Chapter 12 - Learning from SARS: Renewal of Public Health in Canada
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SARS has demonstrated the speed with which a dangerous new disease can
emerge and spread around the planet. The seriousness of the outbreak
and the challenges that arose in containing SARS are widely and rightly
regarded as signposts for the need to strengthen Canada's public health
systems.
In fact, the evidence of actual and potential harm to the health of
Canadians from weaknesses in public health infrastructure has been mounting
for years without a truly comprehensive and multi-level governmental
response. Canada has faced the HIV epidemic, water contamination in Walkerton,
Ontario and North Battleford, Saskatchewan, and threats to the safety
of Canadian blood supplies from HIV and Hepatitis B and C. The events
of September 11, 2001 and the related anthrax attacks on our US neighbour
heralded the possibility of bioterrorism within our borders. Recently,
one part of the country has faced economic hardship caused by fears of
the spread of BSE from cattle to humans, while others are trying to stem
the spread of West Nile virus from birds to humans. And as this report
goes to press, a new public health crisis is unfolding around a meat
packing plant in Aylmer, Ontario.
All these events have represented tangible threats to the physical and
economic well-being of Canadians. All these threats emphasize the need
for a seamless public health system. At minimum, Canadians expect that
the nation's public health systems should be fully prepared to deal with
emergencies caused by infectious diseases, accidental or intended, and
consistently be able to protect them from mass contamination of water
or food. These minimal expectations are not being met.
As a disease outbreak, SARS was relatively small. Nonetheless, the disease
killed 44 Canadians, and caused illness in a few hundred more. The response
to the outbreak paralyzed a major segment of Ontario's health care system
for weeks, and saw more than 25,000 residents of the Greater Toronto
Area placed in quarantine. Psychosocial effects of SARS on health care
workers, patients, and families are still being assessed, but the economic
shocks have already been felt. Estimates based on volumes of business
compared to usual seasonal activities suggest that tourism sustained
a $350 million loss, airport activity reduction cost $220 million, and
non-tourism retail sales were down by $380 million. It seems entirely
possible that the direct and indirect costs of SARS could reach $2 billion.
As Canada recovers from this extraordinary set of events, the National
Advisory Committee on SARS and Public Health has been weighing what lessons
might be learned from the outbreak of SARS in Canada. The foregoing chapters
indicate that there was much to learn - in large part because too many
earlier lessons were ignored. We are confident that related work by other
individuals and groups - including the Senate Standing Committee chaired
by the Hon. Michael Kirby, the expert panel in Ontario chaired by Dr.
David Walker, and the public health investigation by Mr. Justice Archie
Campbell - will lead to many lessons beyond those drawn here. Those ongoing
assessments, however, must not be used by governments as an excuse for
inaction and delay.
Before recapitulating the recommendations from earlier chapters, some
themes and issues from the body of this report may be worthy of review.
Our first theme is that the single largest impediment to dealing successfully
with future public health crises is the lack of a collaborative framework
and ethos among different levels of government. If the experience of
SARS in Ontario were to be repeated in a jurisdiction with fewer resources
and a smaller base of highly-skilled and dedicated personnel, or in the
face of a more virulent infectious disease, the consequences could be
disastrous. Canadians expect to see their governments collaborate responsibly
in the face of a serious threat to the health of the population. The
rules and norms for a seamless public health system must be sorted out
in advance of a health emergency, with a spirit of partnership and shared
commitment to the health of the citizenry, not on an ad hoc basis
in the midst of the battle to contain a viral outbreak.
Systems-based thinking and coordination of activity in a carefully-planned
infrastructure are not just essential in a crisis; they are integral
to core functions in public health because of its population-wide and
preventive focus. To repeat an observation from an earlier chapter: the
Committee does not seek to build public health systems so perfect that
people no longer need to be good. But we believe Canadians should demand
a set of interlocking public health systems sufficiently strong that
bad things do not happen needlessly to good people. The case for a collaborative
and coordinated approach to public health is arguably even more acute
than in our still-fragmented personal health services systems. Weakness
in health protection or disease control in one jurisdiction will rapidly
affect many other jurisdictions. To that end, the Committee has recommended
strategies that will strengthen all levels of the public health system
as well as integrate the components more fully with each other.
The Committee appreciates that F/P/T relations are not straightforward
in Canada (or any other federation). That, in large part, is why we have
proposed new structures and funding mechanisms that aim to remove public
health from the jurisdictional cross-fire. The Committee nonetheless
strongly urges current and future governments to view public health as
a 'constructive-engagement zone' in F/P/T relations for several reasons.
