Animals > Animal Diseases > Avian Influenza > British Columbia (2004)  

Lessons Learned Review: The CFIA's Response to the 2004 Avian Influenza Outbreak in B.C.

News Release - Response to Avian Influenza "Lessons Learned"

Corporate Program Evaluation Directorate
Corporate Planning, Reporting and Accountability Branch
Canadian Food Inspection Agency

January 10, 2005

Table of Contents

1.0 Executive Summary

In July 2004, the CFIA's Corporate Planning, Reporting and Accountability Branch initiated a "lessons learned" review to analyse and document the effectiveness of the CFIA's management of the recent Avian Influenza (AI) outbreak in the Fraser Valley of British Columbia (B.C.). The objective of this review was to:

• learn the most from the experience;
• avoid repetition of errors and emulate success; and
• identify potential improvements that may be implemented and institutionalized for response and management of future outbreaks.

The review identified issues, lessons learned and provided recommendations based on five critical topics of study:

• Leadership
• Intelligence and Information Management
• Processes and Protocols
• Communications and Linkages
• Capacity

The lessons learned approach and methodology was based on collecting observations from those directly involved in the AI outbreak. As such it is based on personal experiences and perspectives. A consistent data collection strategy was used to gather information from multiple sources and to try to create a balanced view of the experience.

This methodology was further supported by an analysis of the AI chronology, background documentation and the findings of other AI review processes which were taking place concurrently to the CFIA's lessons learned study. These reviews included: A scientific peer review of the CFIA's AI epidemiology report; a review by the European Commission's Food and Veterinary Office concerning Canada's control of the AI outbreak; and a multi-jurisdictional AI lessons learned forum (Canadian Poultry Industry Forum) held in Abbotsford, B.C. on October 27 and 28, 2004. The findings and recommendations of these reviews have been analysed and incorporated into this study, where appropriate.

Summary of Findings

This report presents the findings of the lessons learned analysis according to the five critical topics of study. Feedback for each topic area is captured in three sections: What Worked Well, Areas for Improvement and Recommendations. Although some information is provided concerning the strengths of the Agency's response, the lessons learned focus of this review means that more detailed information is presented regarding identified areas for improvement. A summary of findings is presented below. Detailed analysis and recommendations are provided in the body of the report.

Leadership

Focus group and interview participants indicated that effective leadership was provided at multiple levels in the organization (national, local, international). The CFIA President had the ultimate accountability for the Agency's response to the outbreak. One measure of effective leadership was the fact that the CFIA's risk management decisions (e.g. declaration of the control area, depopulation etc.) were supported by the industry, and that consumer and market confidence in Canadian poultry products were maintained throughout the crisis.

Some issues were raised, however, with respect to the respective roles, responsibilities and decision making accountabilities of the CFIA's area emergency response team (AERT), the national emergency response team (NERT) and the AI Executive group. Participants felt that the parameters around which decisions could be made locally versus nationally could be better defined. This lack of clarity may have contributed to the elevation of certain operational decisions to the national level.

The roles and responsibilities of strategic partners could have been better defined and understood by all at the outset of the response. Certain elements of the B.C. Foreign Animal Disease Eradication Support (FADES) plan which required the support of partner organizations (e.g. disposal strategies, laboratory testing, movement controls) may have worked more effectively had they been better planned and exercised prior to the AI outbreak. However, it was also recognized that Canada has not been required to respond to a large-scale, infectious foreign animal disease outbreak since the outbreak of foot and mouth disease in 1952. The shared experience of the AI response has meant that the ability to engage partner organizations in planning and preparedness exercises is now greater than it would have been prior to the crisis.

The CFIA's existing foreign animal disease response plans did not fully address the zoonotic (diseases that can be transmitted from animals to humans) aspect of some animal diseases and therefore did not incorporate collaborative arrangements with public health authorities. As a result, protocols for the coordination of disease response activities with federal and provincial health authorities were established during the outbreak.

