Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 13 - Evidence - October 7, 2010
OTTAWA, Thursday, October 7, 2010
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:31 a.m. to study Canada's pandemic preparedness.
The Honourable Art Eggleton (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
Today we continue with our study on pandemic preparedness with the theme of surveillance, laboratory preparedness and liaison with international public health networks.
Our meeting this morning will have two segments. The first one takes us to Mexico via video conference, and in one hour we will start the second part with two people who will be here with us.
Our first witness is Dr. Celia Alpuche, Deputy Director General of the Institute of Epidemiological Diagnosis and Reference in Mexico, where they are at the centre of dealing with issues of flu. Dr. Alpuche is also involved in coordinating the national network of laboratories of public health in matters of diagnosis, investigation, training and technological development.
A very warm welcome to you, Dr. Alpuche. If you could make some opening remarks, we will then have a question and answer period.
Dr. Celia Alpuche, Deputy Director General, Institute of Epidemiological Diagnosis and Reference: Good morning. Here in Mexico I direct the National Reference Laboratories' Center for Epidemiological Surveillance and Disease Control. I am glad to be talking to you and I am willing to respond to any questions you may have, including on our current collaboration with the National Microbiology Laboratory of the Public Health Agency of Canada in Winnipeg, and all the direct and indirect help that we have received from Dr. Frank Plummer and his group.
The Chair: Could you tell us a little more about that collaboration and how you feel it has benefited both of our countries, particularly during the recent H1N1 pandemic?
Dr. Alpuche: To tell you a little more about how we started the collaboration, I started in this position in Mexico in February of 2007, and I had the opportunity to meet Dr. Frank Plummer in May of 2007 at the Global Health Security Action Group, GHSAG, laboratory network meeting. The GHSAG is based in Canada and is formed by the G7 countries plus Mexico. The Global Health Security Laboratory Network is a very successful working group dedicated to all the goals of this group. It is mostly based on preparedness and responding to different emerging infectious diseases.
I had the opportunity to interact with various members of the working group, particularly with Canada and the United States. Although we previously had the North American partnership collaboration working group, the G7 laboratory network was the most important working group that allowed me to join with and work in this collaboration.
I visited the National Microbiology Laboratory, NML, in Winnipeg in 2008 and had the great opportunity to see the infrastructure you have there. As we were starting a project to build a new national reference laboratory building in Mexico, that was very useful. I met with the expert company that designed the NML, and I was able to get that company to do the preliminary design for our laboratory here in Mexico.
In the week of April 13 to 17, 2009, we recognized that we had an increase of severe acute respiratory diseases in Mexico City and some of the surrounding areas, and I needed some help because we did not have the final diagnosis to define the cause of the disease.
In discussion with my authorities, I decided that it was best to get some help from our North American partners. The Centers for Disease Control and Prevention, CDC, is the national collaborative centre within the WHO influenza laboratory network. We have a signed agreement with CDC to send them all possible specimens for definition. Even the quality assurance of our diagnosis is done through the CDC influenza division.
However, once we knew of the great experience that you had related to the SARS epidemic, and because at that time we did not know exactly what was causing our respiratory problem in Mexico, we thought it was a good opportunity to get some help from the NML; they have a great algorithm to work with unknown pathogens in respiratory diseases.
Since we had had previous experience working with Dr. Plummer through GHSAC and had received help and advice from him on various matters, it was easy for me to send him an email on Friday, April 17, telling him about the situation and asking for his advice and about the possibility of sending some samples to Canada in order to benefit from his knowledge as an infectious disease expert. We tried to get help from both CDC and Canada at the same time.
Dr. Plummer emailed me back immediately, and we set up a teleconference for the next day to discuss the situation in more detail. We were doing the first direct and intensified survey in Mexico City of hospitalized patients over that weekend, the 18th and the 19th. We decided, in conjunction with Dr. Plummer, that we would try to prepare all the samples from the cases that we surveyed over the weekend and get all the necessary permissions to send samples to NML at the beginning of the week. On the following Monday, I got the permissions to ship the samples to NML and did so.
The first shipment arrived at NML on Tuesday, April 21. The same day, almost at midnight that Tuesday, Dr. Plummer called me on my cell phone to tell me that they determined that it was influenza and they were asking permission to keep going with the sequencing to define it as a new virus, possibly the new virus that was already published by CDC.
The next day, Wednesday, April 23, 2009, around two o'clock in the afternoon, Dr. Plummer called directly to my cell phone to say that he wanted to have a teleconference, and he informed me that we have the new virus, which was causing the cases we were seeing in Mexico. His call allowed me to immediately tell my authorities — the deputy secretary of disease prevention and health promotion, Dr. Mauricio Hernández; and from him to the secretary of health, Dr. Cordoba — the results that Dr. Plummer was giving me by phone. An hour later I was given the sequencing of some of the genes of these viruses that proved the presence of the new virus. With that information in my hands, I was able to prove to my authorities that we had a new virus in Mexico, and we started our response because of that.
The same night, at eight o'clock, we received confirmation of the virus in the different lots of samples from CDC with the same results. There were different batches of samples. First they were confirmed by NML in Canada, and later the same evening they were confirmed by CDC.
That was April 23. On the night of April 26, we had people coming from Canada and CDC to help us in the laboratory to set up the new techniques. By the Monday, April 27, we were working all day long to develop the new technique here in Mexico. We even got reagents and supplies coming from both countries — Canada and the United States — to start with the diagnosis. We had three machines, the same ones being used at CDC and NML, and we were able to start with a new diagnosis later the same day, in the evening of April 27.
Personnel from NML stayed with us for a month to help us develop all these new diagnoses and also to help us set up the baseline conditions to set up different labs around the reference lab, and to be able to expand the diagnosis. That helped a lot to define how the epidemic was going on in Mexico and how to work with different responses in different areas in Mexico. We have geographic differences in Mexico, so it was helpful to have people from NML and from CDC to help us during the crisis to help develop the technology quickly. It was not just the technology itself. It was more than that. It was the organization of the laboratory response during the main crisis of the pandemic.
The Chair: Thank you very much. That is a very detailed description of what sounds like a great collaboration that you had both with CDC in the United States as well as with our laboratory here in Canada.
By the way, Dr. Plummer will appear before the committee later on this morning.
We have also been looking at lessons learned, as I am sure you do — everyone does — out of the H1N1 pandemic, because we want to be ready for the next one, whenever that happens. Does anything in particular stand out for you as lessons learned about this crisis that you hope will bring about some changes, either in Mexico or in your collaboration with Canada?
Dr. Alpuche: In Mexico, particularly in the area of laboratories, we have run different lessons-learned meetings to define what we did, what is okay, what we need to prepare even better for the future. In terms of the laboratory in Mexico, it was the need to really think to the future to develop stronger technologies and also to decentralize the confirmatory technology for emerging infectious diseases, not only to have this reference lab but to have better technology in different areas in Mexico to have a much better response.
That was the first thing we were able to detect and that is very good for us now, because now we have a very good network of molecular biology technology developed based on the influenza but the same platform. We were able to expand that platform to other diagnoses and those will improve even more. We have a very strong network now that will help us a lot, and now we need to maintain that network.
The most important thing is the quality of work. It is not just to have it, but to maintain it in good shape and to have quality assurance of the system that we are working with. That is very important.
