August 2018

Table of Contents

Preface

Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) is a federal, provincial, and territorial (FPT) guidance document that outlines how jurisdictions will work together to ensure a coordinated and consistent health-sector approach to pandemic preparedness and response. CPIP consists of a main body, which outlines overarching principles, concepts, and shared objectives, as well as a series of technical annexes that provide operational advice and technical guidance, along with tools and checklists on specific elements of pandemic planning. The CPIP main body and its annexes are intended to be used together.

CPIP was first published in 2004. In 2006, the Pan-Canadian Public Health Network (PHN) Council approved an updated version of CPIP as an evergreen document to be updated as required. In 2009, Canada’s pandemic preparedness planning efforts were tested for the first time, with the emergence of the H1N1 influenza pandemic. In 2012, a CPIP renewal process was initiated by the PHN Council. This latest version of CPIP, was approved by FPT Deputy Ministers of Health 2014, with further update in 2018. It incorporates evidence from H1N1 lessons learned reviews conducted at the FPT and international levels and by various stakeholder groups, and scientific advances. As an evergreen document, the CPIP main body and each annex will be reviewed every 5 years, with updates made between review cycles, if necessary.

Since 2012, The CPIP Task Group (CPIP TG) has overseen the CPIP renewal process.The CPIP TG consists of members with expertise in the areas of pandemic and seasonal influenza, pandemic preparedness planning and response, emergency management, epidemiology, public health, virology, bioethics, immunization, surveillance, and laboratory diagnosis.

The updated CPIP allows for a more flexible and adaptable response to future pandemics, providing scope for provinces and territories (PT) to adapt their own plans and responses to local and regional circumstances. The title of the document also has changed, from Canadian Pandemic Influenza Plan for the Health Sector to Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector, to more accurately reflect its role and intended use as a guidance document.

CPIP now supports a risk-management approach and includes new concepts such as pandemic impact assessment, descriptions of pandemic scenarios of varying impact, and identification of triggers for a Canadian response. It also better reflects Canada’s geographic, demographic, cultural, and socio-economic diversity and the imperative for planners to take this diversity into account. CPIP has been subject to extensive FPT government review and targeted stakeholder consultations. Stakeholders included national-level organizations representing health professionals, emergency preparedness and first responders, community services, the private sector, and Indigenous peoples.

1.0 Introduction

1.1 Background

Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) provides planning guidance to prepare for and respond to an influenza pandemic. Influenza pandemics (subsequently referred to as pandemics) are unpredictable but recurring events that occur when a novel influenza virus strain emerges, spreads widely and causes a worldwide epidemic. Unfortunately, it is not possible to predict the anticipated impact of the next pandemic or when it will occur.

Planning for a prolonged and widespread health emergency of unpredictable impact is challenging but essential. It requires a “whole of society” response and the coordinated efforts of all levels of government in collaboration with their stakeholders.

Pandemic planning activities within the health sector in Canada began in 1983. The first Canadian pandemic plan was completed in 1988 and was followed by several updates. In 2004, the Canadian Pandemic Influenza Plan for the Health Sector was published as the result of extensive collaboration among FPT and other stakeholders. Before this version, the last major update to the CPIP and its annexes occurred in 2006.

The 2009 influenza A (H1N1) pandemic (subsequently referred to as the 2009 pandemic) provided the first real test of Canada’s pandemic preparedness planning efforts. Collaboration among all levels of government and stakeholders was unprecedented compared with previous events like the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. The public health and health care systems were stressed but in most instances were able to cope. Antiviral stockpiles were deployed and pandemic vaccine was administered to millions of Canadians. There were, however, many challenges identified in this experience.

Canada’s pandemic planning continues to evolve on the basis of research, emerging evidence and the lessons learned from the 2009 pandemic. The value of building on seasonal influenza surveillance systems and control measures is well recognized. Making these systems and measures as robust as possible in the interpandemic period will help prepare for a strong pandemic response.

1.2 Purpose

CPIP’s overall purpose is to provide planning guidance for the health sector for pan-Canadian preparedness and response, in order to achieve Canada’s pandemic goals:

First, to minimize serious illness and overall deaths, and second to minimize societal disruption among Canadians as a result of an influenza pandemic.

The main body of CPIP provides strategic guidance and a framework for pandemic preparedness and response, whereas the CPIP annexes provide operational advice and technical guidance, along with tools and checklists. As an evergreen document, CPIP will be updated as required to reflect new evidence and best practices.

It is important to note that CPIP is not an actual response plan. Rather, it is a guidance document for pandemic influenza that can be used to support an FPT all-hazards health emergency response approach. While CPIP is specific to pandemic influenza, much of its guidance is also applicable to other public health emergencies.

1.3 Audience and Scope

CPIP is pan-Canadian pandemic planning guidance for the health sector developed under the guidance of a group of Canadian experts. The primary audiences are the FPT ministries of health together with other ministries that have health responsibilities. While it is anticipated that CPIP’s strategic direction and guidance will inform FPT planning in order to support a consistent and coordinated response across jurisdictions, PTs have ultimate responsibility for planning and decision-making within their respective jurisdictions. CPIP also serves as a reference document for other government departments, non-governmental organizations (NGOs) engaged in health issues, and other stakeholders.

While CPIP provides pandemic planning guidance, it does not address business continuity preparedness or overall management of a health emergency. These activities are critical for an effective pandemic response; however they are more appropriately addressed in the emergency plans of individual jurisdictions and organizations. Neither does CPIP address pandemic preparedness and response in the non-health sectors (e.g., community and social services, public safety), although some of its content may be a useful reference.

1.4 Changes in This Version

There have been considerable changes to CPIP since the 2006 version in both format and content.The strategic nature of the information in the main body of the planning guidance has been strengthened and lessons learned from the 2009 pandemic have been incorporated. While the overall pandemic goals remain the same, new objectives have been added along with a set of principles to support the response. These are accompanied by a discussion of ethical considerations pertaining to pandemic preparedness and response, and consideration of the implications of Canada’s diversity and the needs of vulnerable persons. Roles and responsibilities for each level of government have been described more explicitly.

The new CPIP outlines a risk management approach to support a flexible and proportionate response. Risk management involves setting the best course of action in an uncertain environment by identifying, assessing, acting on and communicating risks. Information has been added about what is known and what is uncertain about pandemic influenza. The planning assumptions have been updated, and four hypothetical planning scenarios have been developed to illustrate the importance of developing plans and response strategies that are flexible and can be adapted as circumstances require. CPIP also provides triggers for action that are based on novel virus emergence and pandemic activity in Canada rather than the global World Health Organization (WHO) phases. Finally, content has been updated in each of the specific response areas.

The CPIP technical annexes are being renamed according to their subject (e.g., Surveillance, Vaccine) instead of being named alphabetically. As part of the CPIP renewal process, it is intended that each of the technical annexes will be revised.

2.0 Context for Planning

2.1 Understanding Pandemic Influenza

2.1.1 Influenza and the Origin of Pandemics

While there are four types of influenza virus (A, B, C and D), only influenza A and B viruses cause seasonal outbreaks in humans, and only influenza A viruses have been known to cause pandemics. Aquatic birds are the natural hosts for influenza A viruses, although a wide range of species can be infected and significant disease outbreaks can occur in poultry, pigs and other species. Most of these animal influenza virus strains do not cause disease in humans although occasional human (zoonotic) infections occur, usually through close contact with infected poultry or animals.

Influenza pandemics or worldwide epidemics occur when an influenza A virus to which most humans have little or no immunity acquires the ability to cause sustained human-to-human transmission leading to community-wide outbreaks. Such a virus has the potential to spread rapidly worldwide, causing a pandemic.Footnote 1

These novel viruses may arise through genetic reassortment (a process in which animal and human influenza genes mix together) or genetic mutation (when genes in an animal virus change, allowing the virus to easily infect humans). Pigs can become infected with influenza viruses from different species and act as a “mixing vessel” to facilitate the reassortment of genes from different viruses.

Not all novel influenza viruses evolve into pandemic viruses. Some novel subtypes, like the avian A (H5N1) virus, have caused sporadic human cases on an ongoing basis since 1997 but have not gained the ability to spread easily in humans. As the overall human case fatality rate for A (H5N1) infections has been over 50%,Footnote 2 there are concerns about the potential of a high impact human pandemic if this virus gains the capacity to spread easily between people.

2.1.2 Typical Pandemic Characteristics

Historical evidence suggests that influenza pandemics occur three to four times per century. In the last 100 years there were four pandemics separated by intervals of 11 to 41 years. They varied greatly in their impact, as measured by illness and deaths. The 1918-1919 pandemic had a high impact, killing an estimated 30,000 to 50,000 people in Canada and 20 to 50 million people worldwide. The impact of the 1957 and 1968 pandemics was considered moderate, whereas the 2009 pandemic had a lower impact.

Pandemics of the Last 100 Years, subtypes and common names: 1918-1919: H1N1 “Spanish flu” 1957-1958: H2N2 “Asian flu” 1968-1969: H3N2 “Hong Kong flu” 2009: H1N1 "Influenza A(H1N1) 2009"

While every pandemic is different, some common characteristics can be recognized:

The pattern of disease is different in pandemics than in seasonal influenza.