Intelligence and Information Management

Despite several challenges experienced with information management systems, the Agency was able to meet critical information requirements using the available tools. The CFIA's emergency information management system (CEMRS) was piloted, at a later stage in the outbreak, to assist in AI information management. However, backlogs in data entry and a lack of user familiarity with the system prevented its successful application. As a result, many units created their own spreadsheets, maps and charts. GIS mapping proved to be a useful information management tool. However some key data, such as farm locations, were not immediately available to the Agency for data entry. This situation improved as industry associations helped to collect the required information.

Overall, it was recognized that a better anticipation of information needs and coordination of reporting activities could improve information flow. Privacy and confidentiality requirements may have precluded the transfer of some information amongst the various stakeholders. Improved information sharing protocols may be required in the future to facilitate the accurate and timely release of information.

Processes and Protocols

Foreign animal disease plans were in place and were tailored to meet the unique circumstances posed by the outbreak. Innovative measures and improved procedures were incorporated to address situations that were not foreseen in the existing contingency plans. For example, novel composting techniques were introduced for the disposal of dead birds. These composting techniques worked effectively, minimized the need to transport mortalities off-farm and could be used as a best practice for future AI outbreaks.

Knowledge and understanding of existing emergency response plans was generally identified as an area for improvement. Some participants felt that there could be a better integration of the emergency management approaches used by the key partners in the response to AI. In addition, the need to formalize the advance planning function within the Agency's emergency management structure and to integrate disease control (including public health) experts within this planning cell was recognized.

While the CFIA carries the responsibility for the occupational health and safety of its employees, the responsibility to protect the broader community falls on public health authorities. CFIA worked with Health Canada and regional health authorities to ensure that appropriate bio-safety protocols were put into place to protect the health of CFIA personnel and contracted workers. Farmers and others working with infected poultry may not have applied similar precautions. In future outbreaks local health authorities will require additional support from Provincial health departments, Health Canada and the Public Health Agency of Canada, particularly with respect to providing personal safety information to protect all persons working with infected poultry.

The development of effective bio-security protocols was identified as a priority for the poultry industry. More effective bio-security compliance measures may be required in the future. Additional training of CFIA and industry personnel in bio-safety and bio-security was identified as a means to enhance personal protection and improve the effectiveness of bio-security measures and protocols.

Compensation policies and protocols were frequently raised during the focus groups, particularly in sessions with industry representatives. The primary concern was that the compensation amounts identified in the Compensation for Destroyed Animals Regulations may not reflect current market values of various types of farmed animals (i.e. specialty birds, breeders, layers). The CFIA was asked to review its compensation policies and protocols to support industry developed rapid containment strategies (pre-emptive culls) to limit the potential spread of future AI outbreaks.

Communications and Linkages

Appropriate mechanisms were put into place at the outset of the emergency to allow for ongoing communication with partners and stakeholders. The CFIA's external communications approaches were comprehensive and well received. Protocols were also in place to communicate with international counterparts.

Multiple meetings and conference calls were organized daily to coordinate response activities, inform partners and stakeholders and meet escalating demands for information. The local emergency operation center had numerous enquiries for information from the public as well as the media. While media calls were directed to appropriate spokespersons, calls from the public were not handled in a similar systematic fashion. Industry representatives indicated that regular interface between the CFIA and the national industry associations has declined in recent years. Maintaining an ongoing interface was identified as critical to building relationships and maintaining a knowledge of key contacts. Assessments of the effectiveness of CFIA communication with federal and provincial partners varied. Most agreed that these linkages improved as the outbreak progressed.

Capacity

The CFIA was able to collapse organizational barriers and employ staff from across Canada to respond to the outbreak. Agency partners and stakeholders became key team contributors. Despite initial delays, the Agency was successful in securing and increasing laboratory capacity through collaborative arrangements with the province of B.C. and by acquiring new equipment and technology.

Protocols for leveraging the support of partner organizations can be better planned and exercised. Representatives of federal and provincial emergency preparedness organizations indicated that CFIA requests for support were limited. Industry representatives also indicated that the Agency can make better use of industry personnel and resources.