The other important thing is human resources. We need to have human resources that are well trained to respond, not just in the techniques themselves but also to respond during a crisis. That is the other collaboration that we have going on with NML. We are working with the command system, which is very important in general, and also in more specific areas such as laboratories and laboratory networks. That is a current collaboration that we have with NML. We are receiving training to develop our organization using the incident command system; that is the other lesson learned during the pandemic, and we are working on that.
The other important thing is risk communication: How will we be able to communicate risk and not create panic? That is even harder for us, because we are depending on different groups that are the ones who will communicate risk based on our results. We still do not have the real answer. We are still working on a plan to improve our risk communication, not just within the country but also internationally. It is very important for us to speak the same language, all of us, to have a much better response.
Plans are not perfect, it is true, but it is much better to have a plan and to work based on a plan than to have nothing. We did have a plan, and one of the things that we learned about our pandemic influenza preparedness and response plan is that we needed to have our standard operational procedures, SOPs, described in more detail. Our SOPs were very general and could not be adapted very easily if the circumstances were not really the same as those that were thought of during the plan. We need to have more detailed SOPs, but at the same time we need SOPs that we are able to adapt to different circumstances. We are still working on a plan to define how we will work better on those SOPs. We do not have much yet.
Open communication, both within the country and internationally, is also very important. This time because we got the final confirmation of this virus through Canada, not just those samples but, after all, they were doing testing for us. They did almost 2,500 independent sample tests at NML for us in the beginning when we were just adapting the diagnosis here. To communicate all that information, it is very important to do it openly and transparently. It is very important for the international community, and I think we did that.
We are hoping we can still do that, but the important lesson learned is that no matter what agreement there is internationally, and all the specific recommendations the WHO will be giving during a pandemic, there will always be political issues that will end up with specific recommendations by countries that will hurt some of the countries if they are unable to communicate the information transparently. You know that very well. They closed the borders and travel to Mexico. That resulted in an important economic and social impact to our country. That is not good. Perhaps some of the countries that will find themselves in the same situation will not be as open as we were in the beginning. That will not be good for the international community.
These are the general considerations we have. I do not have other comments about the international collaboration that we had because I am saying openly that it was great. If this North American collaboration ever worked, it was this time. We had great collaboration, particularly in the laboratory area. We also had some epidemiologists in Canada and the United States working with us. That was very useful during the crisis.
We really learned how to work together. We learned an important lesson that we cannot forget, and we can get better at it.
The Chair: That is helpful. You emphasized communication. We are having that same discussion here as well; communication is key in this situation.
Yesterday we heard about the use of vaccines and antivirals during the pandemic. We were able to have an assured supplier within Canada so that we had the number of doses we needed for vaccines. About 45 per cent of the population was inoculated. Some felt it should have been higher, but it was probably higher than it was in many countries. Could you tell us about your vaccine program, how many were vaccinated and how it went in your country?
Dr. Alpuche: That is not my area of jurisdiction in Mexico. I am working more for epidemic surveillance. I can give you the information generally, but I do not have more detailed information with me.
We have an annual program for seasonal influenza vaccination in Mexico that targets group risk, mostly in children less than three years old and in older people more than 50 years of age. We also have the immune-compromised patients and some people identified for seasonal influenza. For this particular pandemic influenza, in the beginning we did not have more information related to this virus, even before knowing that we had this new virus. When we started to see the increase in respiratory infections, we used the remaining vaccines that we had for seasonal influenza immediately. In April, we started with the vaccination of other groups, particularly health workers and others, with the seasonal influenza vaccine.
About one or two weeks later, we knew that we had this new virus and that we would need the new vaccine. Mexico has a pre-contract to buy vaccine during a pandemic. We were able to buy 30 million doses of the vaccine. The one lesson learned is that there is not enough vaccine production in the world during a pandemic. That was obvious to everyone.
One of the obvious problems we had in Mexico is that without our own production, it did not matter that we had pre- contracts to buy the vaccine. We got the vaccine once the country that was producing it had covered its own needs. Those things happen. They were talking about target groups as priorities, but all the countries that had their own production were doing their own considerations to do the vaccination. We were not able to get the vaccine until late in December, and it was not a lot of the vaccine. Most of our contracts were for January. Our campaign will start in January, February, and so on. We have enough proof that we vaccinated close to 28 million people to use all of the vaccines that we were able to buy. However, the communication to find the risk groups for vaccination during a pandemic is hard. That is more my personal point of view and my personal knowledge and not the government's position, because that is not my area of jurisdiction.
The Chair: I understand. Thank you very much. I will now turn the questioning over to my colleagues at the table. I will start with Senator Ogilvie, the deputy chair of this committee. Senator Ogilvie is from Nova Scotia.
Senator Ogilvie: Thank you, doctor. You have given us a remarkable summary this morning. It was a frank summary of the actual experience that you were directly involved in at a critical point in the detection and development of the response to the outbreak. It was enormously helpful, even just hearing it from your personal point of view.
I have understood all that you have said and it has been extremely helpful to me. I would like to get it in the exact chronological sequence. Could you give me the precise calendar day and year that you sent those first samples off to determine the nature of their contents? You gave the days of the week, and so on. Could you remind me of the actual calendar date?
Dr. Alpuche: Yes. Hopefully I am not wrong about the dates. The first week we started to see this was the weekend of April 18 and 19. Those are the days that I talked with Dr. Plummer by phone. I sent an email on April 17.
The day that I talked by phone with Dr. Plummer was Saturday, April 18. The email was sent on April 17. I sent samples on Tuesday, April 21. I was able to get all the permissions ready to send the samples. Those samples arrived on Wednesday, April 22. The same day, close to midnight, I received the first result from Dr. Plummer.
Senator Ogilvie: Thank you very much. That was 2009, right?
Dr. Alpuche: Yes, 2009.
Senator Ogilvie: Is my recollection correct that you were involved at the very beginning of the identification of this particular outbreak?
Dr. Alpuche: Yes.
Senator Ogilvie: I wanted it in the absolute sequence because you were at the forefront. Yet, because of collaborations you had developed, within a short period of time you were able to identify an outbreak of a new strain of the virus, which could have potential significance.
Dr. Alpuche: Exactly.
Senator Ogilvie: The kinds of things you have outlined regarding the international collaboration and the network you had were critical to the speed with which this was recognized. I find your comments towards the end of your summary interesting, namely that Mexico suffered the same result that we in Canada suffered with regard to SARS: that is, the travel issue for specifically Toronto, Canada, at the time of the SARS outbreak. You experienced that at the very beginning of this outbreak, and I have noted in particular your comments with regard to how we are able to handle those issues in addition to the actual medical situation that is under way.
I found your observations enormously interesting and helpful with regard to the international nature of this situation, the detection at the very beginning of an outbreak, and the steps that you took so rapidly to be able to move it forward. Thank you very much.
Senator Martin: Thank you very much for the information you have shared with us. I echo what Senator Ogilvie has said. The summary you provided helps us to understand the value of this international network.
You also highlighted the lessons learned on Mexico's part from the Canadian laboratories and officials. My question is with regard to the exchange of information from Mexico to Canada. Was there information that you were able to share with Canadian labs and officials that was helpful to Canada in dealing with the pandemic outbreak in Canada?