Pandemics may arrive outside of the usual influenza season and typically have more than one wave of illness.

The total duration of a pandemic is likely to be 12 to 18 months.

During a pandemic, the new pandemic virus replaces other circulating influenza strains. Afterwards, the pandemic strain becomes part of (and may dominate) the mix of seasonal influenza A viruses.

During seasonal influenza, most hospitalizations and deaths occur in the elderly and persons with underlying health conditions, whereas, in a pandemic, disproportionately more severe disease and death is seen in young people and in persons without underlying health conditions. Footnote 3

There is a gradual reversion back to the typical seasonal morbidity and mortality pattern over the decade following the pandemic.

During the 1918-1919 pandemic, 99% of influenza-associated deaths in the United States (US) were in persons under 65 years of age and nearly half of these among previously healthy adults 20-40 years of age. In subsequent pandemics, the proportion of influenza-associated deaths in the US in persons under 65 years of age was 36% (1957-58), and 48% (1968-69).Footnote 4 In the 2009 pandemic 70% of reported deaths in Canada were in persons under 65 years of age.Footnote 5

2.1.3 Pandemic Impact

The term “severity” is often used to describe both severity of disease in individuals (clinical severity) and the overall “severity” of a pandemic in a population. In CPIP, the term severity is used to describe clinical severity of disease in individuals and impact is used to describe the effects of a pandemic on the population.For planning and response purposes, describing the “impact” of a pandemic on the population is a more meaningful approach than talking about its “severity”. It is acknowledged that this usage may vary from the approach of some other authorities. For example, the WHO uses the term “pandemic severity” for what CPIP terms “impact” but the concepts are the same.Footnote 6

Severity refers to clinical severity of disease in an individual (e.g., mild, moderate or severe disease).

Impact refers to the effects of a pandemic on a population (e.g., low, moderate, or high impact).

Pandemics vary in their impact, as do seasonal influenza outbreaks, although usually on a higher scale of magnitude. A low impact pandemic might resemble moderate to severe seasonal influenza outbreaks, although its epidemiological profile would be different in important ways as previously described. In contrast, pandemics of moderate to high impact could result in high rates of illness and death across the country and would severely challenge the health care sector. They could also disrupt the normal functioning of society and put people with limited resources and support systems into a more vulnerable state.

Numerous factors can affect pandemic impact. These are outlined below and described in more detail in Appendix A:

Viral factors are perhaps the most important. These characteristics of the virus itself are usually described as transmissibility (ability to spread) and virulence or clinical severity (the ability to cause severe disease). Transmissibility can be defined in terms of both the extent and the speed of spread and it can vary by season and setting.

Factors affecting population vulnerability include pre-existing population immunity, the presence of underlying health conditions, or unexpected new risk factors for severe disease. Impact may be increased in vulnerable populations, including among Indigenous peoples, or settings such as remote communities, homeless shelters and overcrowded housing.

Response factors include the effectiveness of interventions (e.g., public health measures, vaccine, and antiviral medications), the health care system response (e.g., access, surge capacity), and risk communications, along with the extent of public adoption of desired behaviours and social mobilization.

The impacts of a pandemic in psychosocial terms may be acute in the short term but can also undermine the long-term psychological well-being of the population. Psychosocial issues are not only experienced by those who become ill; distress permeates through the family and the community (e.g. financial stress due to economic downturns, caregiver burnout, occupational stresses, stigma/social exclusion).

The range of issues associated with psychosocial planning is broad involving all levels of government and multiple planning partners, including humanitarian actors such as community-based organizations, government authorities and NGOs and are closely aligned with the practice of risk communicationFootnote 7.

2.2 Uncertainties and Unpredictability

Influenza is unpredictable - every influenza season and every pandemic is different. These uncertainties make pandemic planning challenging and highlight the need for flexibility and adaptability. Some of the major unknown areas about the next pandemic are the following:

When the next pandemic will occur - although historically pandemics have occurred three to four times per century, there is no predictable interval. It should not be assumed that the 2009 pandemic has provided a respite during which preparedness efforts can be relaxed.

Where it will emerge - while most seasonal influenza strains emerge in East/Southeast Asia, Footnote 8 the same is not true for pandemic influenza; the 2009 pandemic emerged in Mexico. An influenza pandemic could emerge anywhere in the world, and there may be very little lead time before Canada is extensively involved.

the same is not true for pandemic influenza; the 2009 pandemic emerged in Mexico. An influenza pandemic could emerge anywhere in the world, and there may be very little lead time before Canada is extensively involved. What the nature of spread will be - pandemics often first arrive outside the usual influenza season (e.g., in late spring or summer) and typically have more than one wave of infection. However, this is not true in all circumstances or in all areas. A small first wave is often followed by a larger second wave, but the relative size of pandemic waves may vary. The speed of spread may also vary - pandemic waves can be intense or more spread-out over time. An intense wave would put more stress on the health care system.

What its characteristics will be - the basic characteristics of the next pandemic virus are unknown, including its antigenic type (e.g., H2, H5, H7), its transmissibility and virulence, and the age groups and clinical groups most affected.

What its impact will be - the last four pandemics demonstrated that population impact can vary from low to high and is not the same in all populations or settings. It is important to consider all possibilities and make plans adaptable for different circumstances. This will help ensure that the response is proportional to the evolution of the pandemic in any specific community.

What effect interventions will have - typical seasonal influenza interventions are expected to be effective during the pandemic. However, the novel virus could be resistant to antiviral medications and/or pandemic vaccine production could be delayed or unsuccessful. The extent of vaccine uptake and adoption of public health measures is also unknown. Furthermore, interventions could have unintended consequences.

2.3 Lessons Learned from the 2009 Pandemic

There were many important epidemiological observations from the 2009 pandemic to take into account in future planning and response. These include the speed with which cases and sporadic outbreaks appeared in Canada after the novel virus was first detected and the early involvement of some remote and isolated communities, with severe disease in some First Nations communities. There was considerable variation in the timing and intensity of pandemic waves, especially the first wave, across the country. Although the symptoms were similar, age groups affected and risk conditions varied from seasonal influenza. Greater impact was seen in pregnant women and Indigenous peoples, and persons with morbid obesity were newly recognized as being at high risk for complications. For the duration of the pandemic, seasonal influenza strains were replaced by the pandemic strain and as with previous pandemics, it was not certain whether this single A strain dominance would continue in the 2010/2011 influenza season, A (H3N2) and B strains began to re-circulate and the pandemic virus became the seasonal A (H1N1) strain.

A number of challenges were identified in the national response. Surveillance demands were very heavy from the start, and were accentuated by the lack of linked information systems in some jurisdictions, unclear protocols for sharing information, and limited capacity for epidemiological analysis. The process for release of the National Antiviral Stockpile (NAS) was uncertain. There was high demand for critical care and ventilators for affected children and adults. Preparation and timely approval of concise national guidelines was difficult. The pandemic immunization program faced challenges with uncertain timelines for vaccine delivery, prioritization of vaccine supply, logistics of local campaigns and communication of changing recommendations.

On the positive side, previous planning processes and relationship-building led to unprecedented FPT collaboration and many successful stakeholder engagement efforts. Existing surveillance systems, like FluWatch, and ready-to-use hand hygiene and respiratory etiquette campaigns were valuable. Mathematical modeling was successfully used to support decision-making in some areas (e.g., recommendations for vaccine prioritization) and it was recognized that a number of other areas would benefit from modeling (e.g. predicting pandemic impact).

Following the pandemic, the Government of Canada (GC)Footnote 9 and most PT governments conducted lessons learned reviews. In addition, the Standing Senate Committee on Social Affairs, Science and Technology held extensive hearings on the response.Footnote 10 Some common themes emerging from these reports and recommendations were identified to improve preparedness, such as:

streamlined FPT governance structure and clarification of roles and responsibilities;

improved scalability and adaptability of response, with triggers to activate and deactivate specific responses while taking into account the variable impact and timing of the pandemic in different geographic regions;

development of integrated electronic information management systems;

strengthened surveillance systems and epidemiological capacity;

collaborative processes to develop and strengthen guidance documents for health care workers (HCW) and other stakeholders to establish timely availability, accessibility, consistency and cultural sensitivity of messages;

strategies to communicate risk, uncertainty and changing information;

active participation of all stakeholders in pandemic preparedness and response;

strengthened linkages with primary care and other front-line service providers;

development of mechanisms for rapid funding and research priority-setting, multi-jurisdictional studies and centralized ethics approval for multi-centre studies;

mechanisms to integrate new research findings into evidence-informed practice; and

regular and rigorous testing of plans at all levels.

2.4 Understanding Canada’s Diversity

Canada’s geographic features and population diversity can create challenges in mounting an effective response to a public health emergency. Canada is a huge country geographically with communities that range in size from large cities to small rural and remote settlements. The proportion of people living in rural areas in Canada (18.9%) is low in comparison to other developed countries and is steadily declining. The proportion of the rural population, however, varies greatly (from 14% to 53%) from one province or territory to another. It is lowest in British Columbia and Ontario and is highest in the Atlantic provinces and the territories.Footnote 11

Canada is diverse in terms of language, religious beliefs, ethnicity, culture and lifestyle. Canada’s Indigenous peoples make up almost 4% of the population, the second highest percentage in the world after New Zealand.Footnote 12 While many Indigenous peoples live in remote and isolated communities in the North, about half live in urban areas. The median age of Canada's Indigenous peoples is considerably younger than that of non-Indigenous peoples (27 years compared with 40 years respectively).Footnote 13

The proportion of foreign-born people in Canada is one of the highest in the world at 20%,Footnote 14 most of whom settle in large cities. Toronto and Vancouver now have over 40% visible minority populations and Montreal has 16%.Footnote 15 In addition there are many temporary residents, such as foreign workers and foreign students.