CFIA planning to support the HR, financial and administrative functions of an Emergency Operation Center (EOC) can be improved. More structured personnel rotation and replacement protocols were required to reduce employee stress. Better employee orientation was required for new staff deployed to the EOC. Logistical support requirements for the EOC were initially underestimated. These emergency support functions were identified as being critical to the Agency's ability to quickly "ramp up" response capacity.

Conclusion

This review has identified a number of areas where additional focus by the CFIA may bring about improvements in the effectiveness of future responses. The identified areas for improvement pertain primarily to emergency planning and preparedness, as well as strategies to improve data management and information flow. However, it important to note that overall, the effort to control the outbreak of AI was widely viewed as being successful. It was recognized that considerable effort was made by all parties to respond to the outbreak, and that as a result, the spread of the disease was contained within the Fraser Valley of B.C. Innovative measures and improved procedures were developed to respond to problems that were not foreseen in the contingency plans. Consumer and market confidence in poultry products were maintained and movement of risk-free product out of the control zone continued. And finally, the effectiveness of Canada's control measures was recognized by trading partners, as evidenced by the fact that regionalisation was accepted by both the E.U. and the U.S.

2.0 Introduction

2.1 Background

Avian influenza (AI) is a contagious viral infection caused by the influenza virus Type "A", which can affect several species of food producing birds (chickens, turkeys, quails, guinea fowl, etc.), as well as pet birds and wild birds. AI viruses can be classified into two categories: low pathogenic (LPAI) and high pathogenic (HPAI) forms based on the severity of the illness caused in birds, with HPAI causing the greatest number of deaths in birds. Most AI viruses are low pathogenic and typically cause little or no clinical signs in infected birds. However, some low pathogenic viruses are capable of mutating into high pathogenic viruses. There are many influenza subtypes, two of which include H5 and H7. Historically, only the H5 and H7 subtypes are known to have become high pathogenic in avian species.

AI is a reportable disease under the Health of Animals Act. This means that all suspected cases must be reported to the Canadian Food Inspection Agency (CFIA). In February 2004, the CFIA identified the presence of a low pathogenic H7 avian influenza in the Fraser Valley area of southern British Columbia. Subsequent tests revealed the presence of highly pathogenic H7 avian influenza in British Columbia in March 2004. The CFIA depopulated all infected premises on which highly pathogenic avian influenza (42 commercial and 11 backyard premises) was found and pre-emptively destroyed all birds in the surrounding three kilometre areas.

Global efforts to mitigate the spread of influenza viruses in humans have placed increasing importance on the role of animal reservoirs as a source of new strains of virus that could be transmitted to humans. The strains of avian influenza viruses that can adapt to humans represent a severe threat since the human host will not have any initial immunity to these emerging pathogens. AI viruses, such as the H5 virus present in Eastern Asia, may, on rare occasions, cause disease in humans. Human transmission has occurred to people having prolonged contact with heavily contaminated environments.

In this context, the recent outbreak of AI in the Fraser Valley of B.C. raised considerable concern in the public health sector as well as economic hardship for the agricultural community. The corresponding efforts of Canada's federal, provincial and municipal response organizations required a major allocation of resources and expertise. The ability of public health and regulatory agencies in Canada to respond effectively to AI and other emerging animal and public health threats is critically important. As serious as the repercussions of AI were, and continue to be, management of the outbreak also provided a valuable opportunity to learn from experience.

2.2 Scope and Objectives

In July 2004, the CFIA initiated a "lessons learned" review to analyse and document the effectiveness the Agency's management of the AI outbreak. The objective of this review was to:

• learn the most from the experience;
• avoid repetition of errors and emulate success; and
• identify potential improvements that may be implemented and institutionalized for response and management of infectious diseases.

The scope of this review was to assess the effectiveness of the CFIA's animal health response and overall management of the AI outbreak. To focus the review process, input was sought and analysis was conducted based on five critical topics of study:

• Leadership
• Intelligence and Information Management
• Processes and Protocols
• Communications and Linkages
• Capacity

3.0 Methodology

This review was conducted by the Corporate Planning and Accountability Branch of the CFIA, under the direction of the AI Executive Group and with the support of an AI Lessons Learned Working Group comprised of representatives from the various branches involved in the response effort. The review process was initiated in July 2004 and concluded in December 2004.