You mentioned that the technology was more advanced and that we had learned from our previous SARS outbreak. In terms of perhaps some of the training that has taken place in Mexico, what was the exchange of information? I should pose this question to our next witness as well, but what were some things that you felt you were able to impart to or share with Canadians?
Dr. Alpuche: Are you talking about the current information we have or during the crisis?
Senator Martin: During the last pandemic outbreak, with the collaboration that you undertook in the exchange of knowledge and information, what were some things that you felt the Mexican officials and scientists and so on were able to share with the Canadian labs?
Dr. Alpuche: I need to be very honest. In the moment of the situation we were living through here in Mexico, it was obvious that we were too overwhelmed with our own situation to be able to discuss what information we could share with Canada or the U.S., other than the information we were receiving during the pandemic regarding the geographic differences, the susceptibility of the virus, the measures we were taking here, and we were providing this information immediately to our North American partners. Other than that, I cannot say specifically what other information we provided to Canada that could be used to help with its pandemic, other than the information we provided immediately as we were receiving that information.
Senator Martin: That underscores what you said before: the real value of this international network, the collaborative process, the ability to communicate almost instantly, and the fact that we are living in this age of global communication, was extremely helpful to everyone involved.
Dr. Alpuche: Exactly.
Senator Callbeck: Thank you, doctor, for sharing your experiences with us.
I want to ask about a report entitled Response to Pandemic (H1N1) 2009 in the Americas. It speaks about the fact that 35 are countries involved in the Pan American Health Organization — Canada, the U.S. and Mexico being three of them — and that there was a difference of opinion on the point-of-entry surveillance and monitoring of the potential cases.
Could you comment on that? Did that cause real problems? If so, are we working on that so that the next time it is corrected?
Dr. Alpuche: Let me see if I understood the question correctly. Are you asking about whether the definition of cases or the entry of information of the Pan American Health Organization caused some confusion in the beginning?
Senator Callbeck: Was the definition the same for Mexico, the United States and Canada? I read somewhere that it was not.
The Chair: Senator Callbeck, do you have any further elaboration that might help the doctor?
Senator Callbeck: Was the definition different among Mexico, Canada and the United States?
Dr. Alpuche: There were mild differences in the definition and the entry of cases. I think the beginning of the confusion was that we were seeing a higher fatality rate here in Mexico than in other countries, and we were seeing the tip of the iceberg in terms of the severe cases. We were not seeing the entire number of cases. There was not a real difference in the case definition or the way that it was defined to collect the information. There was just a moment of confusion during the crisis here in Mexico. We were seeing only the severe cases. We were not conducting outside surveillance to see all types of cases.
Once we corrected that situation, in the second week of the problem, it was solved. At the end, we could all see the same tendency of the epidemic. I do not think the differences hurt that much at the beginning of the situation.
Right now, we are working even more to have a binational or tri-national case definition. We need to work within tri-national agreements in terms of pandemic preparedness to strengthen that part even more. However, I do not think this created too much of a problem after the second week; it was just in the first week that we had those differences.
Senator Callbeck: That answers the definition question.
The first question I asked was about the report stating that there were differing views from country representatives of the Pan American Health Organization about the importance of point-of-entry surveillance and the monitoring of the cases.
Dr. Alpuche: First I want to say that the International Health Regulations, IHR, are very important. This system will help us to homogenize the information with regard to the point of entry or whatever we are working on. A lesson learned is that we need to work harder to implement the International Health Regulations.
I am not sure I understand your question well.
Senator Callbeck: I read that among the 35 countries there were many different views about the importance of point- of-entry surveillance and the monitoring of these cases.
Dr. Alpuche: Yes. Point-of-entry surveillance is very important. We need to focus on the definition of point-of-entry surveillance. For example, one issue we have been discussing with the United States is that they are focused on border surveillance, and there are no geographic borders anymore. We have airports, with many airplanes travelling between our three countries, so we need to work on the International Health Regulations and the port entrance surveillance definitions that are there to homogenize the type of surveillance we have, working within the International Health Regulations. It will not only work for us but for the 35 countries that you are talking about.
I do not want to say more. Also, this is not my expertise, just my general point of view; I am a laboratory person.
Senator Callbeck: Thank you very much.
Senator Merchant: I too want to thank you very much for your detailed information on how you approached this pandemic.
A couple of times you talked about the geographical difficulties that a country like Mexico is faced with. How did you go about collecting so quickly — because you did things quickly in the beginning, as you provided us with your daily progress. How did you go about collecting the specimens? You talked about decentralizing. Could you elaborate a little on the changes that you would now make, having lived through this experience?
Dr. Alpuche: As a correction, I was not talking about geographical difficulties, rather geographical differences in the presentation of the pandemic in terms of time, as well as the magnitude of the spread of the virus within the different geographical areas of Mexico.
We have had an epidemiological surveillance system in Mexico for a long time now. It was reinforced in the 1980s, mostly towards the end of that decade. We have almost 19,000 units reporting to our national epidemiological surveillance system in Mexico.
This influenza surveillance system was in place and mostly reinforced in 2001, and it was even better in 2005. In fact, since 2007, it was completely reorganized in central clinics that are all around the country.
We had a problem before the pandemic. Clinicians were not thinking influenza as a diagnosis, so we received very few samples, mostly in ambulatory cases. The first focus of our orientation was in separate cases because it was not obvious for primary care clinicians to think influenza. As a result we received very few samples.
Once information about the pandemic was out in the early weeks, this network of epidemiological surveillance started to think about influenza and began clinical diagnoses of influenza-like illness, not only in the severe cases but also in the ambulatory cases, and they started to take samples from those patients. Then we had the opposite situation: We were overwhelmed with samples.
That is another problem, that a pandemic can create a crisis in laboratory diagnoses during emerging infections. Even if we defined the amount of testing, that we did not need to have a test for each patient, there was so much demand for it. That was the reason we were able to collect samples from across the country.
Senator Merchant: Canada is a very large country, and the topography is varied. As a result, we have many isolated communities. Do you have many communities like that in Mexico? If so, were you able to work with those isolated communities?
Dr. Alpuche: Yes, we have some isolated communities, mostly in some of the poorest states in the country, which are located to the south of the country, such as Tlapa. In some of the upper areas of those states are located very isolated communities.
However, still in those areas or close to those areas, we have units for epidemiological surveillance. Therefore, we were able to reach them. Of course, we have weaknesses in those areas, as you have mentioned. We have to recognize that. However, in each one of the states, the epidemiological surveillance state groups were doing more active surveillance even in the isolated areas. That was the reason we were able to obtain information.
We are sure there were many more cases than we initially thought. Once we finish our analysis of prevalence, we will see this information much better.
Senator Merchant: Thank you very much.
The Chair: Honourable senators, are there any further questions?
Dr. Alpuche, we are out of questions, so you have answered everything and even more. You have given us some very good and helpful information. We have a better appreciation of the collaboration that exists internationally, particularly between our lab here and your operation in Mexico. Thank you very much for being with us, and we wish you well in your future endeavours.
Dr. Alpuche: Thank you. It was a pleasure to speak with you.
The Chair: On our next panel, let me welcome Dr. Frank Plummer, Scientific Director General, National Microbiology Laboratory, Public Health Agency of Canada. To give you a little background, after Dr. Plummer completed his medical degree, he went to Nairobi to study infectious diseases. He spent the next 16 years researching HIV/AIDS. In 2003, he was appointed director general of the Centre for Infectious Disease Prevention and Control, and in June 2005, Dr. Plummer and his team received funding from the Bill & Melinda Gates Foundation to work on developing a potential vaccine against HIV/AIDS.