The needs of remote and isolated communities may be greater than other communities because of geographic isolation and health, social, environmental, economic and cultural considerations. These may affect the baseline health status and thus increase the vulnerability of their residents. In addition, some remote and isolated communities lack basic amenities, such as household access to running water, that are assumed to be present when public guidance like hand hygiene is issued. It is important to consider these factors, along with limited access to health care and transportation challenges, when planning for all aspects of the pandemic response in remote and isolated communities. Similar concerns may affect urban marginalized or vulnerable populations.

There are individuals within all jurisdictions whose needs are not fully addressed by traditional services or who cannot comfortably or safely access and use standard resources. Examples of these vulnerable persons include, but are not limited to, individuals who are:

physically or mentally disabled (e.g., visually or hearing impaired, mobility limitations, cognitive disorders);

limited or non-English or French speaking;

low literacy;

geographically, culturally or socially isolated;

low income;

medically or chemically dependent;

homeless or street-involved;

housebound or frail seniors; and

new immigrants and refugees. Footnote 16

It may not be a single one of these conditions that determines the degree of vulnerability, but rather a combination of them under certain circumstancesFootnote 17.

Studies indicate that there is a social gradient of risk during influenza pandemics, based on social vulnerabilities that are likely to lead to increased exposure to infection, risk of basic human needs not being met, insufficient support and/or inadequate treatment.Footnote 18 Vulnerable populations might become more marginalized if pandemic health services are streamlined into standard approaches to reach the general population.

Within the nationally coordinated pandemic response it is important to allow sufficient local flexibility to address the unique needs of vulnerable populations. Detailed influenza-specific planning guidance has been developed for vulnerable populations in Canada. Footnote 19, Footnote 20 These referenced documents should be useful for FPT and regional/local planners.

Responsibility for planning for vulnerable populations is often unclear and although public health is typically involved, inclusion of all relevant stakeholders is important for comprehensive planning and buy-in. It is important for planners to address the unique needs of their jurisdiction. This begins with identifying populations and settings associated with increased risk of illness or severe outcomes from pandemic influenza along with persons who might need tailored prevention and care services during a pandemic. Specific planning considerations include information needs (e.g., language, cultural style and methods of dissemination); access to assessment, treatment (including antiviral medications) and convalescence support; access to vaccine; and need for support for activities of daily living.

2.5 Ethical Considerations

This section summarizes the more important ethical considerations in pandemic planning but is not intended to be an actual ethical framework. Ethical considerations are also addressed more specifically in various CPIP annexes with supporting tools and frameworks where available.

In Canada, ethical considerations are increasingly taken into account in the development of health policy. Ethical analysis helps to identify the ethical issues and determine how to do the right thing in a fair, just and transparent way. Many of the issues encountered in pandemic preparedness and response involve balancing rights, interests and values. Examples include decisions over resource allocation; prioritization guidelines for pandemic vaccine and antiviral medications; adoption of public health measures that may restrict personal freedom; roles and obligations of HCWs and persons providing medical first response, as well as their employers; the potential need for triage in the provision of critical care; and responsibilities to the global community.Footnote 21

The application of ethical reasoning to pandemic preparedness and response begins with identifying and prioritizing the ethical questions in the issue under consideration. Analysis should include reflection on the ethical considerations associated with the options, taking into account the societal versus individual interests and values that are at stake. Ethical tensions are inevitable. When weighing the options, it is important to be guided by the Canadian pandemic goals.

As pandemic planning initiatives fall within the domain of public health, they are guided by a code of ethics that is distinct from traditional clinical ethics.Footnote 22 Whereas clinical ethics focuses on the health and interests of individuals, public health ethics focuses on the health and interests of a population. When a health risk like a pandemic affects a population, public health ethics predominates, and a higher value is placed on collective interests.

In practical terms, this means there should be an emphasis placed on trust and solidarity. Successful public health activities require relationship-building and can contribute to creating and maintaining trust between individuals, populations and health authorities. Solidarity is the notion that we are all part of a greater whole, whether an organization, a community, nation or the globe. Another important consideration is reciprocity, meaning that those who face disproportionate burdens in their duty to protect the public (e.g., HCWs and other workers who are functioning in a health care capacity, for example police or fire personnel who are providing medical first response) are supported by society, and that to the extent possible those burdens are minimized.

The concept of stewardship is also closely related to trust. Stewardship refers to the responsible planning and management of something entrusted to one’s care, along with making decisions responsibly and acting with integrity and accountability. Trust, stewardship and the proper building of relationships also mean that the power conferred to government and health authorities will not be abused. For example, if restrictions are deemed essential for proper risk management, they must be effective and proportional to the threat, meaning that they should be imposed only to the extent necessary to prevent foreseeable harm. These restrictions should also be counterbalanced with supports to minimize the burden on those individuals affected.

The concepts of equity and fairness are very important to Canadians. In a pandemic context, they lead to a number of considerations. As much as possible, benefits and risks should be fairly distributed through the population. This may be difficult, however, in some circumstances, such as a pandemic that differentially affects certain populations or a very severe pandemic if resources are in short supply. Decisions should take health inequities into account and try to minimize them, rather than make them worse. Access to necessary health care may be restricted in a health crisis; however, available resources (e.g., vaccine and antiviral medications) should be distributed in a fair and equitable way. What will constitute fair and equitable distribution will be context dependent. Therefore the transparency and reasonableness of decision-making processes are important.

Good decision-making processes are also essential for ethical decision-making. They involve the following:Footnote 23, Footnote 24

openness and transparency - the process is open for scrutiny, and information about the basis for decisions and when and by whom they were made is publicly accessible;

accountability - being answerable for decisions;

inclusiveness - stakeholders are consulted, views are taken into account, and any disproportionate impact on particular groups is considered; and

reasonableness - decisions should not be arbitrary but rather be rational, proportional to the threat, evidence-informed and practical.

2.6 Legal Considerations

The legal considerations that arise in the context of pandemic preparedness and response are varied and complex. International laws as well as FPT legislation will be relied upon during both the preparedness and responses phases of a pandemic.

2.6.1 International Requirements

International Health Regulations (2005)

The current International Health Regulations (2005) [IHR (2005)] came into force in 2007. They provide a framework for monitoring and enhancing global public health capacity and international communication regarding potential public health emergencies of international concern (PHEIC). The aim of the IHR (2005) is to prevent the international spread of disease while limiting interference with international traffic and trade. The IHR (2005) also establish a more effective and transparent process for WHO and its Member States (including Canada) who are States Parties to the Regulations, to follow when determining and responding to a PHEIC. Most importantly, they broaden the scope of international collaboration to include any existing, re-emerging or new disease that could represent an international threat.

The IHR (2005) include obligations for States Parties to:

develop core capacity for surveillance and response;

establish a national focal point (NFP) as the contact point for WHO on all IHR matters; and

notify WHO of all potential PHEIC within specified time frames.

In order for Canada to meet the IHR (2005) requirements, all levels of government must collaborate. In Canada, PTs use established protocols to report influenza infections of international concern to the Public Health Agency of Canada (PHAC), which is Canada’s NFP. After an initial assessment if notification is required, PHAC communicates with the WHO. Reportable influenza-related events include cases of human influenza caused by a new subtype as well as cases having potential international public health implications that meet the notification criteria established under Annex 2 of the IHR (2005). WHO then re-assesses the event to determine whether the event constitutes an actual PHEIC. The first PHEIC declared by the WHO under the IHR (2005) was the influenza A (H1N1) pandemic in 2009.

Pandemic Influenza Preparedness Framework

The Pandemic Influenza Preparedness Framework (PIP Framework) for the sharing of influenza viruses and access to vaccines and other benefits was adopted by the World Health Assembly in 2011. The PIP Framework aims to improve the sharing of influenza viruses with pandemic potential and to achieve more predictable, efficient and equitable access for countries in need of life-saving vaccines and medicines during future pandemics.

Under the Framework, Member States, including Canada, are responsible for:

ensuring the timely sharing of influenza viruses with human pandemic potential with the Global Influenza Surveillance and Response System (GISRS);

contributing to the pandemic influenza benefit-sharing system; and

continuing to support the GISRS.

2.6.2 Federal Legislation

The Emergency Management Act (2007), section 6(1), makes each minister accountable to Parliament for a government institution responsible to identify the risks that are within or related to his or her area of responsibility and prepare emergency management and response plans with respect to those risks; to maintain, test and implement those plans; and to conduct exercises and training in relation to them.

In accordance with responsibilities under the Act, the federal Minister of Health is primarily responsible for developing, testing and maintaining mandate-specific emergency plans for the federal Health Portfolio, which includes Health Canada (HC) and PHAC. These emergency plans outline the federal response to national public health threats or events such as major disease outbreaks (including an influenza pandemic), and to the health effects of natural disasters or major chemical, biological, radiological, nuclear and explosive (CBRNE) events.

