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Canadian federal policy has been to ensure that all Canadians have access to the H1N1 vaccine. In this report, we describe how Canadian federal and provincial governments are responding to the challenges of the 2009 influenza season which has been complicated by the arrival of two influenza strains ("seasonal" influenza and H1N1 influenza) and uncertain information about who is most at risk from H1N1.
A pandemic is a worldwide outbreak of a specific disease which affects a large proportion of the population (Public Health Agency of Canada, nd). The World Health Organization (WHO) has confirmed that we are in phase 6 of the 2009 influenza pandemic, representing widespread and global distribution of the H1N1 influenza. As emerging data about prevention and treatment of the H1N1 influenza virus becomes available, public health policy must quickly react. As of September 20, 2009 there had been more than 300,000 laboratory confirmed cases of pandemic influenza H1N1, and 3917 deaths in 191 countries and territories (WHO 2009). Undoubtedly, these numbers are lower than the actual occurence due to reporting and testing differences among countries.
In Canada, which has a well developed public health reporting and surveillence system, 98.3% of positive influenza diagnoses were of the H1N1 influenza strain, as of September 19, 2009. To date there have been 1467 hospitalized cases including 292 cases in intensive care, 151 cases requiring ventilation, and 87 deaths. To date the Public Health Agency of Canada is characterizing the intensity of Pandemic (H1N1) as low although there has been an increase of influenza activity in southern British Columbia, New Brunswick and Ontario (Public Health Agency of Canada, 2009a). The influenza season is just arriving in Canada as the weather gets colder.
The arrival of the H1N1 influenza strain has been anticipated since its emergence in Canada in the spring of 2009. There has been pressure on all levels of government to be well prepared for the fall and winter of 2009/10.
The role of the federal government in pandemic planning in Canada is to take the lead in mobilizing a pan-Canadian response to a pandemic. The federal government in cooperation with the provinces and territories has a Canadian Pandemic Influenza Plan (Public Health Agency of Canada 2006) which is being used to guide the health sector's activities in preparing for expected H1N1 cases. In August 2009, the federal government announced that it will be purchasing 50 millions doses of the H1N1 vaccine, more than enough for all Canadians. The federal government will fund 60% of the estimated $403 million expense; the provinces will pay for the remaining 40% (Health Edition 2009).
The role of the provincial and territorial governments is to deliver health care in their jurisdictions. Each province and territory has the authority to develop its own pandemic plan.
Tools for implementing effective pandemic service planning and delivery are both financial and non-financial. Financial incentives include support from the federal government which is covering 60% of the cost of the influenza H1N1 vaccine. In some provinces, such as Ontario, the vaccine will be available free to citizens. Non financial incentives include political and social pressure on all levels of government to effectively protect Canadians from the H1N1 influenza.
federal, provincial and jurisdictional governments, patients and the public, health providers
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The response to the H1N1 influenza on levels of government became more intense when the WHO declared H1N1 influenza to be a pandemic. In Canada the federal government estimates that a moderately severe pandemic could lead to infection rates of up to 70% of the population, and to 11,000-58,000 deaths. During its timespan, a pandemic would lead to great pressure on the hospitals (34,000-138,000 hospitalizations), on physician practices, as well as on the transaction of everyday business and social life (Public Health Agency of Canada 2006). It is not clear how severe the eventual effect of H1N1 will be. To date it has been very mild.
In the summer of 2009, opposition parties forced the government to participate in an emergency meeting of the House of Commons Health Committee to talk about the government's plan to deal with the H1N1 influenza. The Health Minister accused the opposition parties of playing politics with the issue. In addition to opposition criticism about the lack of a pan-Canadian plan for H1N1, testimony from such groups as the Federation of Canadian Municipalities cited the lack of a plan to protect front line workers. The College of Family Physicians of Canada reported the government communications to physicians had improved but could be better. The Health Officer for British Columbia indicated that local pandemic plans were not up to date and that more resources for public health infrastructure, especially for communications, were needed (Health Edition 2009).