Dr. Todd Hatchette, Associate Professor, Department of Microbiology and Immunology, Dalhousie University, earned his MD from Memorial University in Newfoundland. He completed internal medicine training at Memorial and followed that with a fellowship in infectious diseases and medical microbiology at Dalhousie University. His main area of focus has been influenza A. He is also a collaborator in the newly created Canadian Center for Vaccinology in Halifax that will bring together basic and clinical researchers investigating vaccine approaches to control infectious diseases.
We will begin with Dr. Plummer.
Dr. Frank Plummer, Scientific Director General, National Microbiology Laboratory, Public Health Agency of Canada: I would like to thank the Senate committee members for this opportunity to talk about the Public Health Agency of Canada's laboratory and surveillance preparedness for and response to the H1N1 pandemic.
As you have heard, I am the chief science officer of the Public Health Agency of Canada, PHAC, as well as the scientific director of the National Microbiology Laboratory in Winnipeg. During the H1N1 pandemic, I led the agency's scientific research and national public health laboratory responses to this novel influenza strain.
As you heard from Dr. Alpuche earlier, on April 17, 2009, the Public Health Agency of Canada first became aware of a problem with severe respiratory illness in Mexico City when we received an email from Dr. Alpuche requesting laboratory assistance.
Within a very short period of time, Mexican laboratory samples arrived at the national microbiology lab for testing and identification, and we were able to identify them as a novel H1N1 virus that had recently been reported in the United States, on April 18, within less than 24 hours.
About 24 hours after that, we got a call from Dr. Hatchette, saying they had identified some untypable influenzas in Nova Scotia, and we received those specimens the following day. They were sent from Halifax in the care of an RCMP officer.
Within a very short period of time, we were able to confirm that we had cases of this new virus in Canada as well as in Mexico and the United States; that was the first indication that there was a pandemic.
Canada's rapid response to H1N1 was in part based upon Canada's strong influenza surveillance program. The Public Health Agency of Canada, in collaboration with provinces and territories, monitors influenza activity through FluWatch, which is our national influenza surveillance system. Through FluWatch, we were able to produce rapidly a national picture of the spread of this new virus and its trends over time.
In response to the dynamics of H1N1 and the increased rates of severe disease, PHAC was also able to expand FluWatch surveillance activities quickly to include the collection of epidemiological data on H1N1 hospitalizations, intensive care unit admissions and deaths.
Throughout the response, PHAC worked with Canada's network of federal and provincial public health laboratories, the Canadian Public Health Laboratory Network, of which Dr. Hatchette is a member, to discuss H1N1 and laboratory detection issues. This close working relationship between federal and provincial public health labs ensured a cohesive and strong national response.
PHAC also put in place a number of other surveillance systems to monitor the purchase of antiviral medications, antiviral resistance and adverse reactions to the H1N1 vaccine. All of this was done on the fly. All these systems functioned together and helped to ensure that Canada's response to H1N1 was grounded in the most up-to-date and accurate information available.
In addition to the strength of Canada's influenza surveillance system, PHAC's National Microbiology Laboratory played a leadership role in supporting both domestic and international efforts by providing technical assistance, support and surge capacity to identify, better understand and monitor the novel flu virus.
You have already heard about the experience with Mexico, and I will elaborate on what Dr. Alpuche said. We were able to send five people to Mexico to assist in enhancing their laboratory capacity. Within a very short period of time, in a circumstance where they were under tremendous pressure to produce results, we were able to get the throughput in their laboratory up from 20 specimens a day to over 1,000 specimens a day.
Within days of the strain's being discovered, we developed and shipped specific H1N1 diagnostic tools to provincial public health laboratories; so within a very short period of time, testing in Canada was decentralized.
That was a matter of importance for a number of reasons. One was simple self-preservation in Winnipeg. We would have been inundated with specimens. In addition, it is important to have testing as close to the patient as possible, and a solution to everything cannot be sent in specimens to Winnipeg.
The NML is nationally and internationally recognized as a state-of-the-art public health laboratory. Because of its reputation, international partners sought our advice and assistance. You have heard in great detail about the collaboration with Mexico, which we were very pleased to do. We helped them a lot. Some of the 2,600 Mexican samples that we received came on the Mexican president's plane, which was kind of an interesting experience. The president's plane visited Winnipeg twice.
On May 5, through the expertise, dedication and work of the staff of the National Microbiology Laboratory, Canada was the first nation to submit entire genomic sequences of Mexican and Canadian strains of pandemic influenza to GenBank, and this substantially contributed to international scientific understanding of this novel strain.
Canada's successful domestic surveillance and public health laboratory response to the H1N1 pandemic was in part due to the strong pre-established relationships that we have with international partners at the policy, technical and senior officials' levels.
Because of these established relationships, we collaborated and shared information with the U.S. Centers for Disease Control and Prevention and the Mexican national public health laboratory regularly throughout the early stages of the pandemic.
As you heard from Dr. Alpuche, we are also a member of the Global Health Security Action Group, an initiative that was started post-9/11 by the G7 countries and Mexico. Health Canada hosts the secretariat for that, and the National Microbiology Laboratory is the chair of the laboratory network that is part of that Global Health Security Action Group.
The Global Health Security Action Group provided a valuable pre-established network, which facilitated the exchange of epidemiological information and the mitigation strategies employed by other countries. Canada also levered other pre-established relationships with international organizations such as the Pan American Health Organization and the World Health Organization. Together, our ongoing international partnerships, cooperation and collaboration greatly facilitated the exchange of critical information on the nature of the pandemic and the public health response, which helped to ensure that Canada remained at the forefront of preparedness and response to H1N1.
To conclude, the H1N1 pandemic was an important test of Canada's public health surveillance and laboratory system, and a test to which I think we responded very well.
We continue to work with our federal, provincial, territorial and international influenza partners to improve and enhance our processes and mechanisms for the rapid sharing of information and materials between jurisdictions and nations. Together these efforts will strengthen our continued work to address future national and international public health issues.
Dr. Todd Hatchette, Associate Professor, Department of Microbiology and Immunology, Dalhousie University, as an individual: I would like to thank the committee for inviting me here. It is a privilege to be able to offer some reflections on my experiences with the pandemic that has passed.
I have prepared a statement and I can pass it on afterwards. I may read from it during some of my presentation, but I will also be addressing some of the comments that have been made so far.
On April 25, our laboratory in Nova Scotia was the first lab in Canada to diagnose the novel influenza virus. I have had a unique opportunity to experience the pandemic from many different perspectives.
As a father, I watched anxiously as my middle son developed pandemic influenza because I knew that although mild in most, it was killing young people unexpectedly. As an infectious disease consultant, I was on service during the height of the pandemic. I would walk through the ICU in amazement as half of the ICU was filled with pandemic H1N1 patients. This is not something we have seen before and is not typical of seasonal influenza. One of the things I would like to emphasize is that from my personal perspective, this was not seasonal influenza.