First, public health threats have generalized impacts. The success of
Ontario and British Columbia in containing SARS spared the rest of the
country. We cannot afford to have any weak links in a pan-Canadian chain
of health protection and disease control.
Second, public health costs are modest - perhaps 2-3% of health spending,
depending on how one defines numerators and denominators. The actual
amount of new federal spending that the Committee has recommended would
reach $700 million per annum by 2007. This is what F/P/T governments
currently spend on personal health services in Canada between Monday
and Wednesday in a single week.
Third, the Committee's recommendations for new funding are oriented
to supporting all jurisdictions. Until now, there have been no federal
transfers earmarked for local and provincial/territorial [P/T] public
health activities. Public health has instead been competing against personal
health services for health dollars in provincial budgets, even as the
federal government has increasingly earmarked its health transfers for
specific health service priorities. About 75% of the new federal spending
that we have recommended will flow to support local and provincial/territorial
public health activities. This includes $300 million per annum for front-line
public health activities under the new Public Health Partnerships Program,
$100 million per annum to support P/T purchase of costly new vaccines
under a reinvigorated National Immunization Strategy, and $100 million
in a Communicable Disease Control Fund to support second-line defences
at the P/T level and link P/T and federal centres of excellence in surveillance,
prevention, and containment of infectious threats to health. Furthermore,
the new Canadian Agency for Public Health would make significant new
investments in health human resources, research, and surveillance for
non-communicable diseases - all of which will have direct benefits for
P/T jurisdictions.
Fourth and finally, the fiscal and strategic approaches set out in this
report are entirely consistent with international precedents and, we
believe, the expectations of Canadians. Similar programs of transfers
for public health to states and territories exist in Australia and also
operate under the auspices of the Centers for Disease Control and Prevention
[CDC] in the USA. Public health authorities in the European Community
are building capacity to coordinate health protection and facilitate
networking among national foci for disease control. With the globalization
of health threats and growing importance of international collaboration
in disease control, the Committee urges F/P/T governments to coalesce
around public health as a pan-Canadian priority.
We turn back now to the Committee's recommendations.
The first section consists of a series of recommendations that require
urgent attention by governments as part of preparation for the winter
season and the associated increases in the incidence of respiratory viral
illnesses. They are largely self-explanatory.
The sections thereafter recapitulate recommendations presented in the
body of the report. Arguments in support of each recommendation were
given in the relevant chapter. For brevity, we do not repeat the rationale
for the recommendations or elaborate on them below.
While the Committee is providing its advice and recom-mendations to
the federal Minister of Health, public health broadly and health emergencies
more specifically are national issues that require pan-Canadian collaboration
and involvement. No one level of government has sole responsibility over
all aspects of public health. And, given the roles and experiences of
various Committee members, we believed it would be a dereliction of responsibility
for us to focus very narrowly on federal issues. Therefore, by necessity,
we present recommendations or sub-recommendations that apply to jurisdictions
in addition to or other than the federal government.
Among these are recommendations that deal with the personal health services
sector and aspects of local public health arrangements where P/T jurisdiction
is relatively clear. Most of these were first set out in Chapter 8. The
information and evidence bearing on those recom-mendations was carefully
collected, albeit primarily from one large province. We repeat these
recommendations in the hope that they may be useful to all P/T jurisdictions.
A further caveat is that many of the recommendations apply to public
health broadly. Infectious diseases are an essential piece of the public
health puzzle, but cannot be addressed in isolation, particularly since
in local health units, the same personnel tend to respond to both infec-tious
and non-infectious threats to community health. Furthermore, the success
of health emergency planning and outbreak management is dependent upon
a broad and solid public health foundation. Implementation of these recommendations
should therefore greatly enhance the capacity of Canada's public health
systems to respond to infectious diseases or other health emergencies,
while simultaneously renewing the general public health infrastructure
and its ability to protect and improve the health of Canadians.
12A. Preparing for the Respiratory Virus Season
As Canada recovers from SARS, preparations must begin for the next respiratory
virus season. SARS may or may not re-emerge; however, even if it does
not, the public health system and the health care system will be forced
to respond to many false alarms. While many of the initiatives needed
to renew the public health system will require months or years of hard
work, there are some areas that, in the Committee's view, require attention
over the next three months.
