some examples are:

• If target groups were chosen for the prophylaxis strategy, certain uniformity across Canada in the definition of people included in these categories would be desirable. Examples are critical infrastructure workers (which jobs, what percentage of employees) and health care resources (in private sector or not, treating flu patients or all patients).
• The organization of health care delivery differs from one jurisdiction to another. Consequently the organization of antiviral delivery for prophylaxis may differ.
• Implementation strategies will need to consider storage and distribution issues that are particularly challenging for some remote communities.

Many operational considerations will require resolution during the planning process to implement the treatment strategy. More operational considerations are described in the Health System/Logistical paper and these may become F/P/T issues if they are very different from one jurisdiction to the other and convert into disparate access across Canada.

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