As a physician who has been involved in pandemic planning since 2005, I have had numerous opportunities to interact in various capacities with both provincial and national bodies. I am the co-chair of the Pandemic Influenza Laboratory Preparedness Network, or PILPN, which is a subgroup of the Canadian Public Health Laboratory Network. Our job was to develop the lab preparedness guidelines for a Canadian influenza pandemic plan.
During this pandemic, I was the Canadian Public Health Laboratory Network's representative on the Pandemic Coordination Committee, PCC. I was also a co-chair of the Surveillance, Epidemiology and Laboratory Task Group for PCC and a member of the Clinical Care and Antivirals Task Group for PCC, so I have had a bit of experience with the various task groups. I will provide some reflections on how I think we did and some areas that perhaps need to be improved.
The Pandemic Influenza Laboratory Preparedness Network was established to develop the laboratory annex guidelines, or Annex C, for the Canadian pandemic plan. Prior to the pandemic, we developed a key document that outlined the minimal requirements needed by provincial public health labs to be able to meet the challenge of diagnosing novel influenza strains. Central to this plan was the implementation of molecular diagnostics to look for the genetic fingerprint, rather than growing the virus.
The NML must be commended: They provided generous funding to allow the public health labs to purchase the necessary equipment to rise to that need. Like the Mexican experience, much of the equipment purchased by the labs prior to the pandemic was the same as the equipment the Mexicans purchased so they could respond. We saw we needed to do that even before the pandemic hit.
Once the virus was identified in Canada, within 48 hours the necessary reagents were disseminated to the provincial public health labs so that we could diagnose the virus on our own. That is very important because, as Dr. Plummer mentioned, the provincial public health labs are often used as the key labs for diagnosing influenza in many areas of the country.
In addition, they were able to modify the CDC testing protocol to machines that exist in all provincial public health labs, thereby increasing capacity. Another key feature that happened toward the middle of the pandemic was that they worked closely with one of our provincial partners, the BC Centre for Disease Control, to modify a procedure they had in their lab that was able to identify resistance to oseltamivir and distribute those reagents to the provincial public health labs across the country.
Why is this important? These were all outlined in our laboratory annex, so we had thought of all these things and everything worked very smoothly. In fact, I would like to say that the labs are probably the best example of how things should work.
That said, some things have been highlighted that we probably could improve on. Communication is an oft-repeated theme here. The communication with our external partners, meaning the front-line hospitals and clinicians, probably could have been strengthened. As we reached capacity for lab testing, we had to modify algorithms, and improving our communication with those partners perhaps would have smoothed things over.
As Dr. Plummer mentioned, the communication between the labs was very smooth. That is because of the pre- existing relationship we all had. It was easy to get on the phone in teleconferences and share information we needed.
The same cannot be said for the epidemiology side and the lab side. These are two different sides to the surveillance coin. Often we do not talk well enough together. I will address that highlighted point next.
As the co-chair of the Surveillance, Epidemiology and Laboratory Task Group, I was able to learn many things because I am a lab physician and not an epidemiologist. The mandate of the group was to coordinate the overall strategy for surveillance, epidemiology and lab activities in Canada related to the pandemic H1N1 2009.
Surveillance is the underpinning to any control or mitigation to any disease. I was at a conference recently, and Rob Webster, who was my post-doctoral supervisor and one of the grandfathers of influenza, said that without surveillance we have nothing.
I think the members of the influenza surveillance group worked hard to respond to the constant questions that were asked of them. They had to analyze the data in real time to provide the necessary background to support the decisions that were being made at higher levels. However, despite this, there was a perception from many in the group that their advice and recommendations were underappreciated at the higher levels and that the surveillance issues were not given adequate weight at the table.
In my personal opinion, the greatest challenge faced by the surveillance section is the lack of resources. Prior to the pandemic, the surveillance group at PHAC consisted of four individuals — a medical specialist, a senior epidemiologist, a junior epidemiologist and a virologist. During the pandemic there was a secondment of another senior medical specialist and another senior epidemiologist, and a number of junior epidemiologists came and went throughout the pandemic, staying anywhere from two to four weeks.
This made responding to the near constant questions, queries and multiple meetings and teleconferences very challenging. Sometimes having more bodies was more difficult than time-saving because these people had to be brought up to speed on influenza and the surveillance around the disease.
An additional challenge we faced as a surveillance group was that there was no mechanism to rapidly disseminate information. In the United States, CDC has the Morbidity and Mortality Weekly Report, MMWR. We did not have that, so we suggested that the Purple Paper be created, which was our way of knowledge translation. There is also a lack of clarity where influenza surveillance fits within the PHAC structure.
Finally, there is a need for enhancement and more formal linkage between labs and epidemiologists, as I mentioned previously. Providing a better understanding of the data being generated by these two different but complementary sides of the surveillance coin is essential. This will become more important as labs have gained the ability to use more sensitive and versatile molecular tools for respiratory pathogens. At the same time, these tests cost a lot of money, and we have to develop novel algorithms on how to use them. Unless the epidemiologists understand how the lab is testing, they may not be able to interpret the data it is generating.
The last issue I would like to highlight relates to my involvement in the Clinical Care and Antivirals working group. Although PHAC's mandate is public health, it was the perception of some provinces and many members of the public that PHAC would provide leadership in the guidance on clinical care.
This task group was developing clinical care guidelines and was co-chaired by a PHAC member, yet because the mandate of PHAC was not to be involved with clinical — I guess legally they are not allowed to provide clinical advice — there was no one really in charge. Toward the end of the pandemic I think this was clarified, where PHAC's role was seen more to facilitate and support the development of these guidelines through the various national societies and bodies. However, early on that was not clear; and I think that because of that, there was a delay in the guidelines, and many of the provinces went on to develop their own.
Finally, I would like to take this opportunity, as co-chair of PILPN and the Surveillance, Epidemiology and Laboratory Task Group, to thank personally and publicly each of the members for all the time and effort they put in during the years prior to the pandemic in the planning stage and in the demanding but very exciting months during the pandemic. Without the efforts of these volunteers and every other clinician, laboratory physician, scientist, pharmacist and other allied professionals who volunteered their time at the national and provincial level, Canada would not have been able to rise to the challenge of pandemic H1N1.
The Chair: That is a lot of quite helpful information coming from lessons learned. You will give us something in writing, but do you have some thoughts on each of those areas as to specific mechanisms, particularly with regard to the communications? You do not need to go into that now, but we need to know if you have any suggestions you could give us.
Dr. Hatchette: I could certainly provide something in writing. I will give you the transcript of this and elaborate perhaps in communication.
The Chair: It is helpful to have this because you are from outside the system. You have that objective angle, yet you also know the good work that has been done.
My question could go to both or either of you. We heard about the collaboration with Mexico and how you, Dr. Plummer, were able to be of help to Mexico, but I take it that it was two ways. We were also getting information we needed here. Indeed, wherever there will be an outbreak in a future pandemic, we will need to get vital information from other countries.
However, in a report, apparently some comments were made to the WHO Global Influenza Surveillance Network about some regions of the world less developed in flu surveillance, and it was said this could pose a problem. Could you talk more about that, and what needs to be done to overcome it?
Dr. Plummer: The capacity to diagnose influenza is variable around the world. Some countries would have very little capacity to diagnose a novel influenza strain. Even a country like Mexico, which is a middle-income country, was not able to identify it as a novel strain because they did not have the technology at the time. Had they had a different technology, they would have been able to find the outbreak about a month earlier; they had some signals of illness of an undefined nature prior to that.