- A national manual for the investigation and control of SARS outbreaks
should be completed. Parts of this manual exist in Health Canada guidelines,
and in Ontario and British Columbia directives and guide-lines. A coordinated
and detailed package needs to be available to hospitals and public
health units across the country. Health Canada funding and a secretariat,
as well as P/T cooperation and collaboration, will be necessary.
- In addition to a comprehensive technical manual for outbreak containment,
Health Canada should coor-dinate the development of an educational
package about routine practices, SARS, and SARS surveillance for the
coming winter season that can be distributed to hospitals, programs
and institutions involved in educating health professionals, and various
professional associations and stakeholder groups for use in training
front-line staff.
- The F/P/T Conference of Deputy Ministers should immediately designate
lead public health officials to develop guidelines for federal, provincial,
local, and institutional roles and responsibilities during an outbreak
of SARS or similar agent. This work would be antecedent to more comprehensive
and longer-term development of intergovernmental agreements on public
health roles and responsibilities. It should specify the roles of institutions
and various levels of government in both domestic and international
elements of responding to SARS.
- Real-time alert systems for SARS and similar respiratory illnesses
need to be created and coordinated. This includes: mechanisms for rapid
reporting of activity within Canada to Health Canada, mechanisms for
infor-ming Canadians rapidly of developments in other juris-dictions,
and mechanisms for prompt communication of the evolving scientific
data from Canada and other parts of the world. The alert systems must
extend to all health care facilities and, to the greatest extent possible,
should also reach primary care providers.
- National recommendations on surveillance for SARS should ideally
be completed by mid-October. Primary care providers require guidelines
for assessment and referral of respiratory illnesses, given the high
volume of such patients in their offices during the winter months.
Definitive diagnoses will generally be made in emergency departments
and hospitals. Hence, for clarity of responsibility, surveillance planning
should be led by the Nosocomial and Occupational Infections Section
within the Centre for Infectious Disease Prevention and Control [CIDPC]
with input from other key divisions. The surveillance strategy should
include recommendations for appropriate laboratory testing for SARS
and other viral pathogens, a manual of definitions and procedures,
and a software program for data entry at the hospital level for reporting
to local public health units.
- The National Microbiology Laboratory, through the Canadian Public
Health Laboratory Network, should establish guidelines for the necessary
laboratory capacity across the country. Provincial ministries of health
should coordinate provincial and hospital laboratory resources to ensure
that adequate capacity for SARS and other viral testing is available
by mid-November, and that clinicians are educated as to what specimens
are needed, how they should be sent, and the timeframe for reporting
of results.
- Health Canada should work ahead of the Health Emergency Response
Team [HERT] framework to create, organize, and resource two national
epidemic response teams. Their roles, responsibilities and reporting
structure need to be negotiated with the provinces and territories,
with due consideration given to the needs and responsibilities of the
local public health units and other institutions or agencies that the
teams would be sent to assist.
- A full research evaluation and publication of the effec-tiveness
of passenger screening on the detection of 'importation and exportation'
of SARS should be completed as soon as possible. Health Canada should
share these results with other jurisdictions that are performing passenger
screening antecedent to the multilateral dialogue on passenger screening
recommended below.
- International technical liaison offices, at a minimum with the World
Health Organization [WHO] and the US CDC, should be established for
the National Microbiology Laboratory and the CIDPC. Protocols for the
exchange of liaison officers during epidemics must be negotiated.
- Health Canada should coordinate an open scientific meeting late in
the Fall, with objectives that include: updating Canadians on the science
of SARS, discussing plans for SARS surveillance for the winter season,
and reviewing the roles of travel advisories and passenger screening.
12B. Recommendations for Renewal of Public Health in Canada
12B.1 New structures for Public Health
- The Government of Canada should move promptly to establish a Canadian
Agency for Public Health, a legislated service agency, and given it
the appropriate and consolidated authorities necessary to provide leadership
and action on public health matters, such as national disease outbreaks
and emergencies, with or without additional authorities regarding national
disease surveillance capacity.
- The Government of Canada should ensure that the scope of the Agency's
mandate covers public health broadly with appropriate linkages to other
government departments and agencies engaged in public health activities.
The Government's scoping exercise for the new Agency must be informed
by a careful review of public health service provision and health promotion
for First Nations and Inuit Canadians.
- The architects of the new Canadian Agency for Public Health should
ensure that its structure follows a hub and spoke model whereby links
are made to existing regional centres with particular strengths in
public health specializations while some other functions and new ones
are devolved to other regions of the country, with a vision that these
parts support the entire system.