Furthermore, the Quarantine Act (2005) strives to prevent the introduction and spread of communicable diseases into and out of Canada by providing the Minister of Health with the authority, including enforcement mechanisms, to take public health measures as required. Pandemic Influenza Type A is listed in the Act’s Schedule of Diseases.

2.6.3 Provincial/Territorial Legislation

Health emergency management in the PTs in Canada is governed by legislation specific to each jurisdiction. This legislation requires the PT governments to have comprehensive emergency plans respecting preparation for, response to and recovery from emergencies and disasters, including those with potential impact on critical infrastructure. Important health emergency management powers are also found in public health legislation.

The 2009 pandemic provided an opportunity to identify problems or gaps in existing legislation (including public health legislation) that should be addressed in order to respond more effectively to a future pandemic. An effective response requires an authority to establish appropriate leadership for a coordinated response, along with authority for PT and local public health officials to implement appropriate control measures. Planners should ensure that they will have authority to mount an effective response whether or not an emergency is officially declared.

3.0 Canada's Approach to Pandemic Influenza

3.1 Goals and Objectives

Goals serve an important purpose in guiding preparedness and response, and in prioritizing the use of resources if necessary. Canada's goals for pandemic preparedness and response are:

First, to minimize serious illness and overall deaths, and second to minimize societal disruption among Canadians as a result of an influenza pandemic.

These national goals were originally presented in the Canadian Pandemic Influenza Plan for the Health Sector, which was endorsed by FPT Ministers of Health in 2004. The goals, and their sequence, had undergone extensive deliberation by FPT pandemic planners and other stakeholders. A survey carried out as part of the Canadian Program of Research on Ethics in a Pandemic (CanPREP) found that over 90% of participants agreed that the most important goal of pandemic influenza preparations was saving lives.Footnote 25 During the 2009 pandemic, the pandemic goals were invaluable in guiding aspects of the response.

The supporting objectives for the health sector are as follows:

Minimize serious illness and overall deaths by reducing the spread of infection through promotion of individual and community actions;

protecting the population through provision of pandemic vaccine and implementation of other public health measures; and

providing treatment and support for large numbers of persons while maintaining other essential health care. Minimize societal disruption by supporting the continuity of health care and other essential services;

supporting the continuation of day-to-day activities as much as possible and promoting a return to normal community functioning as soon as possible;

maintaining trust and confidence through support of evidence-informed decision-making by collection, analysis and sharing of surveillance and other scientific information; and communication of appropriate and timely advice to decision-makers, health professionals and the public; and

supporting a coordinated response by working collaboratively with all levels of government and stakeholders.

3.2 Guiding Principles and Approaches

The following principles underpin Canadian pandemic preparedness and response activities and decision-making:

Collaboration - all levels of government and health care stakeholders need to work in partnership to produce an effective and coordinated response. This implies adopting consistent and collaborative approaches to planning, response and recovery, and having an effective FPT decision-making process. It also implies involvement of stakeholders in these steps.

Evidence-informed decision-making - decisions should be based on the best available evidence to the extent possible. It is recognized that other factors also enter into decision-making, such as legal and institutional constraints, values, costs and availability of resources. Footnote 26

Proportionality - the response to a pandemic should be appropriate to the level of the threat.

Flexibility - actions taken should be tailored to the situation and subject to change as new information becomes available. The pan-Canadian approach should be consistent, although patterns of spread may mean that regional and local jurisdictions will require flexibility in terms of the scale and timing of their response.

In addition to these main guiding principles, Canadian pandemic planning and response activities are also guided by:

A precautionary/protective approach - this approach is particularly applicable in the early stages of a pandemic when evidence-informed decision-making is not possible due to lack of data and the uncertainty of an evolving event. This means taking timely and reasonable preventive action, proportional to the threat and evidence-informed to the extent possible. This does not mean that in the absence of evidence, all actions must be taken; rather, it means that as emerging evidence reduces uncertainty, evidence-informed actions may supersede those precautionary measures taken at the outset.

Use of established practices and systems to the extent possible - it is extremely difficult to implement new ways to do things during an emergency. Effective seasonal influenza responses support a strong pandemic response, as well-practised strategies and processes can be rapidly ramped up to manage the pandemic.

Ethical decision-making - ethical principles and societal values should be explicit and embedded in all decision-making, including the processes used to reach decisions. It is especially important to ensure that all actions respect ethical guidelines tailored to the concerns of public health, while respecting the rights of individuals as much as possible.

3.3 Coordination of National Preparedness and Response

The global nature of a pandemic requires a response that differs from many other types of emergency. Traditionally, the responsibility to deal with an emergency is placed first on the individual/household to manage the effects of the emergency as it affects them, and then on successive levels of government as the resources and expertise of each are needed. Public Safety Canada is responsible for coordinating the whole of government response when the federal government is involved in the response to an emergency. Within the PTs a similar function is performed by the appropriate ministry or emergency measures organization.

In a pandemic situation, a pan-Canadian whole-of-government response is required so that all potential resources can be applied to minimizing the pandemic's negative health, social and economic impacts. Pandemic plans should be aligned across jurisdictions to facilitate successful FPT collaboration during a pandemic.

The following sections provide a high-level overview of FPT health emergency planning and response relevant to pandemics.

3.3.1 Emergency Management Frameworks and Plans

The GC has in place a coordinated system of federal emergency management frameworks, systems and emergency response plans, many of which can be accessed at Public Safety Canada's web site. These plans are based on the four components of the emergency management continuum (prevention and mitigation, preparedness, response and recovery) and they use an all-hazards approach. Emergency response plans for the federal Health Portfolio are part of this GC system.

The FPT health sector also has a system of frameworks and emergency response plans parallel to those of the federal health sector, that are comprehensive and flexible enough to address any type of national health emergency. The development and maintenance of some of these documents, including CPIP, is overseen by the PHN.

The federal and FPT emergency management plans are supported by various operational annexes and guidance documents. These are nested under the generic all-hazards emergency response plans and deal with more specific threats.

3.3.2 Pan-Canadian Coordination of the Pandemic Health Sector Response

Because a pandemic is a significant health event, the FPT ministries of health have the primary mandate for the health sector response in their respective jurisdiction and act as advisor for other sectors on health issues.

At the federal level, the Centre for Emergency Preparedness and Response (CEPR) at PHAC is the Health Portfolio's focal point for coordinating and providing a wide range of emergency management services with other federal departments, PT governments, NGOs and the private sector. CEPR is responsible for the Health Portfolio Operations Centre (HPOC) in Ottawa and its linkages to other operational centres at the FPT level.

Coordination of the FPT health sector response to a pandemic will follow the governance structure outlined in the FPT Public Health Response Plan for Biological Events (FPT-PHRPBE). The FPT-PHRPBE is complementary to and used in conjunction with existing jurisdictional planning and response systems.

The FPT-PHRPBE is intended to bridge the gap between PT public health response plans and federal health response plans by providing a single, common overarching governance framework for the FPT health sector that can be applied, in full or in part, during a significant public health event requiring a coordinated FPT response, such as an influenza pandemic.

The FPT-PHRPBE defines a flexible FPT governance mechanism that identifies escalation considerations and response levels for a scalable response, and to improve effective engagement amongst public health, health care delivery and health emergency management authorities during a coordinated FPT response. This will ensure that at the time of a response, notification processes and inter-jurisdictional information-sharing will be enhanced; public and professional communication will be addressed; and advance planning and decision-making between and amongst multiple jurisdictions will be facilitated.

Finally, as the effects of a pandemic are not exclusive to the health system, it is critical for FPT governments and emergency management partners to use a common approach in responding to a pandemic. Emergency social services (e.g. non-medical services considered essential for the immediate physical and social well-being of people affected by disasters) should be coordinated within the broader PT response and aligned with health system activities.

3.3.3 North American Plan for Animal and Pandemic Influenza

The North American Plan for Animal and Pandemic Influenza (NAPAPI) outlines how Canada, Mexico and the US intend to work together to combat an outbreak of animal influenza or an influenza pandemic in North America. The NAPAPI addresses both animal and public health issues, including early notification and surveillance, joint outbreak investigation, epidemiology, laboratory practices, medical countermeasures (e.g., vaccine and antiviral medications), personnel sharing and public health measures. It also addresses border and transportation issues. While the NAPAPI is not legally binding, it reflects strong commitments by the countries involved to work collaboratively.

3.4 Pandemic Roles and Responsibilities

Collaboration in pandemic planning and response is strengthened by having clearly defined and well-understood roles and responsibilities. While this section focuses on government responsibilities, it is acknowledged that other partners also have important roles and responsibilities in a pandemic. These partners include the non-health sector, private sector, NGOs, municipalities and local/regional health authorities, and international organizations. Similarly, members of the general public bear responsibility for keeping themselves informed and for cooperating with measures to reduce the spread of illness.