On October 1, the leader of the Opposition, Michael Ignatieff, called for the end of the Minority government of Mr. Stephen Harper. Among his criticisms of the government, he highlighted the response of the federal government to the H1N1 pandemic. He pointed out that the federal government had spent six times as much money on publicizing its response to the recession as it has to warn Canadians about the dangers of H1N1. He also criticized the government for not having the H1N1 vaccine available for Canadians (it is expected to be available in November; it was available for health workers in the US in October) and for a lack of a national approach for dealing with the pandemic (Ignatieff, 2009). The minority Conservative-led government survived the non-confidence motion.
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Since the SARS epidemic in 2003, Canada has improved its ability to idenify and keep track of unusual illnesses. FluWatch is a national reporting mechanism developed from reports from: a network of laboratories across the country; a network of physicians working in clinics to study influenza-like illness; and provincial and territorial medical specialists who report influenza outbreaks in their region.
As well, Canadian jurisdictions monitor global pandemic trends through the Global Intelligence Network, an internet-based information gathering and distribution system which uses emails and web alerts to inform jurisdictional public health officials. Canada is one of the few countries in the world to have an agreement with a vacinne manufacturer to develop and supply a pandemic influenza vaccine as soon as a new strain is identified. A ten year contract was signed between the Government of Canada and GlaxoSmithKline Biologicals of Quebec in 2001 (Public Health Agency of Canada 2006). However this contract has been criticized because it ties Canada into obtaining all of its H1N1 vaccine from one provider and on the schedule of the provider (The Globe and Mail 2009).
The approach of the idea is described as:
Stakeholders have been quite unanimous about the need for proactive steps to protect the population from the H1N1 influenza virus. The controversery has been about the pace of development of a pan-Canadian plan. In anticipation of the fall meeting of the Ministers of Health, Canada's most influential health care associations ( the Canadian Medical Association, the Canadian Healthcare Association, the Canadian Nurses Association and the Canadian Pharmacists Association) issued a joint communique urging the Ministers to continue planning and preparing for a possible increase in the severity of the influenza pandemic (Canadian Medical Association, 2009). In October the lead editorial of the country's most influential newspaper critized the federal government for the slow response to the arrival of H1N1 and for not joining 9 other countries to donate some of its vaccine to developing countries (The Globe and Mail, 2009).
In response, the Public Health Agency of Canada has reported that to date, there is no widespread influenza activity in Canada. Therefore the Agency was not going to speed up release of the H1N1 vaccine. Delays in its availability are due to clinical trials which are underway about the correct dosage of the H1N1 vaccine. As well production is slower because in Canada the decision has been made to add adjuvants to it. Some provincial public health officials feel that H1N1 could quickly peak before the vaccine is available (Alphonso, 2009c).
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To date, both the seasonal and the H1N1 influenzas have been reported in Canada. To date the seasonal flu strain has been more dangerous to health than the H1N1 strain. All provinces in Canada have been planning to vaccinate citizens against the seasonal flu and to administer a separate vaccine against the H1N1 virus.
In August 2009, the Public Health Agency of Canada issued guidelines for H1N1 sequencing which suggested that those most at risk be priorized to receive the vaccine. At the time it was thought that those people included those with chronic medical conditions under the age of 65, pregnant women, children six months to under 5 years of age, people living in remote amd isolated settings or communities, health care workers involved in pandemic response or who deliver essential services; household contacts or caregivers of those who are high risk or those who cannot be immunized; and populations otherwise identified as high risk (Public Health Agency of Canada 2009b). (To compare recommendations in different countries look for other reports on H1N1 in our search engine)
The Canadian experience in the spring 2009 indicated the people living in rural and remote locations, especially on First Nations reserves were at higher than average risk of poor outcomes from the H1N1 virus. In Manitoba, residents of northern reserves were more likely to be hospitalized in intensive care beds (White, 2009). The federal government took steps to assist those living on reserves by sending health supplies, including body bags. Leaders of reserves in Manitoba captured national media attention when they held a protest. The issuance of body bags was viewed as an outrage on some reserves because preparing for death is a cultural taboo. In response the federal government apologized and established a monthly communications forum for native leaders. People living on reserves can be more at risk of communicable diseases such as influenza because of poverty and overcrowded housing, lack of potable water and sanitation facilities ( White 2009).