- The Government of Canada should create the position of Chief Public
Health Officer. The Canadian Agency for Public Health should
be headed by the Chief Public Health Officer who would report
directly to the federal Minister of Health and serve as the leading
national voice for public health, particularly in outbreaks and other
health emergencies.
- The Government of Canada should create the National Public Health
Advisory Board, and ensure that nominations of board members come forward
through provincial and territorial as well as federal channels. The
mandate of the Board will be to advise the Chief Public Health Officer
on the development and implementation of a truly pan-Canadian public
health strategy.
- The F/P/T Conference of Deputy Ministers of Health should initiate
a new Network for Communicable Disease Control that would link F/P/T
activities in infectious disease surveillance, prevention, and manage-ment.
This initiative should be started as soon as possible, and integrated
with the existing F/P/T Network for Emergency Preparedness and Response.
- The Canadian Agency for Public Health should create a Public Health
Ethics Working Group to develop an ethical framework to guide public
health systems and health care organizations during emergency public
health situations such as infectious disease outbreaks. In addition
to the usual ethical issues, the Working Group should develop guidelines
for collaboration and co-authorship with fair apportioning of authorship
and related credit to academic participants in outbreak investigation
and related research, and develop templates for expedited ethics reviews
of applied research protocols in the face of outbreaks and similar
public health emergencies.
12B.2 New Funding for Public Health
- The Government of Canada should budget for increases in core functions
of the new Canadian Agency for Public Health that will rise, over the
next 3 to 5 years, to a target of $200 million per annum in incremental
funding beyond that already spent on core federal public health functions.
- The Government of Canada should fund a new Public Health Partnerships
Program under the auspices of the Canadian Agency for Public Health.
The Agency would thereby provide program funding to provinces and territories
to strengthen their public health programming in agreed areas and in
support of the National Public Health Strategy. The funding for the
Public Health Partnerships Program should rise over 2-3 years to $300
million/annum.
- Through the Canadian Agency for Public Health, the Government of
Canada should invest $100 million/annum within 12 to 18 months to realize
the National Immunization Strategy whereby the federal government would
purchase agreed-upon new vaccines to meet provincial and territorial
needs and support a consolidated information system to track vaccinations
and immunization coverage.
- Under the aegis of the new Canadian Agency for Public Health, the
Government of Canada should budget for a Communicable Disease Control
Fund, allocating a sum rising over 2-3 years to $100 million per annum
in support of provincial, territorial, and regional capacity for infectious
disease surveillance, outbreak management, and related infection control
activities, including the sponsorship of a new F/P/T network. Initial
allocations from this Fund should be made to facilitate immediate preparedness
for a possible return of SARS to Canada during the winter season of
respiratory illnesses and influenza.
12B.3 National Public Health Strategy
- The Canadian Agency for Public Health should play a catalytic role
in developing a National Public Health Strategy in collaboration with
provincial and terri-torial governments and in consultation with a
full range of non-governmental stakeholders. The new Strategy should
delineate priorities and goals for key categories of public health
activity along with provisions for public reporting across jurisdictions
of progress towards achieving goals.
- The Government of Canada should incorporate into the new Agency the
current grants and contributions programs of the Population and Public
Health Branch of Health Canada. These grants and contributions should
be reviewed and their uses aligned with the National Public Health
Strategy and made complemen-tary to the Public Health Partnerships
Program.
12B.4 Emergency Planning, Outbreak Management and Crisis Communications
- The F/P/T Network for Emergency Preparedness and Response, in collaboration
with the new F/P/T Network for Communicable Disease Control, should
urgently move ahead with the development of a comprehensive approach
to managing public health emergencies through a pan-Canadian system
that includes:
- harmonizing emergency preparedness and response frameworks
at the federal, provincial and territorial levels;
- developing seamless planning and response capacities as envisaged
by the 31 recommendations of the Special Task Force on Emergency
Preparedness and Response;
- building an integrated F/P/T planning, training and exercising
platform for responding to all-hazard disasters, including public
health emergencies created by large scale disease outbreaks;
- developing and applying a common set of principles, concepts
and capabilities for large scale disease outbreaks; and
- creating the requisite linkages to major employers, the travel
and hotel industry, and relevant NGOs.
- Health Canada in collaboration with provincial/ territorial jurisdictions
should lead the development of a national legislative and policy framework
for a measured, harmonized, and unified response to public health emergencies.