As part of the International Health Regulations' activities, the World Health Organization is committed to strengthening laboratories around the world. The Global Health Security Action Group, which I mentioned, has a particular lab network committed to helping the World Health Organization do that through providing technical assistance when requested.
It is a big task, however. There are many countries and many labs. With the World Health Organization, as a preliminary step in this we are doing mapping of global laboratory capacity. We have developed a software tool, called GLaDMap, that maps all laboratories in the world and identifies laboratory networks. You can click on a lab in Africa and find out their capability and what their relationships are with other laboratories. As I said, though, it is a big task.
The Chair: In the case of Mexico, you went directly. It was not the international body that got the information and got in there to work with the Mexicans; you and people from CDC went directly.
What does that tell us about the ability of the international network? In the future, if a virus starts in another country, will we be able to build up the capability in that country to be able to provide the surveillance needed?
Dr. Plummer: This is a slightly different situation in that we are on the same continent as Mexico, and we had a trilateral agreement for assistance with pandemic influenza. When they started off they did not know it was flu. They knew they had a severe respiratory illness. Additionally, I had a personal relationship with Dr. Alpuche, so they got in touch with us.
Normally a country would make a request to the World Health Organization through its regional office, and then that request would be passed on to other countries.
The World Health Organization operates a network called the Global Outbreak Alert and Response Network, GOARN, which is a kind of like a volunteer fire department. A country will come to the WHO and say it has a particular problem it needs help with. The WHO will assess that problem and then put out a call for certain kinds of expertise, which countries would provide on a voluntary basis.
We do that fairly regularly. We have an advanced mobile laboratory capability that can be on a plane going anywhere in the world within three hours. We have sent that team to Angola, the Dominican Republic, Vietnam, China, Hong Kong and other places.
There is a system. Is it perfect? No. Does it need strengthening? Yes. Public health labs around the world are very uneven in their capabilities.
The Chair: Is something being done to strengthen it? Ultimately, it impacts us all, and it is important to get this information. We have capability, but this comes under a WHO-led organization, I take it. Is that body really making improvements at this point?
Dr. Plummer: I think it is making improvements, but it is slow. I have already mentioned the mapping exercise we are involved in. We are really doing it for WHO. We have a lot of experience in lab networks, and we are also working with WHO in using our expertise to create other lab networks around world.
You heard Dr. Alpuche talk a little about what they are doing in Mexico with a lot of support from us. Work is being done. Is it as fast as ideal? No.
Dr. Hatchette: I am not really privy to this above the Canadian level.
Senator Eaton: Thank you, gentlemen. I would like to talk a bit more about communication. When we hear "pandemic Phase 6," does the WHO set those scales? Do they say it is a Phase 5 or a Phase 6?
Dr. Plummer: They make the determination that it is a Phase 6, basically that there is a new virus that is essentially everywhere in the world.
Senator Eaton: That is based on what is happening in the whole world, is it?
Dr. Plummer: Correct.
Senator Eaton: The virulence of this disease was enormous. I think when most of us saw "pandemic at the scale of a Phase 6," it initially raised people's expectations, only to realize that 500 people, I think, died in the H1N1 pandemic. How many die a year from seasonal flu? Is it 4,000 or 6,000?
Would it not serve us to have our own scale? The WHO might say it is at Phase 6 around the world, but you, sir, might say it is at Phase 2 in Canada. In that way, Canadians would see the difference. It might be a Phase 7 here and a Phase 2 around the world. In that way, we would really have a fairer assessment and a better feel for what is really happening.
Dr. Plummer: I have a couple of responses to that. First, Phase 6 does not in any way reflect the severity of disease. Basically, it is the extent of geographic spread. That is what it is intended to convey.
The public's perception of what a pandemic is consists of something along the lines of the 1918 flu. The severity has nothing to do with the definition of "pandemic." This whole issue is a matter of debate now at the World Health Organization because other countries are concerned there is this perception that a pandemic means a severe disease. It does not. It is just the extent of geographic spread.
Having said that, although there were only 400 deaths in Canada, it would have been worse had we not had the excellent critical care, including antivirals and vaccines.
Senator Eaton: I agree with all of what you are saying.
Dr. Plummer: Most people who were admitted to ICU would have died.
Senator Eaton: I agree, but I think many people did not take advantage of the vaccination because once they realized that the second stage was over, they stopped worrying. The WHO was saying "Pandemic 6," but people were not dying in droves, so people took an "oh well" attitude towards it.
Dr. Plummer: We need to better understand through additional research why people did not get vaccinated.
People made some odd decisions. I was interviewed at a public event a couple of weeks ago. I asked the journalist who was interviewing me if she got the vaccine. She said she did not. I asked her why she did not, and she was worried about side effects, yet she got her children immunized. I could not figure out the logic of that.
Senator Eaton: Again, that is an issue of information and communication.
Dr. Hatchette: Regarding our 4,000 a year who die, that has been generated through modelling and looking at excess mortality during influenza and pneumonia season. We will not know the final tallies until we look at other things. Never before have we actually looked in-depth at people admitted to hospital with influenza. Part of it is that our previous estimations might be wrong. We have been touting those figures for years because we know influenza kills people every year. How accurate they are is not clear, and we might see some differences in the years to come.
Senator Eaton: We do not talk about a flu pandemic. We simply tell people to get their flu shots and to be careful about washing their hands. We do not say in the symptoms that they might die.
Dr. Hatchette: It depends on whom you speak to. When I give talks to health care professionals, my first question to them is, "How many of you are coming to work to kill a patient today? Because if you do not get a flu shot, that is potentially what you could do." It depends on the target audience. Everyone is complacent about influenza. Regularly we hear people comment, "I had a bit of the flu this weekend." If you had influenza, you would know it is more than a bit of flu because it knocks you down for a number of days. It is people's perception of what influenza is. Perhaps that is our communication challenge. The biggest mistake from a staging perspective was not clarifying that Level 6 meant spread, not severity. As Dr. Plummer said, they are looking at revising all of that.
Canada's pandemic plan had a sort of 6.1 or 6.2, depending on whether there was an extensive spread across the world or within Canada. We did try to nuance that, but it becomes difficult to message.
Senator Eaton: It is like the homeland security alerts, which can be orange or red depending on the level of threat. People automatically assume it is the depth of the danger perceived, not geographical.
Senator Ogilvie: This last discussion really illustrates the challenge that you folks and health authorities have in general with situations of this nature. Dr. Hatchette, you got into some aspects of it and could talk to us all day about the different subgroups of the regular flu, those susceptible to the different levels, and whether you build up against them the longer you live relative to the number of times you have been exposed, et cetera. It is a complex issue. I have looked at these things from a chemist's point of view, and I do not think you have any simple way of reaching the population. In the 1918 pandemic, younger adults in the barracks were decimated by the flu while older folks, although they succumbed, did not do so at the same rate. It has to do not only with previous exposure but also with the concentrations of people in an area and many other things. I do not envy you trying to advise us in detail on how we can reach the population as a whole.
We heard confirmation today that the virus in this hemisphere was identified definitively in three locations within a week of each other: the U.S., Mexico and Canada. Almost certainly the virus was in those countries for some time prior to that confirmation. You mentioned that perhaps it might have been detected a month earlier in Mexico had they had different capability. Do we know where the virus likely arose?