In late September, new data on about 1500 individuals from four Canadian provinces (BC, Alberta, Quebec and Ontario) seemed to indicate that receipt of the seasonal vaccine raises the risk of contracting the H1N1 virus for those under age 50 by 50%. The severity of the H1N1 influenza by these patients has been mild. These results are in a study which is still in the process of being peer-reviewed but in light of its findings, Canadian provinces have taken action. By September 30, all provinces and the territories except New Brunswick modified their vaccination plans.
Given that the safest way to protect the public is not clear now, many provinces and territories (BC, Saskatchewan, Manitoba, Ontario, Nova Scotia, Prince Edward Island, Newfoundland and Labrador, the Yukon and the Northwest Territories) decided to delay adminsitration of the seasonal flu vaccine to adults and children. In these jurisdictions, starting in October the seasonal flu vaccine will be administered only to people 65 and older and to residents of long-term care facilities (international data indicate that the elderly are less vulnerable to H1N1 than younger people). In November, the H1N1 vaccination programs will be rolled out to vulnerable groups and others who request the vaccine. In December the seasonal flu vaccine will be offered to everyone under the age of 65. Quebec and Nunavit are delaying their seasonal vaccinations to everyone and perhaps will not offer them to anyone (Alfonso, 2009 b). New Brunswick is rolling out its seasonal vaccination program earlier than usual, starting in October.
The change in approach has been controversial. Some public health officials have expressed several concerns: the study is being peer-reviewed and therefore the results are open to challenge on methodogical or other grounds. A study by the Public Health Agency of Canada of patients who were hospitalized with influenza did not find a link between receipt of the seasonal flu vaccine and occurence of H1N1 influenza. The Public Health Agency has since commissioned a review of data from British Columbia. Given the fact that the results of the unpublished Canadian study have not been found in other countries, there is some skepticism about them. Nevertheless most public health officials feel that they cannot ignore the results.Other concerns have been expressed about public confusion about the changes to provincial messaging about the steps to take about vaccination. One physician referred to the current situation as an "epidemic of confusion" (Alphonso 2009b). There is also concern that some of the public may decide not to be vaccinated at all (Alphonso 2009a; Boyle 2009; Alphonso 2009b). It has been reported that only 45% of Canadians were willing to be vaccinated before the controversy broke out (Health Edition, 2009a). Most importantly, the division in provincial approaches creates disarray in the pan-Canadian approach to pandemic planning, with potential consequences for the health of the population.
By mid October, it was clear that the impact of H1N1 was quickly growing and the Public Health Agency of Canada changed its approach by expediting approval of the vaccine by Health Canada, and making the vaccine available to the provinces in October. Most provinces started their vaccination programs in late October. As well the Agency purchased vaccine without adjuvants from Australia to make it available quickly to pregnant women.
There is an ongoing pan-Canadian monitoring system in place to track the occurence and impact of the H1N1 influenza across the country.
None at this time.
Perhaps no other area of health care requires as much speed and flexibility as government response to natural disasters and health pandemics. Clearly, Canada is reasonably well prepared to deal with the H1N1 influenza. However, several worrisome issues have arisen.
First, although there is pan-Canadian sharing of information, the provinces have not agreed to take the same actions. If the results of the Canadian study are valid and reliable, the fact that New Brunswick, for example, is offering its seasonal influenza vaccination in October, could have adverse effects in New Brunswick and potentially in other jurisdictions. Second, there is a need to be especially proactive in rural and remote communities, especially on reserves, to reduce the impact. Currently, in Nunavit, the H1N1 influenza strain is the one that is circulating in remote communities (Alphonso 2009b). Third, the changes in vaccination planning must be clearly communicated to the public to encourage as much trust in public health advice as possible. Lastly, there is some justification for the decision of New Brunswick to go it alone to implement its seasonal vaccination program as planned. The risks of seasonal flu are substantial with up to 8,000 deaths annually in Canada attributed to seasonal flu. Since the H1N1 virus emerged in Canada in April 2009, there have been 87 deaths. Seasonal influenza is expected to peak in mid-December in Canada but it is unclear when the H1N1 influenza will peak or what its impact will be.
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Margaret MacAdam, Ph.D., Senior Fellow for Health