3.4.1 World Health Organization

WHO's pandemic roles and responsibilities are outlined in the WHO pandemic influenza risk management guidance document and include:Footnote 27

coordination of the international response under the IHR (2005), including conducting global risk assessments;

communication of the global situation using the global pandemic phases;

declaration of a PHEIC and pandemic as required under the IHR;

provision of information and support to affected States Parties;

selection of the pandemic vaccine strain and determination of when to move from seasonal to pandemic vaccine production; and

provision of oversight and support for implementation of the PIP Framework.

3.4.2 Canada - FPT Governments

Responsibility for health services in Canada is shared across all levels of government. High-level roles and responsibilities for FPT governments are outlined below; more detailed information about roles and responsibilities for specific response components can be found in the CPIP annexes. It is recognized that responsibilities for federal populations, which are summarized at the end of this section, are complex and evolving.

A. International aspects

International aspects of influenza management and liaison are a federal responsibility.

The federal government is responsible for:

acting as the national focal point for the WHO on all IHR (2005) matters and managing all international aspects of pandemic preparedness and response;

providing travel health notices and other health related information relevant to international travel; and

exercising powers under the Quarantine Act to protect public health by taking comprehensive measures to help prevent the introduction and spread of communicable diseases in Canada. Such measures may include, but are not limited to, the screening, examining and detaining of arriving and departing international travellers, conveyances (e.g., airplanes and cruise ships) and their goods and cargo.

B. Collaboration, communication, information sharing and policy recommendations

While PT governments are responsible for communications plans and messaging within their jurisdictions, a coordinated pan-Canadian pandemic response requires collective infrastructures, response capacities and coordinated activities.

The federal government is responsible for:

ensuring that risk assessments for novel and pandemic viruses are prepared and communicated as required; and

facilitating the coordination of the overall pan-Canadian response to a pandemic.

FPT governments will work collaboratively to:

coordinate and support the process required for development and periodic updating of CPIP and its annexes, for which PHAC acts as the custodian;

assess capacity gaps for a pan-Canadian response and address gaps as necessary;

align federal pandemic plans for federal populations, (see Section F for federal populations), with PT plans, where relevant;

assess surveillance capacity, standards and protocols and modify as necessary;

assess laboratory capacity, standards and protocols and modify as necessary;

establish and support pan-Canadian policies and recommendations on the use of antiviral medications and vaccine during a pandemic;

develop and implement public health guidance;

ensure development and dissemination of clinical care guidance;

develop a pan-Canadian communication strategy that reflects Canadian linguistic, literacy and cultural characteristics and allows for the alignment of messaging by FPT jurisdictions where appropriate;

establish protocols for the sharing of relevant information, including but not limited to FPT plans and drafts; surveillance information; jurisdictional communications, strategies and messaging; and pandemic response interventions and impacts; and

identify and address rapid research response priorities and leverage their respective research undertakings.

C. Antiviral medications and influenza vaccine

The federal government is responsible for:

providing regulatory authorization to market antiviral medications and influenza vaccines;

acting as the focal point for vaccine manufacturers and international regulatory collaboration;

providing regulatory authorization to conduct clinical trials;

negotiating with manufacturers and establishing contracts for the FPT purchase of antiviral medications and vaccine for pandemic purposes;

national monitoring of adverse reactions to antiviral medications and vaccines; and

providing antiviral medications and vaccine to those federal populations not covered by arrangements for PT provision.

PT governments are responsible for maintenance, monitoring, distribution and administration of antiviral medications and vaccine in their respective jurisdictions. They will work collaboratively to:

provide antiviral medications and, when available, vaccine to recommended populations;

share information regarding the distribution and use of antiviral medications and vaccines in their respective jurisdictions; and

monitor and report adverse vaccine reactions.

The PT governments are also responsible for the distribution of vaccines and antiviral medications to most federal populations, but this varies by federal population and jurisdiction (see section F on federal populations).

FPT governments will work collaboratively to develop strategies to mitigate the effects of insufficient or delayed antiviral drug and/or vaccine supply, should such a situation arise.

D. Health sector preparedness and response

Health sector preparedness and response remains the responsibility of each jurisdiction. In some jurisdictions responsibility for emergency social services also falls to the health sector.

PT governments are responsible for:

ensuring that PT pandemic plans (or all-hazards plans depending on the jurisdiction) are developed, tested and periodically updated;

considering the content and intent of CPIP in the development of their PT jurisdictional plans;

communicating and engaging with the general public, media and stakeholder groups about their respective plans; and

activating PT pandemic or all-hazards plans.

The federal government has similar responsibilities for federal departments within the health sector and for federal populations in collaboration with the PTs (see section F on federal populations).

E. Health care provision

The provision of health care is an essential component of pandemic response and is primarily a PT responsibility.

PT governments are responsible for:

developing plans to increase surge capacity in order to care for affected persons in their jurisdiction;

providing health care services for persons within their jurisdiction, including for federal populations while leveraging agreements that are in place (federal populations and federal responsibility are covered in the next section);

developing and maintaining memoranda of understanding and protocols as needed, preferably before the pandemic, to facilitate interprovincial/territorial movement of patients and licensed health care professionals during a pandemic and other aspects of mutual aid;

developing, as necessary, a strategy for collecting and monitoring data on health care service use;

ensuring the provision of medications, supplies and equipment required for provision of pandemic health care services; and

working collaboratively to establish protocols and guidelines for prioritizing health care services during times of high service demand and staff or supply shortages in the respective jurisdiction.

The federal government is responsible for:

ensuring the provision of health services, medications, supplies and equipment for specified federal populations/employees who normally access federally operated health care services;

facilitating access to surge capacity, including from federal programs, employees and resources, to support PT responses if required;

mobilizing medical supplies in the National Emergency Strategic Stockpile (NESS) as surge capacity to support PT responses; and

facilitating the acquisition of extra medical supplies through Public Services and Procurement Canada and other federal agencies as appropriate.

F. Federal populations

Federal populations are those populations for which the federal government either provides health care and benefits, goods and/or services or reimburses the cost of providing health care and benefits. With the exception of the Canadian Forces which has its own distinct health care system for active members, the needs of federal populations must be integrated into PT pandemic planning activities in order to establish a comprehensive and coordinated pandemic response.

Federal populations include the following:

First Nations on-reserve, inclusive of First Nations who have assumed responsibility for health services under a transfer agreement;

active members of Canadian Forces;

federal offenders or inmates of federal penitentiaries;

refugee claimants, protected persons, detainees under the Immigration and Refugee Protection Act, rejected refugee claimants, and other specified populations; and

Canada-based staff at missions abroad.

The federal government is responsible for:

supporting the provision and distribution of medications, supplies and equipment to federal populations, as noted in the list above, through existing FPT distribution and administration systems.

The federal government will work collaboratively with PT governments to:

ensure that access to pandemic health services for all federal populations is available on the same basis as is provided to other residents of Canada, while leveraging agreements that are in place. This involves but is not limited to access to antiviral medications, influenza vaccines and supplies needed for provision of pandemic health care services; and

facilitate the coordination of federal planning for federal populations with PT pandemic plans.

3.5 Risk Management Approach

3.5.1 Overview

Risk management is a systematic approach to setting the best course of action in an uncertain environment by identifying, assessing, acting on and communicating risks. A risk management approach provides a useful framework for addressing the uncertainties inherent in pandemic planning and response. Risk management supports the CPIP planning principles of evidence-informed decision-making, proportionality, and flexibility; and a precautionary/protective approach when there is uncertainty early in an event.

Figure 1 provides a graphic overview of the risk management process as outlined in ISO 31000, the international standard for risk management. The individual steps involved in risk management are then briefly described.

Figure 1 - ISO 31000 Risk Management Process Footnote 28 Figure 1 - ISO 31000 Risk Management Process - Text Equivalent The ISO 31000 is the international standard for risk management. The individual steps involved in risk management are briefly described.

Risk assessment is a central component of risk management. Its purpose is to provide evidence-informed information and analyses for making informed decisions on how to treat particular risks and select between options. There are three parts to risk assessment:

Risk identification involves identifying what might happen, or what situations might exist that could affect achievement of the objectives of the organization or system.

Risk analysis involves analysing the risks in terms of their probability and potential impact (who is affected and to what extent). This analysis helps identify the planning considerations and options for each component of the response. The analysis should also assess the public's perception of risk and how it could influence the risk management response, so that communications strategies and messaging can be tailored appropriately.

Risk evaluation involves determining the significance of the level and type of risk in order to make decisions about future actions. Ethical, legal, financial and other considerations are also inputs to the decisions. Decisions may include the need and priorities for treatment, whether an activity should be undertaken or which of a number of paths should be followed.

Risk treatment follows risk assessment and involves identifying and recommending risk treatment options, i.e. options for management or control. Risk treatment options should include steps that need to be taken in advance, as well as potential actions at the time of the pandemic.

Communication and consultation are also integral parts of the risk management process. Effective communication with stakeholders should facilitate adequate understanding of the risk management decision-making process, ensure that the process is transparent and help people to make informed decisions. A risk communications plan should be developed at an early stage.

Monitoring and review are important for assessing factors that could change over time and for documenting effectiveness of interventions. Such reviews should lead to periodic updates of the risk assessment.

3.5.2 Risk Management Considerations in Pandemic Planning and Response

Given the large number of variables that are involved in influenza pandemic planning, comprehensive risk management is challenging. The four pandemic planning scenarios described in section 3.7 can assist with risk identification by providing a starting point to think through the risks that would be associated with pandemics of varying impact and their implications.