Dr. Plummer: The thinking is that the virus has North American swine sequence, Asian swine sequence, human sequence and bird sequence. Somehow, the virus picked up all of these different genes. Where that happened, no one is really sure. Most people would guess that it was in Mexico, but it could have been in California. I do not think it was in Canada. This is really a guess. There is no good way of going back and figuring it out.
Senator Ogilvie: I appreciate the point you make. It arose within a close period of time in three areas with some distance between them. Does anything in that issue and in your search back regarding the identity of the virus give us any hint as to how these things might be detected at an earlier stage of evolution?
Dr. Plummer: Prior to this pandemic, much thought had gone into how to contain the avian flu — H5N1 — at source when it first becomes sustainably transmitted in human populations. This experience shows the futility of thinking that can be done. This virus was out the door so fast that by the time the problem was recognized, it was everywhere. Nova Scotia was the first province to identify the problem, but it was in other provinces as well. Given the number of air travellers between Mexico and Canada in the winter and spring, I do not think anything can be done to contain it at source. If you were able to do something, it would have to be based on a robust laboratory capacity in countries around the world.
Dr. Hatchette: Part of the challenge in determining the source of the virus is the lack of surveillance in the swine populations. When people look at the origin of a virus, they compare its genetic fingerprint with everything that exists in the data banks. There is a span of 10 years or so for which there is no data on swine viruses circulating. In that 10- year period, this could have been happening in any of the different areas in the U.S. or the U.K. The problem is that there is not a lot of animal surveillance, and it is a challenge to get animal surveillance happening.
Senator Ogilvie: I wanted to get that on the record from experts with regard to that particular aspect of that issue.
Dr. Hatchette, I go back to your comments about getting the word out. I am from Nova Scotia, where it is difficult in the fall to not know there is a flu circulating and who is most susceptible. It must be one of the most highly publicized health issues in Nova Scotia that I can even imagine relative to any other disease. Thank you.
Dr. Hatchette: It is interesting that, for whatever reason, the eastern part of the country had better vaccination rates than the western part of the country. A member of our department, Shelly McNeil, is looking at why that might be. We hope her results will help to inform vaccination strategies in the future.
Senator Cordy: Thank you both very much for the work you have done. We have to recognize that Canada has done a substantial amount of excellent work. This is about the lessons learned and how to do things better. Dr. Hatchette, you mentioned that immunization rates were higher on the East Coast and that was being looked at to determine how that could be beneficial as we plan for the next pandemic.
Dr. Hatchette, the first recognizable cases in Canada were in Nova Scotia. I believe they were students who had travelled to Mexico. How does it work? You talked about surveillance being so important, and I liked the comment that without surveillance we have nothing because if we do not find out that it is out there, we cannot do anything about it. How does it work? How did you get the information? Was it from the doctor who treated those students because they were all in the same area? Was it through the hospital? How did you end up with the information that you can send to the health agency?
Dr. Hatchette: Part of it has to do with the way we test. We test for influenza using a generic test that picks up any influenza. In the previous flu seasons before the pandemic, we knew that the two seasonal types circulating had different resistance patterns. From a clinical perspective, it was important to know whether it was an H1 or an H3 in order to treat them.
We were doing a lot of sub-typing, to identify exactly what that virus was. It was a little bit of serendipity, a bit of good planning and a little bit of good epidemiology that all went into this. I had been to a conference that week and had heard Stephen Lindstrom from the CDC release the two cases of the novel swine virus in kids in California. I got back on Thursday and received information from our epidemiology colleagues that there was a cluster of illness in a school that had contact with Mexico. Knowing from the ProMED releases that there was this unusual respiratory outbreak in Mexico, we said we would make sure to sub-type these viruses to ensure that it is just the seasonal influenza. We did that about three o'clock in the afternoon, and we were not able to type them as normal seasonal influenzas. These viruses we could not type were our red flag to send it on to the NML for confirmation so that they could inform the WHO — the chain of command, if you will, for diagnostics.
We did that test not only once but twice, because it is always exciting to be the first, but you would hate to be the first person wrong.
Senator Cordy: True.
Dr. Hatchette: These things always happen on a Friday afternoon, and by that time it was six o'clock. FedEx does not transport things, so we had to figure out a way to get the sample to Winnipeg as soon as possible. Because novel pathogens are considered a higher level of bio-security, because they are a risk to the population, we could not just send it on a normal courier service. We were able to second an RCMP officer to personally escort the sample, and that way we did not have to go through the same regulations for transportation of dangerous goods. Although the sample was packaged the same way, there were not the courier necessities in order to get it to the laboratory.
It was my youngest son's third birthday, and I was on the phone all day with teleconferences, but I can remember quite clearly getting a call at 11:30 from Yan Li at the NML and having a teleconference with Dr. Plummer, Dr. Butler-Jones and my supervisor, and saying, yes, we have the novel strain in Canada.
It actually followed the exact path that it should have followed. We identified a virus that we could not show as human; we went up the chain, and within 24 hours we were able to do so. The only thinking on our feet we did there was how to get the sample to Winnipeg on a Friday afternoon.
Senator Cordy: Samples are taken in these situations and then forwarded to your laboratory; is that the way it works?
Dr. Hatchette: Correct. From a public health perspective, if there is a cluster of respiratory disease, they take samples and then forward them on to the local provincial laboratory where the necessary testing will be done to rule out normal respiratory pathogens. We generally start with influenza A, influenza B, respiratory syncytial viruses — RSVs — and some other viruses. From a public health perspective, there are mitigation strategies to use within small populations. If some people in a closed environment are infected, antivirals are given to the rest of them to prevent infection. That is done rapidly. Communication between the epidemiologists and the laboratories facilitates that. We have electronic means to ensure that happens — CIOSC alerts and things where the provinces can let other public health people in the province as well as laboratories know that there is a respiratory outbreak in this facility with these symptoms, and then that can be updated.
Senator Cordy: When you talked about surveillance and some of the challenges you faced during the H1N1 pandemic, staffing was one of the things that you mentioned, not having enough staff and then people coming in and out for two or three weeks, which required time to bring them up to speed. You talked also about difficulties in communication. When we are writing our report, what kinds of things should we put in as recommendations for the next pandemic in relation to surveillance?
Dr. Hatchette: From my personal perspective, surveillance and laboratory diagnostics are often overshadowed by the more sexy things like antivirals and vaccines. When I was a member of the now-sunsetted Pandemic Influenza Committee, PIC, I can remember going to my first PIC meeting, and both surveillance and laboratory were in the last 15 minutes of the meeting. You can imagine how many people were still at that meeting for that presentation.
This has highlighted the strengths of the laboratory system and the surveillance system, but also the funding for the epidemiology side of things, at least in influenza — and I cannot speak to the rest of the surveillance of other diseases — has been underfunded. I have seen people come and go through that section since 2005, which means that although you bring new ideas to the table, you also lose a lot of institutional memory, which can be very important when you are dealing with something that has a long history.
Maintaining people in those positions would be a challenge. I do not know whether it is a remuneration issue. I do not know why that is happening. However, I do think that you need more than four people in a section to deal with influenza. I do not know the exact numbers, but it would be good to add that to your report.