- As part of Health Canada's legislative renewal process currently
underway, the Government of Canada should consider incorporating in
legislation a mechanism for dealing with health emergencies which would
be activated in lockstep with provincial emergency acts in the event
of a pan-Canadian health emergency.
- F/P/T governments should develop and provide training programs and
tools to support local public health units and institutions in systematically
developing, implementing, and evaluating crisis and emergency risk
communication strategies.
- The F/P/T Conference of Deputy Ministers of Health should support
the continued activity of the F/P/T Network for Emergency Preparedness
and Response with a view to enhanced surge capacities in all jurisdictions,
including:
- developing an integrated risk assessment capability for public
health emergency response;
- assessing the National Emergency Stockpile System [NESS] to
optimize its role in supporting the response to large-scale disease
outbreaks; and
- developing and funding the Health Emergency Response Team concept,
including a psychosocial response component, as a practical,
flexible mechanism for addressing the need for human resource
surge capacity.
12B.5 Surveillance/Data Gathering and Dissemination
- The Canadian Agency for Public Health, in partnership with the new
F/P/T Network for Communicable Disease Control, should give priority
to infectious disease surveillance, including provision of technical
advice and funding to provincial/territorial jurisdictions and programs
to support training of personnel required to implement surveillance
programs. The Agency should facilitate the longer-term development
of a compre-hensive and national public health surveillance system
that will collect, analyze, and disseminate laboratory and health care
facility data on infectious diseases and non-infectious diseases to
relevant stakeholders.
- Assuming some lag time to inception of a new Agency or F/P/T Network,
Health Canada and the provinces and territories should urgently commence
a process to arrive at business process agreements for collaborative
surveillance of infectious diseases and response to outbreaks. (This
work dovetails with the above-noted SARS surveillance initiative for
the Fall of 2003). The business processes for infectious disease surveillance
would be extended over time with support from the Agency's Centre for
Surveillance Coordination and the Public Health Partnerships Program,
to a national system for non-communicable diseases and population health
factors.
- The Government of Canada should seek the establish-ment of a working
group under the auspices of the Canada Health Infoway Incorporated
and Health Canada and/or the new Canadian Agency for Public Health,
to focus specifically on the needs of public health infostructure and
potential investments to enhance disease surveillance and link public
health and clinical information systems.
12B.6 Clarifying the Legislative and Regulatory Context
- The Government of Canada should launch an urgent and comprehensive
review of the application of the Protection of Information Privacy
and Electronic Documents Act to the health sector, with a view
to setting out regulations that would clarify the applica-bility of
this new law to the health sector, and/or creating new privacy legislation
specific to health matters.
- The Government of Canada should launch a compre-hensive review of
the treatment of personal health information under the Privacy
Act, with a view to setting out regulations or legislation specific
to the health sector.
- The Government of Canada should embark on a time-limited intergovernmental
initiative with a view to renewing the legislative framework for disease
surveil-lance and outbreak management in Canada, as well as harmonizing
emergency legislation as it bears on public health emergencies.
- In the event that a coordinated system of rules for infectious disease
surveillance and outbreak management cannot be established by the combined
effects of the F/P/T Network for Communicable Disease Control, the
Public Health Partnerships Program, and the above-referenced intergovernmental
legislative review, the Government of Canada should initiate the drafting
of default legislation to set up such a system of rules, clarifying
F/P/T interactions as regards public health matters with specific reference
to infectious diseases.
12B.7 Renewing Laboratory Infrastructure
- The F/P/T Conference of Deputy Ministers of Health should urgently
launch an expedited review to ensure that the public health laboratories
in Canada have the appropriate capacity and protocols to respond effectively
and collaboratively to the next serious outbreak of infec-tious disease.
The review could be initiated through the Canadian Public Health Laboratory
Network and engage with the new F/P/T Network for Communicable Disease
Control as soon as the latter is operational.
- Health Canada, in collaboration with the relevant provincial/territorial
authorities, should urgently initiate the development of a laboratory
information system capable of meeting the information management needs
of a major outbreak or epidemic. The laboratory information system
must be designed in such a way as to address the functional needs of
laboratories, be readily integrated with epidemiologic information,
and be aligned with data-sharing agreements across jurisdictions and
institutions.
- The F/P/T Conference of Deputy Ministers of Health should launch
a full review of the role of laboratories in national infectious disease
surveillance systems, with the aim of creating a more efficient, timely,
and integrated platform for use of both public and private laboratories
in surveillance.