It is also worthwhile to anticipate key decisions that will need to be taken during the pandemic to help guide the development and analysis of options. It is also worthwhile to clarify ahead of time and to the extent possible what level(s) of government should be involved with which types of decision when the time comes. Examples of these key decisions are as follows:

what is the scale of the response;

whether (and when) to escalate or de-escalate the response;

when, what and how to communicate with the public;

what amount of vaccine and the formulation(s) to order;

how vaccine use should be prioritized;

what public health interventions should be used, when and within which populations, and whether they need to be adjusted over time;

what influenza testing and treatment strategies to recommend and whether they need to be adjusted over time; and

what supplementary assessment and treatment services might be needed and, if necessary, when they should be started and stopped.

Anticipating key decisions should be accompanied by identification of the types and sources of information required for decision-making. Establishing robust surveillance for seasonal influenza establishes baselines, develops capacity and provides a platform for escalation during the pandemic.

Anticipating key decisions should also lead to development of relevant options for risk treatment. From a pandemic preparedness perspective, examples of risk treatment include continuity of operations planning; establishment of stockpiles for antiviral medications and other key supplies; development of advance contracts for pandemic vaccine; strengthening influenza surveillance systems, diagnostic and analytical capacity; establishment of protocols for pandemic research; and establishment of communications networks to plan effective and coordinated risk communications strategies.

When a pandemic occurs, planning scenarios are replaced by a real event and response activities will be guided by the available evidence. During the initial stages, little may be known about the likely pandemic impact or the populations most at risk. Many decisions will have to be made before solid information is available and then adjusted, if necessary, as more becomes known, keeping in mind that it is often difficult to scale back a response. As the evidence emerges over time, understanding of the situation will continue to change as new information becomes available and will always be incomplete. A risk management approach will be used throughout the response by all responders. Risk assessments will provide key input into FPT decision-making by identifying what is known at that point in time, what might occur and when, and the major areas of uncertainty.

PHAC will facilitate development of timely and credible risk assessments to support FPT decision-making. These formal risk assessments will be conducted at the start of the pandemic to inform the initial response and then periodically as new information emerges (e.g., at the end of a pandemic wave). Risk assessments will address key information needs, including viral characteristics, the anticipated or experienced impact on the health care system and community, age and risk groups most affected, occurrence of antiviral resistance and estimated effectiveness of control measures. As the pandemic progresses, there will be questions about likely occurrence of more pandemic waves, whether new risk factors are emerging and whether the response should be escalated or de-escalated. Appendix B identifies relevant considerations for initial and ongoing pandemic risk assessments and identifies potential sources for the supporting information.

3.6 Planning Assumptions

This section on planning assumptions and section 3.7 on pandemic planning scenarios describe two important tools for pandemic planning. These tools provide distinct but complementary approaches.

Identifying planning assumptions is a way to deal with uncertainty. Assumptions provide a useful framework for planning but should not be regarded as predictions. While planning assumptions are rooted in evidence to the extent possible,Footnote 29, Footnote 30 they are basically educated guesses. As the pandemic unfolds, emerging evidence is used to guide the response. Informing the planning assumptions identified below is the WHO's Pandemic influenza risk management interim guidance (2013), the UK's Scientific summary of pandemic influenza & its mitigation (2011) and discussions from the Canadian Pandemic Influenza Preparedness Planning Assumptions Workshop held in 2011.

3.6.1 Origin and Timing

The next pandemic could emerge anywhere in the world and at any time of year.

There may be no lead time before the novel virus reaches Canada.

The first peak of illness in a geographic area within Canada could occur within weeks of first detection of the novel virus in that area. The first peak in mortality is expected to be several weeks after the peak in illness.

3.6.2 Transmission

The pandemic virus will behave like seasonal influenza viruses in significant ways: incubation period - is expected to last from one to three days; period of communicability - adults are infectious from 24 hours before and up to five days from the onset of symptoms, and children may be infectious for up to seven days. Longer periods have been found, especially in persons with immune compromising conditions; methods of transmission - mainly by large droplet and contact (direct and indirect) routes; the role of airborne transmission is unclear.

Transmission is expected to be relatively lower in spring and summer than in fall and winter (the general pattern of transmission in temperate countries).

Transmission is possible from asymptomatic persons but is greater when symptoms, such as coughing, are present and viral shedding is high (i.e., early in the symptomatic period).

3.6.3 Pandemic Epidemiology

Most communities will experience two or more pandemic waves of different magnitudes. In any locality, the length of each wave will be from several weeks to a few months but may vary by community.

There will be geographic variability with regard to the timing and intensity of waves, although multiple jurisdictions will be affected simultaneously.

The pandemic is expected to last 12 to 18 months.

The novel virus is expected to displace other circulating seasonal strains during the pandemic. After the pandemic, the pandemic virus will continue to circulate as a seasonal strain. It may completely replace previously circulating seasonal influenza A subtypes or continue as one of several circulating seasonal A subtypes.

Relatively more severe disease and mortality is expected to occur in the young and in persons without underlying health conditions compared to seasonal influenza.

3.6.4 Clinical Features

Population clinical attack rates (averaged across all age groups) are expected to be 25% to 45% over the course of the pandemic.

Clinical symptoms are expected to develop in about two-thirds of people who are infected with the pandemic influenza virus.

The general, uncomplicated clinical picture is expected to be the same as for seasonal influenza: respiratory symptoms, fever and abrupt onset of muscle ache, fatigue and headache or backache.

Persons at high risk for complications from seasonal influenza Footnote 31 are expected to also be at increased risk of severe disease and complications from pandemic influenza infection, although additional risk groups may emerge.

3.6.5 Impact and Interventions

Impact will vary across communities, and vulnerable populations are expected to be affected more severely.

Workplace absenteeism may be higher than the estimated clinical attack rate because of caregiving or concern about personal safety in the workplace in addition to worker illness.

Vaccine is expected to be available in time to have an impact on the overall pandemic but will not be available for the first wave.

Personal hygiene measures are expected to help to reduce transmission between individuals and within households and other settings.

3.7 Pandemic Planning Scenarios

This section discusses another important tool for pandemic planning. The use of multiple planning scenarios is specifically intended to support the planning principles of evidence-informed decision-making, proportionality, and flexibility; and a precautionary/protective approach.

Planning scenarios provide a starting point to think through the implications and risks that would be associated with pandemics of varying population impact. Scenarios can also be used for exercises and training in support of pandemic plans. To help with risk identification, four pandemic planning scenarios have been developed that describe potential pandemic impacts varying from low to high. Figure 2 displays the four scenarios in a two-by-two table and estimates where the past four pandemics might be placed, according to an analysis conducted by the US Centers for Disease Control and Prevention (CDC).Footnote 32

Figure 2 - Framework for the planning scenarios, with previous pandemics placed as per CDC analysis Footnote 33 Figure 2 - Framework for the planning scenarios, with previous pandemics placed as per CDC analysis - Text Equivalent Planning scenarios provide a starting point to think through the implications and risks that would be associated with pandemics of varying population impact. Scenarios can also be used for exercises and training in support of pandemic plans. To help with risk identification, four pandemic planning scenarios have been developed that describe potential pandemic impacts varying from low to high. The four scenarios can be described by having a four quadrant table with the x axis being clinical severity and the y axis being transmission ranging from low to high. Quadrant A is at the origin of the x and y axis, Quadrant B, is the left upper quadrant above A, Quadrant C, is the right lower quadrant to A, and Quadrant D, is the right upper quadrant. The table is populated with estimates of the past four pandemics, according to analyses conducted by the US Centers for Disease Control and Prevention (CDC). Reed C, Biggerstaff M, Finelli L et al. Novel framework for assessing epidemiological effects of influenza epidemics and pandemics. Emerg Infect Dis. 2013;19:85-91. The 1918 pandemic is populated in quadrant D.

The 1957 pandemic is populated mid-point between quadrant B and D.

The 1968 pandemic is populated in quadrant B.

Lastly, the 2009 pandemic is populated mid-point between quadrant B, and origin quadrant A.

Scenario A (low impact) - this scenario involves an influenza virus with low transmissibility (ability to spread) and low virulence (clinical severity). Its impact is comparable to that of moderate to severe seasonal influenza outbreaks or the 2009 pandemic. It might be expected to stress health care services.

Scenario B (moderate impact) - this scenario involves an influenza virus with high transmissibility and low virulence. Its impact is worse than seasonal influenza in terms of numbers ill, which would be expected to stress health care services through sheer volume. High absenteeism would put all sectors and services under pressure.

Scenario C (moderate impact) - this scenario involves an influenza virus with low transmissibility and high virulence. Its impact is worse than seasonal influenza outbreaks in terms of severe clinical illness, which would be expected to stress critical care health services. The high virulence could cause significant public concern and may lead to people staying home from school and work.

Scenario D (high impact) - this scenario involves an influenza virus with high transmissibility and high virulence, and its anticipated impact is much worse than that of seasonal influenza outbreaks. It would cause severe stress on health care services, and high absenteeism would put all sectors and services under extreme pressure.