The lessons learned approach and methodology was based on collecting observations from those directly involved in the AI outbreak. As such it is based on personal experiences and perspectives. A consistent data collection strategy was used to gather information from multiple sources and to try to create a balanced view of the experience. This methodology was further supported by an analysis of the AI chronology, background documentation and the findings of other AI reviews.

The approach used to conduct the lessons learned analysis included the following:

1. A review of background documentation and chronology of the AI outbreak.
2. Identification of five critical topics of study. Design of data requirements and preparatory material.
3. Identification of group clusters based on involvement in AI outbreak (focus groups).
4. Identification of key positions/functions requiring one-on-one interviews (directed interviews).
5. Use of a consistent data collection strategy for all focus groups and interviews.
6. Summary of findings and lessons learned analysis.
7. Development of recommendations.

Eight focus group sessions were conducted in both Ottawa and B.C. The following groups participated in the Ottawa-based focus group sessions:

• CFIA - AI Executive Group
• CFIA - National Emergency Response Team
• Public Safety and Emergency Preparedness Canada (PSEPC)
• National Poultry Industry Associations
• Laboratories (CFIA and B.C. Ministry of Agriculture, Food and Fisheries)

The following groups participated in the B.C. focus groups:

• CFIA - Area Emergency Response Team (B.C. Emergency Operations Centre)
• B.C. Poultry Industry Associations
• CFIA/Health Canada Joint Session with B.C. partners (federal/provincial/municipal)

In addition to the focus groups, directed interviews were conducted with senior managers from the CFIA, as well as Health Canada and the Privy Council Office.

3.2 Data Collection Process

A standard data collection strategy was used for all focus groups and interviews. Participants were provided with preparatory material and were asked to explain their involvement and role in the event. The participants were also asked to provide feedback on the five critical topics of study (leadership, intelligence and information management, processes and protocols, communications and linkages, and capacity) and related questions. The review was conducted based on an analyses of the observations of direct participants in the AI outbreak regarding:

• What worked
• What did not work
• What improvements are required

As part of the data collection process, an "issues log" template was developed in order for the AI working group to provide additional analysis of issues consistently identified during the interviews, focus groups or document review.

3.3. Other AI Reviews

A number of other AI review processes were taking place concurrent with the CFIA's lessons learned study. The findings and recommendations of these reviews have been analysed and incorporated into this lessons learned study, where appropriate. These reviews included:

1. A CFIA led scientific peer review of the Agency's AI epidemiology report. The final evaluation report which summarizes the results of this peer review process is attached as Annex 1.

2. A review by the European Commission's (E.C.) Food and Veterinary Office concerning Canada's control of the AI outbreak. A final E.C. mission report was provided to the CFIA in December 2004 and is attached as Annex 2.

3. An AI forum entitled the "Canadian Poultry Industry Forum" was held in Abbotsford, B.C. on October 27 and 28, 2004. The forum was jointly convened by the CFIA, B.C. Ministry of Agriculture, Food and Fisheries (MAFF) and the B.C. Poultry Industry. The objective of the forum was to review and learn lessons from the AI outbreak in B.C., and to recommend strategies to improve the multi-jurisdictional response to future outbreaks. A summary of the proceedings and recommendations from this forum is attached as Annex 3.

4.0 Lessons Learned Analysis: Findings and Recommendations

Following the data collection phase of the AI review, a lessons learned analysis was conducted in order to provide a synopsis of key issues and conclusions. This analysis involved a review of the summary reports from the focus groups and interview sessions to identify common themes, issues and recommendations for improvement. This analysis was also supported by a review of the AI chronology and background documentation, as well as an analysis of the findings and recommendations of other AI reviews.