- The Government of Canada, through the Canadian Agency for Public
Health, should invest in the expansion of the Canadian Public Health
Laboratory Network to integrate hospital and community-based laboratories.
This includes alignment of incentives and clarification of roles and
responsibilities for infectious disease control. The relevant monies
could flow from the Public Health Partnerships Program or the Communicable
Disease Control Fund.
- The Canadian Agency for Public Health should give priority to strengthening
the capacity of provincial/ territorial laboratories as regards testing
for infectious diseases. The Agency should provide incentives to increase
the participation of provincial public health laboratories in national
programs. It should support provincial/territorial public health laboratories
in the creation of provincial laboratory networks equivalent to the
Canadian Public Health Laboratory Network; these would connect in turn
to the national network. The relevant monies would flow from the Communicable
Disease Control Fund.
- The Canadian Agency for Public Health should support participation
and leadership in international laboratory networks by our national
laboratories, thereby building on the success of the international
collaboration in the response to SARS.
- Health Canada, in collaboration with provincial/territorial authorities,
should sponsor a process that will lead to a shared vision for the
development, incorporation, and evaluation of leading-edge technology
in the public health laboratory system. Among the issues that require
elucidation are the role of national systems for the real-time surveillance
of infectious disease through molecular fingerprinting of micro-organisms,
toxicology capacity to detect illnesses caused by the poisoning of
natural environments and occupational hazards, and the potential for
linking genetic testing and infectious disease surveillance in novel
programs that would target cofactors associated with the development
of chronic diseases.
- A national report card of performance and gap assess-ment for public
health laboratories should be developed through the Canadian Public
Health Laboratory Network and/or the F/P/T Network for Communicable
Disease Control, allowing comparative profiling of various provincial
and national laboratories against international standards.
12B.8 Building Research Capacity
- The Canadian Agency for Public Health should earmark substantial
funding to augment national capacity for research into epidemiologic
and laboratory aspects of emerging infectious diseases and other threats
to population health. This enhanced national public health science
capacity should be strongly linked to academic health institutions
through co-location, joint venture research institutes, cross appointments,
joint recruitment, interchange, networks and collabo-rative research
activities.
- The Canadian Agency for Public Health, in partnership with provincial/territorial
governments and through the F/P/T Network for Communicable Disease
Control, should directly invest in provincial, territorial, and regional
public health science capacity.
- The F/P/T Network for Communicable Disease Control, in partnership
with the CIHR and the Canadian research community, should develop clear
protocols for leadership and coordination of future epidemic research
responses.
- The Canadian Agency for Public Health and the F/P/T Network for Communicable
Disease Control should ensure that epidemic response teams initiated
as part of the Health Emergency Response Team [HERT] concept, provide
not only surge capacity for outbreak containment per se, but also a
mobile "B-team" and investigative infrastructure, including epidemiologists,
programmers, and analysts.
- The Canadian Agency for Public Health, in partnership with provincial/territorial
governments, should develop clear rules, reinforced by intergovernmental
agreements, on the sharing of information, the establishment of national
databases, and the use of biologic materials for research in response
to epidemics.
- The Canadian Agency for Public Health, in collaboration with the
CIHR, should establish a task force on emerging infectious diseases
to recommend research priorities and funding mechanisms. The Agency,
in collaboration with the CIHR and other national research funding
bodies, should support the development of special funding mechanisms
and processes for fast-tracking research related to epidemics of infectious
diseases.
- The Canadian Agency for Public Health, in partnership with research
agencies and provincial/territorial governments, should work with universities
to improve research training opportunities in infectious diseases and
outbreak management for the full range of involved disciplines. This
capacity-building focus should be a priority within the broader health
human resource strategy of the Agency.
- The Government of Canada should strengthen its R&D functions
in international health outreach, with particular emphasis on emerging
infectious diseases on a global basis.
- The Government of Canada should foster workable public-private partnerships
with the biotechnology, information technology, and pharmaceutical
industries for shared research interests in the realm of emerging infectious
diseases, including new vaccines, antiviral compounds, immunotherapies,
and diagnostic technology.
12B.9 Renewing Human Resources for Public Health
- Health Canada should engage provincial/territorial departments/ministries
of health in immediate discus-sions around the initiation of a national
strategy for the renewal of human resources in public health. This
F/P/T strategy should be developed in concert with a wide range of
non-governmental partners, and include funding mechanisms to support
public health human resource development on a continuing basis.