There are several important points to note about the scenarios:

Whatever the pandemic impact, the epidemiological picture is expected to be significantly different from that of seasonal influenza, in that relatively more severe disease and mortality will occur in the young and in persons without underlying health conditions compared to seasonal influenza. Footnote 34

The four basic scenarios do not incorporate all of the potential factors (or “what-ifs”) that can affect the impact of a pandemic and should be considered in risk assessment. Some of these factors are population-wide and could affect all scenarios (such as seasonality, pre-existing immunity or antiviral resistance), whereas others might be setting-specific (such as planning for a remote community). See Appendix A for more details about these additional factors and their potential impact. Additional risks may also be identified as planners consider all stages of the pandemic and components of the proposed response.

Table 1 provides some added description to the scenarios for planning purposes, along with potential impact considerations associated with each scenario.

Table 1 - Description and potential impact of the four pandemic planning scenarios Nature of impact Pandemic scenario A

(low impact) B

(moderate impact) C

(moderate impact) D

(high impact) Basic virus characteristics Low transmissibility/ low virulence High transmissibility/ low virulence Low transmissibility/ high virulence/ High transmissibility/ high virulence Nature and scale of illness Similar numbers as in moderate or severe seasonal influenza outbreaks

Mild to moderate clinical features (in most cases) Higher number of cases than large seasonal outbreak but similar clinical severity

Overall increased numbers needing medical care and with severe disease Similar number of cases as with large seasonal outbreak but illness is more severe Overall increased numbers needing medical care and with severe disease Large numbers of people ill

High proportion with severe disease Impact on health care services Ambulatory and acute-care services stressed but able to cope

ICUs at capacity

Public health and laboratory services stressed

Long-term care may or may not be affected (depending on pre-existing immunity) Ambulatory and acute-care services very stressed

Health care services no longer able to continue all activities

ICUs under severe pressure

Long-term care may or may not be affected

Settings with limited surge capacity (e.g., nursing stations) may be even more stressed Ambulatory and acute-care services very stressed

Health care services no longer able to continue all activities

ICUs under severe pressure

Long-term care may or may not be affected

Settings with limited surge capacity e.g., nursing stations) may be even more stressed Health care services may be overwhelmed

Ambulatory services fully stretched

Hospitals able to provide only emergency services

Triaging necessary for critical care services

Collapse of services could lead to higher mortality than expected

Settings with limited surge capacity (e.g., nursing stations) may be highly stressed Broader societal impact Limited workplace disruption

Some school disruption

Elevated public concern High workplace absenteeism

Some services experience pressures

Schools likely disrupted

Some supply chain problems

Elevated public concern

Surges in need for health care services. Potential workplace absenteeism and school disruption from fear of exposure

Considerable public concern over occurrence of very severe disease High absenteeism

Services and businesses under extreme pressure

Potentially severe supply chain problems

Could disrupt provision of basic services

Extreme public concern and psychosocial distress

Mass fatalities may overwhelm death care services (e.g. funeral homes,mortuaries) Economic

impact Minimal if any Productivity may be affected Productivity may be affected Very high

Initial period when impact is unknown - A formal scenario has not been proposed for the initial period when the pandemic has not yet been characterized in terms of its potential impact. However, some of the possible observations for this preliminary period are as follows:

sporadic cases and limited outbreaks may be occurring;

there will likely be elevated demand on telephone information lines, ambulatory care and laboratory services;

public health services may be stressed;

elevated media and public concern can be anticipated;

international travel and trade could be disrupted; and

there could be increased demand and shortages of publicly available supplies, e.g., infection control and basic emergency supplies, antivirals.

3.8 Pandemic Phases and Triggers for Action

3.8.1 WHO Pandemic Phases

Pandemic phases were introduced into pandemic plans to assist planning and serve as triggers for action, thus supporting the principles of flexibility and proportionate response. Previous Canadian pandemic plans incorporated the WHO pandemic phases, with additional designations proposed to identify activity levels within Canada.

After the 2009 pandemic, the IHR Review CommitteeFootnote 35 recognized that the WHO pandemic phases had presented challenges in interpretation and were used in different ways - as a planning tool, as a method to describe the global situation and/or as an operational tool to trigger action. The Committee recommended simplifying the WHO phase structure and separating operational considerations at country level from the WHO global preparedness plan and its phases.

WHO's 2013 pandemic guidanceFootnote 36 describes the four phases that WHO will use to communicate a high-level global view of the evolving picture. The phases reflect WHO's risk assessment of the global situation regarding each influenza virus with pandemic potential that is infecting humans. The four global phases are:

Interpandemic phase - the period between influenza pandemics;

Alert phase - when influenza caused by a new subtype has been identified in humans. This phase is characterized by extra vigilance and careful risk assessment;

Pandemic phase - the period of global spread of human influenza caused by a new subtype. Movement between the interpandemic, alert and pandemic phases may occur quickly or gradually;

Transition phase - reduction of the assessed risk resulting in de-escalation of global actions.

The global phases and their application in risk management are distinct from (1) the determination of a PHEIC under the IHR (2005) and (2) the declaration of a pandemic. These are based upon specific assessments and can be used for communication of the need for collective global action, or by regulatory bodies and/or for legal or contractual agreements, should they be based on a determination of a PHEIC or on a pandemic declaration.Footnote 37

As pandemic viruses emerge, countries face different risks at different times and should therefore rely on their own risk assessments, informed by the global phases, to guide their actions. The uncoupling of national actions from global phases is necessary since the global risk assessment, by definition, will not represent the situation in each country.

3.8.2 Canada's Approach to Pandemic Phases and Triggers for Action

Canada's response to the novel/pandemic virus will relate to its presence and activity levels in this country, which may not coincide with the global picture. Therefore, the WHO global phases will not be used to describe the situation in Canada or be used as triggers for action in Canadian jurisdictions. While the triggers for action described below may parallel some of the global WHO phases, it is not expected that they will line up exactly. For example, Canada might be well into the first pandemic wave before WHO announces the global pandemic phase (as happened in the 2009 pandemic) or conversely Canada might be still anticipating the first domestic outbreaks when the pandemic phase announcement is made.

In the 2009 pandemic, there was considerable variation in pandemic wave activity across Canada and even within PTs, in terms of both timing and intensity. This was particularly apparent in the first wave making blanket descriptions, triggers or responses inappropriate.

Describing pandemic activity

Descriptive terms such as the start, peak and end of a pandemic wave, will be used instead of phase terminology to describe pandemic activity in the country or in a jurisdiction within Canada. Pandemic wave activity can be further characterized for jurisdictions of any size using FluWatch definitions for no activity, sporadic activity, localized activity and widespread activity.Footnote 38

Triggers for action

Table 2 - Pandemic Triggers and Typical Accompanying Actions Trigger Typical actions for consideration Comments Novel virus causing human cases detected somewhere in the world (no or limited transmission) Preparations to enhance surveillance within Canada

Intelligence gathering from affected areas

Relevant public and health sector communications Tailored communications to health sector and general public continue throughout the response Novel virus with sustained human transmission detected somewhere in the world Enhanced surveillance by PTs within Canada

Intelligence gathering from affected areas; preliminary risk assessment

Development of specific laboratory diagnostics

Enhancement of illness prevention messages and other public health measures (e.g., hand hygiene, respiratory etiquette) as appropriate

Confirmation of pandemic vaccine arrangements with manufacturer Pandemic may be imminent or have already started Novel/pandemic virus (with sustained human transmission) first detected in Canada Continuation of above activities

Activation of health emergency response protocols

Detailed investigations of early cases to determine epidemiological and clinical characteristics and inform risk assessment

Arrangements for antiviral access/strategic deployment of NAS

Provision of clinical guidelines and public health advice Depending on circumstances, activation of health emergency protocols might already have occurred Novel/pandemic virus detected in PT or local jurisdiction Treatment of cases

Ramping up health sector capacity to deal with increasing number of cases

Additional public health measures (e.g., school closures) as appropriate

Preparation for vaccine distribution, administration and monitoring

Ongoing surveillance to monitor influenza activity and epidemiological analysis to characterize pandemic

Relevant public and health sector communications

Assess need for supportive emergency and social services (e.g. reception centres, volunteers, faith-based organizations) Escalation of activities as pandemic activity moves from sporadic cases into full pandemic wave, followed by de-escalation as it wanes Demands for service start to exceed available capacity Further escalation of surge capacity

Prioritization or triage of services as needed

Implementation of broader public health measures (e.g., banning of large gatherings) May not reach this level in any or all jurisdictions The pandemic wave wanes and demand for service falls to more normal levels Preparation for a resurgence of influenza

Replenishing of supplies as needed in anticipation of another wave

Evaluation of response and revision of plans as required

Preparation for immunization program

Ongoing surveillance to detect resurgence

Assessment of the psychosocial impact on the population (e.g. workforce resiliency, mental health, social cohesion) of the first wave Pandemic vaccine is available for administration Administration of vaccine as quickly as possible

Monitoring of vaccine uptake, safety and effectiveness Second or subsequent pandemic wave arrives Treatment of cases

Continuation of immunization if already started

Ongoing surveillance to monitor influenza activity, antiviral resistance and strain changes Pandemic is over and normal activities resume Completion of pandemic studies and reports

Evaluation of response and revision of plans as required

Return to more normal operations

Preparation for post-pandemic seasonal influenza Identification of lessons learned and their incorporation into pandemic planning are critical activities in the recovery from a pandemic

4.0 Key Components of Pandemic Influenza Preparedness and Response

Triggers for action provide guidance for initiation of FPT activities and for their modification and cessation. Pandemic response should be appropriate to the local situation, so it is important that triggers and related actions be applied at PT or regional/local level as appropriate to the situation. Potential triggers for action in Canadian jurisdictions during the initial alert stages and the pandemic itself are identified in Table 2. The typical actions listed are at a high level; more detailed triggers for individual response components can be found in the annexes. Note that the triggers are not necessarily linear; for example, not all jurisdictions may find their capacity exceeded and therefore some may not need to invoke that particular trigger.