The findings of this lessons learned analysis are grouped below according to the five critical topics of study. Feedback for each topic area is captured in three sections: What Went Well, Areas for Improvement and Recommendations. Although some information is provided concerning the strengths of the Agency's response, the lessons learned focus of this review means that more detailed information is presented regarding identified areas for improvement.

4.1 Leadership

Leadership was identified as one of the five primary critical topics of the study. Specific aspects of leadership that were reviewed included: governance, collaborative arrangements, decision- making and accountability.

The following types of questions were used to guide focus group/interview participants:

1. Did you receive adequate direction/leadership? Were leaders accessible?
2. Were roles, responsibilities and delegation mechanisms clear?
3. How were decisions made?
4. Were decisions made in a timely fashion?
5. Did the CFIA provide adequate guidance to the leadership of the team?
6. How was coordination with other organizations/groups managed? Was it managed effectively?

What Worked Well:

Overall, participants indicated that effective leadership was provided at multiple levels in the organization (national, local, international). Leaders were engaged, accessible and provided adequate direction. It was clear that the CFIA President had the ultimate accountability for the Agency's response to the outbreak. One measure of effective leadership was the fact that the CFIA's risk management decisions (e.g. declaration of the control area, depopulation etc.) were supported by the industry, and that consumer and market confidence in Canadian poultry products were maintained throughout the crisis.

It was also noted, particularly by representatives of the national poultry associations, that the CFIA's pre-established leadership role and reputation in the area of animal health helped facilitate the response to the outbreak. It was further indicated that maintaining this level of organizational credibility will require a sustained effort on behalf of the Agency to consult with and engage stakeholder associations. Participants also recognized the personal leadership demonstrated by CFIA and other personnel, through their professionalism and willingness to relocate and work long hours.

Areas for Improvement:

Some issues were raised with respect to the clarity of roles, responsibilities and delegation mechanisms. While the Agency's basic emergency response reporting structure is outlined in the CFIA's Emergency Book, it was felt that certain roles and responsibilities (e.g. Chief Veterinary Officer, epidemiology group, Area Emergency Director) could benefit from further clarification. For example, the role and reporting arrangements of CFIA epidemiological resources were not well understood and could have been more focussed on providing support to decision-making. In addition, the relative roles, responsibilities and decision making accountabilities of the area emergency response team (AERT), the national emergency response team (NERT) and the AI Executive group were not commonly understood.

Many participants felt that decision making could have been more localized and that the requirement for certain policy/strategic decisions to be made by the CFIA AI Executive group at headquarters impacted on the timeliness of decision-making. Others recognized that it was necessary for the AI outbreak to be managed as a national emergency with policy and domestic and international trade implications that extended beyond the province of B.C. Overall it was felt that the parameters around which decisions can be made locally (i.e. tactical) versus nationally (i.e. strategic) can be better defined. This lack of clarity may have contributed to the elevation of certain operational decisions to the national level.

With respect to collaborative arrangements it was noted that while partners and stakeholders (government and industry) actively participated in resolving the outbreak, some improvements can be made to the management of these relationships. The roles of public health authorities, provincial partners and emergency management organizations (federal and provincial) evolved over time and these relationships improved as the outbreak progressed. The fact that provincial, local and industry representatives were co-located in the CFIA's Emergency Operations Center (EOC) in Abbotsford, B.C. was viewed as contributing positively to emergency response decision-making and information sharing. However, it was noted that the roles and responsibilities of strategic partners could have been better defined and understood by all at the outset of the response. For example, stakeholder acknowledgement and understanding of the existing B.C. Foreign Animal Disease Eradication Support (FADES) plan (2002) was limited. The FADES plan is a federal/provincial agreement which identifies the arrangements whereby federal, provincial and local agencies will provide the assistance required by the CFIA in the eradication of a foreign animal disease outbreak. Certain protocols in the FADES agreement which required the support of partner organizations (e.g. disposal strategies, movement controls) may have worked more effectively had they been better planned and exercised prior to the AI outbreak. However, it was also recognized that Canada has not been required to respond to a large-scale, infectious foreign animal disease outbreak since the outbreak of foot and mouth disease in 1952. The shared experience of the AI response has meant that the ability to engage partner organizations in planning and preparedness exercises is now greater than it would have been prior to the crisis.