- Health Canada should catalyze this strategy by urgently exploring
opportunities to create and support training positions and programs
in various public health-related fields where there are shortfalls
in workforces (e.g., community medicine physicians, field epidemiolo-gists,
infection control practitioners, public health nursing, and others).
- The Canadian Agency for Public Health should develop a National Public
Health Service, with a variety of career paths and opportunities for
Canadians interested in public health. The National Public Health Service
should include an extensive program of secondments to and from provincial/territorial
and local health agencies, with arrangements for mutual recognition
of seniority and a range of collaborative opportunities for advancement.
- Educational institutions, in collaboration with teaching hospitals
as applicable, should develop contingency plans to limit the adverse
impact on their students and trainees from infectious disease outbreaks,
while maximizing learning opportunities from these events. These plans
should include communications, education regarding infection control,
preparedness with appropriate protective gear, guidelines for support
of students/trainees in quarantine or work-and-home isolation, strategies
to limit the impact of impeded access to usual teaching and research
sites, and guidelines for the involvement of students in the care of
patients with serious infectious conditions.
12B.10 International Issues
- The Government of Canada should take the lead, along with an international
consortium of committed partners, in the detection of global emerging
diseases and outbreaks. This should be done through enhance-ments to
the Global Public Health Intelligence Network and similar programs.
- The Canadian Agency for Public Health should have a mandate for greater
engagement internationally in the emerging infectious disease field,
including the initiation of projects to build capacity for surveillance
and outbreak management in developing countries.
- The Canadian Agency for Public Health should be the institution responsible
for direct communication with the World Health Organization, the US
CDC, and other international organizations and jurisdictions. The Agency
should disseminate within Canada infor-mation received from international
organizations and jurisdictions on global health threats, and in turn,
it would inform the World Health Organization and other jurisdictions
of relevant Canadian events. During out-break situations, the Agency
would perform the role of liaising between Canadian and international
organiza-tions and jurisdictions to maximize mutual learning.
- The Government of Canada should review its travel screening techniques
and protocols with a view to ensuring that travel screening measures
are based on evidence for public health effectiveness, while taking
into account the financial and human resources required for their implementation
and sustained operation. The Government of Canada should also initiate
a multilateral dialogue with other nations that are currently engaged
in SARS travel screening to determine whether and when some or all
of these measures should be modified or discontinued.
- The Government of Canada should seek the support of international
partners to launch a multilateral process under the auspices of the
World Health Organization that would set agreed-upon standards of evidence
for the issuance of travel advisories and alerts by member states.
The multilateral process should also seek to determine the role of
WHO in issuing travel advice, and to establish a procedure for providing
advance notice for possible alerts and advice. The notice process should
provide a mechanism for consultation with and a response by the target
country.
- The Government of Canada should ensure that an adequate complement
of quarantine officers is main-tained at airports and other ports of
entry, as required. Fully trained and informed quarantine officers
should be available at airports to deal with health threats, to provide
information to and educate airport staff, customs officials, and airline
personnel concerning the recognition of illness and measures to be
taken to contain risk. Close collaboration with airport authorities
and airline personnel to clarify responsibilities in the event of a
health threat is necessary.
- The Government of Canada should ensure that incoming and outgoing
passengers are provided with health information about where and when
health threats exist, including any precautionary measures to take,
how to identify symptoms of the disease, and what first steps to take
in case of suspected infection. A partnership with the travel industry
would facilitate this process so that information could be provided
at the time of bookings. The current Health Canada web site containing
information for travelers should be made more prominent and its existence
promoted.
- All federal/provincial/territorial/municipal response plans should
include port/cruiseship- and airport/airplane-specific protocols for
infectious diseases as well as protocols for employee protection guidelines
and decontamination of aircraft, ships, and/or facilities. Jurisdictional
issues concerning travel and health need to be resolved through the
plan. The plan should be developed with input and buy-in from local
health officials, response agencies, ports, airports and the relevant
companies in the shipping and airline industries.
12B.11 Clinical and Local Public Health Issues
- F/P/T departments/ministries of health should facilitate a dialogue
with health care workers, their unions/ associations, professional
regulatory bodies, experts in employment law and ethics, and other
pertinent government departments/ministries concerning duties of care
toward persons with contagious illnesses and countervailing rights
to refuse dangerous duties in health care settings.
- The CEOs of hospitals and health regions should ensure that there
is a formal Regional Infectious Disease Network that can design and
oversee implemen-tation of hospital strategies for responding to outbreaks
of infectious disease. These Networks should map out programs of hospital
surveillance for infectious diseases that cross-link institutions and
connect in turn to a national surveillance program so as to integrate
hospital and community-based information.