This chapter provides a high-level overview of the major components of influenza preparedness and response. Each section of the chapter describes the purpose and strategic approach of one of the response components and demonstrates how it supports the overall pandemic goals. Detailed operational guidance and tools for each component can be found in the respective CPIP annex.

All parts of the health sector, including public health, will be under stress during a pandemic. Advance planning, training and exercises will greatly assist in handling this increased demand on health services, staffing, resources and supplies and in providing the best possible clinical outcomes for persons ill with influenza. Continuity of operations and surge capacity planning are key components of health sector preparation, together with strong infection prevention and control and occupational health programs within each organization that provides health services.

Public health authorities play a leadership role in their jurisdiction in pandemic preparedness, response and recovery. They are responsible for communication to the public, the health sector and other stakeholders. The public health response to a pandemic also includes surveillance (both epidemiological and laboratory), the provision of pandemic vaccine and antiviral medications, and the application of public health measures such as promotion of personal and social distancing measures to reduce spread in households and the community.

In planning for the delivery of health services, it is important to encompass the entire continuum of care from medical first response to critical care, and to include community health partners. Planning for the provision of health care needs to be linked with public health and community-wide partners so that interdependencies can be identified and addressed.

The health care system includes workers of many disciplines, who will be at varying levels of risk during an influenza pandemic. HCWs are defined broadly as individuals who provide health care or support services in the health care setting, such as nurses, physicians, dentists, nurse practitioners, paramedics, medical laboratory workers, other health professionals, temporary workers from agencies, unregulated health care providers, students, volunteers and workers who provide support services (e.g., food, laundry, housekeeping). The concepts and advice that are provided for HCWs also apply to other workers who are functioning in a health care capacity, for example police or fire personnel who are providing medical first response.

4.1 Surveillance

The purpose of pandemic surveillance is to provide decision-makers with the timely information they need for an effective response. Pandemic surveillance uses data obtained through routine and enhanced surveillance activities (e.g., data from sources such as laboratories, PT partners, hospital networks and sentinel practitioners) together with information from special studies to obtain a comprehensive and timely epidemiological picture of the pandemic.

These pandemic surveillance programs will monitor parameters such as:

the geographic spread of the novel/pandemic virus across Canada;

the trend of disease occurrence as it rises and falls within each PT and across the country;

the intensity and impact of the pandemic (e.g., clinical cases, hospitalizations and deaths; severe clinical syndromes and associated risk groups; and demands on the health system); and

changes in the antigenicity and antiviral sensitivity of the virus.

Strategic approach

A risk management approach to an influenza pandemic requires access to timely information, analysed and presented in a way that is useful to decision-makers. Epidemiological and laboratory surveillance data are key components of the formal risk assessments that will be produced to inform the response. One of the most critical needs is an early assessment of the potential impact of the pandemic so as to prepare the health care system and to plan interventions that are proportional to the situation. Systems or studies to produce the early impact assessment and other required information need to be in place before the pandemic.

Pandemic surveillance should be built on existing surveillance systems for seasonal influenza, which involve an extensive network of surveillance partners and are practised every year.

During a pandemic, collection of additional surveillance elements may be required to identify risk factors for severe disease and populations at increased risk. Targeted surveillance activities may be required for remote and isolated communities, including many Indigenous communities, to describe outbreaks appropriately in these regions. Other special studies (e.g., seroprevalence surveys) will be needed to inform decision-making.

Surveillance activities will need to be adapted in response to rapidly evolving situations; they may be streamlined, expanded or scaled down depending on information needs at particular times within the evolving pandemic. The scope of the pandemic and the urgency of information needs will require expedited and secure electronic data transfer and enhanced capacity for data analysis and interpretation.

More details about pandemic surveillance strategies and activities can be found in the Surveillance Annex.

4.2 Laboratory Services

Laboratory-based surveillance is an integral part of monitoring influenza activity. Because the signs and symptoms of influenza are similar to those caused by other respiratory pathogens, laboratory testing must be conducted to diagnose influenza definitively. Rapid identification of a novel influenza virus and timely tracking of virus activity throughout the duration of the pandemic are critical to the success of a pandemic response. In the early stages of a pandemic, laboratory services also contribute to appropriate clinical treatment.

The purpose of laboratory services during a pandemic is to:

identify the first cases of a novel influenza strain occurring in Canada;

support public health surveillance by monitoring the geographic spread of disease and the impact of interventions;

facilitate clinical management by distinguishing patients infected with the pandemic influenza virus from those with other respiratory diseases;

monitor circulating influenza viruses for antiviral resistance and strain characteristics; and

assess influenza vaccine match and support vaccine effectiveness studies.

Strategic approach

The pandemic laboratory response is built on the principles of collaboration, flexibility and use of established practices and systems. As part of annual influenza surveillance, all public health laboratories and other laboratories that routinely test for influenza submit aggregate data weekly during the influenza season to the National Microbiology Laboratory (NML). These data are collated and disseminated by PHAC through the Respiratory Virus Detection Surveillance System and FluWatch. In addition, public health laboratories and other designated laboratories across the country submit isolates to the NML to monitor for antigenic changes within the circulating viruses. This information is shared with international partners through GISRS. Sustaining these relationships and strengthening capacity within the laboratory system during the interpandemic period will support a timely and effective pandemic response.

During a pandemic, influenza testing laboratories will support epidemiological efforts to track the spread and trends of the pandemic, monitor antiviral resistance and support clinical management. The Canadian Public Health Laboratory Network (CPHLN) will support public health and diagnostic laboratories by providing recommendations and best practices for specimen collection and testing for the novel influenza virus. The NML will share protocols, reagents and proficiency panels to ensure that test methods are capable of detecting the new virus. Molecular testing is the primary method used for the diagnosis of influenza.

Antiviral resistance will be monitored and outcomes will inform clinical management of patients. Antiviral resistance testing is conducted primarily at the NML, as well as some provincial laboratories.

The laboratory response will be adjusted as the pandemic progresses. Initially the NML will be heavily engaged in characterization of the novel virus and development of diagnostic reagents. All laboratories should anticipate high test volumes initially as the novel virus spreads across the country. During peak periods, laboratories will need to prioritize specimen collection to prevent overload. At this point, diagnosis of influenza in the community will be made primarily by clinical assessment; however, testing to support the management of certain patients (e.g., those requiring admission to hospital) will be expected to continue together with identification of outbreaks and surveillance. If ongoing monitoring shows increasing levels of antiviral resistance, more testing may be necessary to support clinical management of severely ill patients, especially those not responding to treatment.

Throughout the pandemic, public health, diagnostic and research laboratories, including those involved in the Canadian Immunization Research Network (CIRN), will also play an important role in supporting studies to better understand the novel pandemic virus and its impact.

More details about pandemic laboratory strategies and activities can be found in the Laboratory Annex.

4.3 Public Health Measures

Public health measures are non-pharmaceutical interventions that can be taken by individuals and communities to help prevent, control or mitigate pandemic influenza. Public health measures range from actions taken by individuals (e.g., hand hygiene, self-isolation) to actions taken in community settings and workplaces (e.g., increased cleaning of common surfaces) to those that require extensive community preparation (e.g., pro-active school closures). The purpose of public health measures is to:

reduce transmission of the novel/pandemic virus, thereby helping to reduce the overall size of the outbreak and the number of severely ill cases and deaths; and

slow the rate of transmission in order to reduce the peak burden on the health care system and buy time in anticipation of vaccine.

Strategic approach

Public health measures are typically implemented at the community level. The responsibility and legislative authority for implementing public health measures belong to the relevant PT and local public health authorities, with the exception of international border and travel related issues for which the federal government is responsible. In addition, the Canadian Forces Health Services is responsible for implementing public health measures on all Canadian Forces establishments/bases/wings/stations across Canada and for Canadian Forces personnel deployed abroad.

There are important concepts to consider when planning and implementing public health measures. The measures should be used in combination to provide “multi-layered protection”, as the effectiveness of each measure on its own may be limited. Actions should be tailored to the anticipated pandemic impact and the local situation, supporting the principles of flexibility and proportionality. Some measures, like hand hygiene and respiratory etiquette, are applicable in all pandemics. Other measures (e.g., proactive school closures and travel restrictions) might be used only in moderate- to high-impact situations, as they can be associated with significant societal and economic costs.

A risk management approach will help weigh the potential advantages of particular interventions against their disadvantages and unintended consequences. Decisions about which measures to deploy also raise fundamental ethical challenges. For example, when considering restrictive measures, it is important to balance respect for autonomy against protection of overall population hea