At the CDC, I think there are 300 people involved in influenza, both laboratory and epidemiology. In Canada, I think there are 15 people involved on the laboratory side of influenza at the national level and four people involved on the epidemiology side. Even if you take the one-in-ten dilution that we always do with the U.S., we are still underfunded from a human resource perspective.
Dr. Plummer: To add to that a little bit, one of the challenges we need to figure out is how to link laboratory and epidemiologic information. The way information flows is that a specimen comes into the laboratory and the result goes back to the provincial laboratory. There is another information flow, which is epidemiologic information that comes in to PHAC from a different part of a provincial government. We have tremendous difficulty linking those two things together, which limits our ability to comment on severity of illness and all kinds of things. That is an issue where we need to figure out a better way.
At the national laboratory, we have about 10 people who work on influenza, including two research scientists, so we are not that deep either.
Dr. Hatchette: I would like to echo Dr. Plummer's comments on the laboratory-epidemiology linkage. The national laboratory has tremendous resources in computer science, and it is possible to link these databases, but there are some logistical issues that seem difficult to overcome. Some of them are privacy issues; some of them involve the province not wanting to give up the data. They can all be overcome; whether you describe them as easy or not is, I guess, your perspective. It is a highly important thing in order to correlate this data properly.
Senator Merchant: I may be just following along the last area you spoke about. I am not sure how much responsibility you have for this linkage.
You have identified the virus, but how do you communicate the severity, or do you? Is it up to you to communicate the severity of the problem? Do you have some say in the type of antivirals or vaccines that would respond to this particular virus? How much needs to be purchased? Those are the kinds of things that we have been dealing with in the last two or three days. I do not understand exactly the sequencing. Also, how do they get enough information? There was a bit of confusion with the adjuvanted vaccine and whether it was appropriate for pregnant women. That confused people early on. Have we learned something from the process that we can benefit from in the future?
Dr. Hatchette: Right now laboratories are lucky to get the appropriate name and birth date on a requisition, let alone clinical information. Often laboratories actually have no clinical data whatsoever about the specimen that they are processing, which is why it is so important to link it with epidemiologic information, because the epidemiology people will be able to say that this was a particularly severe virus, and then they can look to see how much antiviral resistance is there.
When to test antiviral resistance again depends on criteria that are set out by the laboratories. We have tried to establish some general criteria, but ultimately the province will decide what they are. We cannot test every virus for antiviral resistance, but we have set up criteria — for example, patients who seem to be failing therapy or who have been on antivirals, that sort of thing, and that may be able to provide some guidance regarding whether or not the antivirals are effective.
The effectiveness of vaccines is something a bit different from the clinical side of things. It really requires special scientific studies. You can look at the laboratory markers of vaccine efficacy, meaning that this proportion of people actually developed antibodies over this threshold. That means they should be protected, but you need to look to see how many people who were vaccinated got infected versus those who did not. That takes a large case-control design study, which could happen if there is better sentinel linkage with the lab.
With our current surveillance, the lab forwards data to the respiratory surveillance system, and it is aggregate data. We say that we have done 1,000 tests in the last month and 300 of them are positive for influenza A. At the same time, the sentinel physicians across the country say, "Okay, these proportions of people who are attending my clinic have influenza-like illness." We cannot correlate what those are. The sentinel physicians are not necessarily testing people with influenza-like illness, so we cannot tell you what proportion of those people with influenza-like illness actually have influenza. Until you make that linkage a bit better, it is hard to understand who is getting flu, what influenza-like illness symptoms they are getting and whether that is influenza. We know that two thirds of the time it may be flu in the peak of the season, but that means a third of the time it is not.
To get back to antivirals for a minute, the biggest challenge from a clinical perspective is to have a diagnostic test that is sensitive and rapid so that you have a result within 30 minutes. Rapid tests are available, but they perform quite poorly with the pandemic virus, let alone seasonal virus. With the pandemic virus, the sensitivity of the test — that is, the ability of the test to pick up the virus — ranged anywhere from 13 per cent to 60 per cent. That means 40 per cent to 80 per cent of the time you are missing the virus, even though that person may actually be infected. You could not rely on a quick test like that to say, "I am confident you do not have infection, so I am not going to give you antivirals."
The testing for the detection of the virus, these rapid tests, needs to be pushed forward. The CDC has provided a lot of funds and grants to companies that are trying to do that. That is sort of the Holy Grail of influenza diagnostics, and that will facilitate identification of virus in under-resourced countries as well.
Dr. Plummer: Decisions about what antivirals to stockpile must be taken years before the actual pandemic, although during a pandemic you can monitor whether the virus remains susceptible to those. We know that there is resistance to these antivirals, so we have a diversified antiviral stockpile, although probably not as diversified as we would like because there are not that many drugs that are effective for influenza.
With vaccines, as you heard yesterday, you really have to make them once the virus has emerged. The technology we are using for influenza vaccines is pretty old technology. Other technologies are possible. Maybe we could even have a universal influenza vaccine. Vaccine research is an important area.
Senator Merchant: Thanks so much. I think that is all.
The Chair: An interesting case was reported recently. We always see the reports about the virus going from animals to humans, but a reverse case was reported out west — or was it going the other way around, from a human to a swine? Was there anything of significance to that? How was that followed up?
Dr. Plummer: It was on a pig farm in Alberta where pigs became ill. The pigs presumably acquired the virus from the farm family, a number of whom were ill with the H1N1 virus.
The virus moves back and forth between swine and humans relatively frequently. Swine have a type of influenza virus that can infect people. Every year or so, we find one or two cases of this virus in humans, sometimes even in small children. Although they live on a pig farm, they have not been exposed to pigs. Presumably, they got it from their mother or their father.
The worry is that this will potentially result in the creation of a new virus that can be of increased virulence, but the actual harm this virus does to pigs is very little. That is why the animal industry is not interested in doing surveillance. Pigs get flu. They cough a little bit, and they get better. It does not really affect the meat production. It does not kill them, so they have limited interest in our interest in doing greater swine surveillance.
The Chair: Thank you.
Senator Braley: Your surveillance is superb. Did anything unusual come out of the surveillance in Canada? Were there any specific concentrations because of travel or other items, or is that not really being looked at?
Dr. Plummer: We have been looking at it. We have just submitted a whole genome sequence on 250 H1N1 viruses from the pandemic. There are some pretty interesting things in there. One is that obviously there were multiple introductions of this virus to Canada, as you might expect, from Mexico or wherever else. There are some regional differentiations into sort of sub-strains. There was only one big cluster of highly related strains, and that was in Manitoba, basically on First Nation reserves.
The virus came in many times, not just once. We cannot expect to keep viruses out at our borders. We have to deal with them once they are here.
Senator Braley: Would that information help us, or was there less resistance in certain areas of the country?
Dr. Plummer: Do you mean antiviral resistance?
Senator Braley: No, a build up internally.
Dr. Plummer: Not that I am aware of. There were pretty high attack rates on some First Nation reserves and smaller communities in Nunavut. I think that may be related to crowded conditions, that kind of thing, rather than anything biological.
Senator Braley: Thank you.
The Chair: Is there anything else? If not, I wish to thank both of our witnesses who have been here this morning. You have been very interesting to hear from and have given us many good ideas and thoughts.
We will not be here next week, so the week after we will be back on the Monday.
Senator Cordy: What time is it on Monday?
The Chair: It is scheduled for 6:30 on Monday, October 8.
(The committee adjourned.)