It was also generally recognized that all response organizations need to fully understand the potential public health implications of AI outbreaks. Recent outbreaks of highly pathogenic AI in Eastern Asia have increased concerns around the potential transmission of new strains of the virus to humans. While federal and provincial health authorities were advised of the AI outbreak at an early stage (February 18, 2004) it took some time before the potential public health implications of the disease were fully recognized in the broader community (e.g. non-public health agencies, industry). This may have been due to the fact that the initial strain of virus detected during the outbreak was low pathogenic.

The CFIA's existing foreign animal disease response plans did not fully address the zoonotic (diseases that can be transmitted from animals to humans) aspect of certain animal diseases and therefore did not incorporate collaborative arrangements with public health authorities. As a result, protocols for the coordination of disease response activities with federal and provincial health authorities were established during the outbreak. The lessons learned analysis has identified the need to enhance the linkages between public health and veterinary health authorities and to integrate the various animal health/public health emergency response plans.

Recommendations:

CFIA Response: Activation protocols for the various levels of emergency response are currently being reviewed by the Agency to ensure a nationally consistent approach. The CFIA is also reviewing the structure and function of its area and national emergency response teams to more clearly define the roles, responsibilities and delegated decision-making authorities at all levels. Public Safety and Emergency Preparedness Canada has been invited to participate in this review process. It is anticipated that updated emergency response structures and protocols will be recommended by the spring of 2005.

CFIA Response: The CFIA has initiated discussions with Health Canada and the new Public Health Agency of Canada (PHAC) regarding collaborative arrangements for response to zoonotic disease outbreaks. The Agency will work with both Health Canada and PHAC to develop an updated roles and responsibilities framework and a Memorandum of Understanding (MOU) which will include an appendix considering response to zoonotic disease outbreaks, by December 2005. It is expected that this appendix to the MOU will also include protocols for liaising with provincial health authorities.

CFIA Response: The CFIA is currently developing a common template for FADES agreements which will be used to negotiate and finalize new or revised agreements with all provinces and territories. It is expected that the template will be completed by February 2005 and that consultations with partners and stakeholders will begin in March 2005. A fixed schedule for exercising the agreements will be a mandatory component of all FADES plans.

4.2 Intelligence and Information Management

Elements of intelligence and information management that were assessed include data ownership, data capture and analysis, information sharing and confidentiality. The following types of questions were used to guide focus group/interview participants:

1. How was intelligence gathered?
2. What information management systems were available?
3. Was information accurate?
4. How did information flow?
5. Was information received on a timely basis?
6. What information sharing processes were in place?
7. How compatible were data collection and sharing processes with those of other organizations?
8. Did information sharing improve or deteriorate over the course of the outbreak?

What Worked Well:

Interaction with partners and stakeholders took place on a daily basis through CFIA coordinated conference calls and meetings. The co-location and daily briefing of federal, provincial, municipal and industry representatives in the local EOC was instrumental in keeping all parties informed. Within the CFIA, meetings, end of day situation reports, decisions documents and web site usage facilitated information flow. Geographical Information System (GIS) mapping proved to be a useful information management tool, however the availability of key data to populate GIS maps remained an issue. Throughout the outbreak the CFIA experienced several challenges with respect to information management systems. However, it appears that the Agency was able to meet critical information requirements using the available tools.

Areas for Improvement:

Weaknesses in data management/information technology hampered a fully efficient operation. The CFIA did not have an integrated information management system available for the timely collection and dissemination of disease control information (i.e. field data, laboratory results, GIS maps, status reports). For example, information collected through farm visits could be more systematically captured to enable roll up and analysis. The CFIA's emergency information management system [Canadian Emergency Management Response System (CEMRS)] was piloted at a later stage in the outbreak (end of March, 2004) to assist in AI information management. However, backlogs in data entry and a lack of user familiarity with the system prevented its successful application. As a result, many units created their own spreadsheets, maps and charts, creating some inefficiencies. It appears that despite these systems challenges, the Agency was able to meet critical information needs.