- As part of its activities, the F/P/T Network for Emergency Preparedness
and Response should examine provincial and federal emergency measures
with a view to ensuring that all emergency plans include a clear hierarchy
of response mechanisms ranging from the response of a single ministry
to a response from the entire govern-ment, with appropriate cross-linkages.
- Provincial/territorial ministries and departments of health should
ensure that emergency plans include provisions for appropriate compensation
of those individuals required to respond to and those affected by an
emergency.
- Provincial/territorial ministries and departments of health should
revise their statutes and regulations to require that every hospital
or health region has formal-ized and updated protocols for outbreak
management. These plans must include mechanisms for getting information
and supplies to those outside the institutional sector, such as primary
care physicians, ambulance personnel/paramedics, and community care
providers.
- The CEO of each hospital or health region should ensure that each
hospital's protocol for outbreak management incorporates an understanding
of the hospital's interrelationships with local and provincial public
health authorities.
- The CEO and relevant clinical chiefs of each hospital or health region
should ensure that there is continuing education for hospital staff,
particularly front-line health care workers, to enhance awareness of
outbreak/ infectious disease issues and institutional/clinical infection
control.
- Provincial/territorial ministries and departments of health should
ensure that all key health leaders are trained in crisis communications.
Hospital and health region CEOs in turn should ensure that clinical
leaders and key administrators are also trained in crisis communications
and that the organization has a clear cut protocol for providing all
relevant information to staff and hearing their concerns in a timely,
respectful, and participatory fashion.
- Provincial/territorial ministries and departments of health should
require through regulation and provide funding to ensure that emergency
departments have the physical facilities to isolate, contain and manage
incidents of infectious disease. Emergency departments should also
be equipped with appropriate infostructure to enable their participation
in infectious disease surveillance networks, including receipt of all
necessary national and international alerts.
- Provincial/territorial ministries and departments of health should
provide the necessary funding for renovation to achieve minimal facility
standards for infection control in emergency departments.
- Provincial/territorial ministries and departments of health should
ensure that each hospital has sufficient negative pressure rooms for
treatment of patients with infectious disease.
- Provincial/territorial ministries and departments of health should
ensure that, for emergency situations, at least one hospital in each
'region' of a province/territory has sufficient facilities and other
infrastructure to serve as a regional centre to anchor the response
to outbreaks of infectious disease.
- Provincial/territorial ministries and departments of health should
ensure that systems are developed to ensure that providers and the
public receive timely, accurate and consistent information and directives
during an outbreak of infectious disease.
- Public health managers and facility/regional health authority CEOs,
in collaboration with relevant unions, professional associations and
individuals, should create a process/mechanism to include front-line
public health and health care workers in advance planning to prepare
for related to outbreaks of infectious diseases and other health emergencies.
Occupational health and safety issues should be given prominence in
this process.
- Provincial/territorial ministries and departments of health should
engage the Canadian Council for Health Services Accreditation to work
with appropriate stakeholders to strengthen infection control standards,
surveyor guidelines and tools that are applicable to emergency services
as well as outbreak management within health care institutions. The
standards should also include descriptors of the appropriate expertise
required to maintain hospital infection control.
12C. Postscript
The SARS story as it unfolded in Canada had both tragic and heroic elements.
The toll of the epidemic was substantial, but thousands in the health
field rose to the occasion and ultimately contained the SARS outbreak
in this country. The Committee emphasizes that in drawing lessons from
the SARS outbreak, our intent has been not to 'name, shame, and blame'
individuals, but rather to move and improve systems that were suboptimal.
The challenge now is to ensure not only that we are better prepared for
the next epidemic, but that public health in Canada is broadly renewed
so as to protect and promote the health of all our citizens. It is to
these latter ends that the Committee's recommendations have been offered.
We believe the recommendations represent a reasonably comprehensive and
affordable starting point for strength-ening and integrating public health
at all levels in Canada. As our colleagues in government contemplate
these recommendations, the Committee commends to them the vision of Benjamin
Disraeli (1804-1881) who, on introducing his Public Health Act to British
Parliament in 1875, remarked that public health was the foundation for "the
happiness of the people and the power of the country. The care of the
public health is the first duty of a statesman." Less eloquently, the
Committee in closing repeats the simple question we put earlier to all
health ministers, finance ministers, and first ministers: If not now,
after SARS, when?
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