Laboratory data was captured via the Laboratory Sample Tracking System (LSTS). The LSTS system does not currently have the capability of generating summary reports, and as a result, ad hoc spreadsheets were prepared. In addition, the LSTS "crashed" a number of times during the outbreak, requiring the labour intensive re-entry of data and results.

GIS mapping was used by the CFIA at both the local and national EOC levels. Support for GIS mapping was provided by Public Safety and Emergency Preparedness Canada (PSEPC) at headquarters, and by the B.C. MAFF at the Abbotsford EOC. Although the ability to create GIS maps was critical to providing decision makers with consistent situational awareness, some key data such as farm locations were not immediately available to the Agency for data entry. This situation improved as industry associations helped to collect the required data. However, the use of different GIS systems meant that the GIS maps used by the local and national EOCs were not entirely consistent.

As in most emergency response situations, the demand for information, briefings and reports quickly escalated throughout the AI outbreak. While protocols were in place to facilitate internal and external information flow, some focus group participants indicated that they were not satisfied with the timeliness and relevance of the information provided. In particular, laboratory testing results were identified as key information that was not being shared in a timely fashion. Problems with the LSTS system described above and the requirement for laboratory results to be reported at the headquarters level prior to being forwarded to the local EOC were identified as contributing to delays.

Overall it was recognized that a better anticipation of information needs and coordination of reporting activities could improve information flow. For example, the requirements of senior decision makers for information on the status of farms, number of birds depopulated, compensation costs etc. were entirely predictable. While situation reports were shared with federal and provincial partners, some felt that the information contained in these reports was outdated. However, it was also noted that regular AI updates were being posted on the Agency's website.

The recording and displaying of important EOC information (i.e. status boards, logs, maps etc.) should be more centrally available to the EOC manager to facilitate outbreak management and to help maintain a consistent level of situational awareness. This issue was raised with respect to both the national EOC in Ottawa and the local EOC in Abbotsford.

Privacy and confidentiality requirements may have precluded the transfer of some information (e.g. names of infected farms, farm owners) amongst the various stakeholders. Industry representatives indicated that lists of infected farms were required to effectively manage bio-security. A similar information requirement was raised by public health officials, to permit early implementation of human health surveillance and protective measures. It was agreed that confidentiality issues and protocols should be addressed in updated foreign animal disease response plans. Information security also became an issue in the local EOC, following several breaches in protocols for release of information to the media. Improved information sharing/security protocols may be required in the future to facilitate the accurate and timely release of information.

Recommendations:

CFIA Response: The CFIA will develop and implement an action plan that includes both short-term and longer-term IM/IT solutions to improve information management during emergency response situations. As an interim measure, the Agency has also developed partnerships with other departments and agencies to obtain GIS services.

CFIA Response: Based on the lessons learned from both avian influenza and BSE, the CFIA will be developing options to address information management and sharing issues. Protocols will be developed to improve both internal and external information flow. These protocols will be incorporated into new and updated FADES agreements as appropriate.

4.3 Processes and Protocols

Standard processes and protocols are those which are developed in the preparedness phase and implemented during the emergency response. The types of processes and protocols addressed included generic and disease specific emergency response plans, as well as occupational health and safety, compensation and other protocols. The following types of questions were used to guide focus group/interview participants:

1. Were standard operating procedures (SOPs) in place for disease investigation and response. Were these SOPs followed?
2. How effective and applicable were the SOPs to the AI outbreak?.
3. Was there any flexibility in the application of the SOPs? Were SOPs tailored to circumstances?
4. What challenges did you face with respect to implementing the SOPs?
5. Did processes and protocols evolve over the duration of the outbreak. How were these changes communicated?

What Went Well:

Foreign animal disease plans such as the AI specific disease response plan and the FADES plan for B.C. (2002) were in place and were tailored to meet the unique circumstances posed by the outbreak (e.g. disposal volumes). Innovative measures and improved procedures were incorporated to address situations that were not foreseen in the existing contingency plans. For example, novel composting techniques were introduced for the disposal of dead birds during the outbreak. These composting techniques worked effectively, minimized the need to transport mortalities off-farm and can be used as a best practice for future AI outbreaks.

The CFIA Emergency Book, which describes the concepts and structure of emergency management in the Agency, had been in place since 2002 and generic emergency management training courses had been conducted nationally by the CFIA in 2002-03. Occupational health and safety (OHS) protocols for CFIA employees and contracted workers were in also place. CFIA personnel assigned to the EOC in B.C. were provided with OHS orientation and vaccination, medication and clothing protocols were in place to ensure personal safety.

Areas for Improvement:

Knowledge of existing emergency response plans was generally identified as an area for improvement. For example, industry and public health representatives indicated that they had little or no awareness of the B.C. FADES plan. The FADES plan was developed in 2002 and had not been exercised since that time. Amongst the CFIA focus group participants, knowledge and understanding of the CFIA Emergency Book, the AI specific response plan and the B.C. FADES agreement was not comprehensive. CFIA personnel were also unfamiliar with the existing Canadian Pandemic Influenza Plan which was implemented by Health Canada to coordinate public health response activities. Ongoing training and exercises were recognized as being key to improving knowledge of emergency response plans and protocols, as well as building relationships between the CFIA and its partner organizations.

Some participants felt that there could be a better integration of emergency management approaches used by key partners in the response to AI (i.e. CFIA, B.C. MAFF, B.C. Provincial Emergency Program, Health Canada). For example, the province of B.C. has adopted an Incident Command System (ICS) approach as the basis for emergency response. The ICS approach is built around five major elements: command, planning, operations, logistics, finance and administration. The common organizational structure and terminology used by organizations which adopt ICS is believed to improve the interoperability of emergency responders. While the CFIA's emergency response approach has some similarities with the ICS model, particularly at the level of the Area Emergency Response Team, one principal difference was the lack of a formalized planning cell.

Focus group/interview participants identified the need to formalize the advance planning function within the Agency's emergency response structure and to integrate disease control experts within this planning cell. Separating the advance planning function from the operational response was viewed as necessary to allow for the improved development of contingency strategies and a better anticipation of required decisions. Inclusion of public health experts in the advance planning cell would help to ensure that both the human health and animal health implications of the outbreak were fully considered. It was also suggested that the CFIA's epidemiological investigation specialists could be focussed on contributing intelligence to the advance planning cell.

Some standard operating procedures for foreign animal disease response activities (e.g. disposal strategies, cleaning and disinfection, transportation of laboratory samples) could be better planned and exercised. For example,commercial airlines could not be relied upon to ship laboratory samples to the National Centre for Foreign Animal Disease (NCFAD) laboratory in Winnipeg, therefore a private carrier was required to be secured. Industry representatives also suggested that CFIA protocols for cleaning and disinfection of farms following an outbreak need to be more rigorous. Cleaning and disinfection procedures are currently the responsibility of the farm operator, with verification and approval by the CFIA once completed. The time frame within which cleaning and disinfection must be completed is not currently established within CFIA protocols. Concerns were also expressed about the subjective nature of CFIA verification (some farms had to start over several times). Industry representatives also questioned the policy of assigning the responsibility of cleaning and disinfection to farm owners. Given the importance of this task to maintaining industry bio-security, it was suggested that professional teams be assigned.

The CFIA worked with Health Canada and regional health authorities to ensure that appropriate bio-safety protocols, including protective clothing, were put into place to protect the health of CFIA personnel and contracted workers. Regional workplace health staff were able to provide CFIA workers with pre-placement medical assessments, occupational health advice, influenza vaccine and anti-viral medication. One issue that was raised concerned protocols set by Health Canada for the use of anti-viral medication (oseltamivir). A maximum period of six weeks was recommended for the use of oseltamivir, after which workers were re-assigned to areas that did not put them into direct contact with infected poultry. During the outbreak it was not clear when workers who had initially taken anti-viral medication for the allowable period could resume taking the drugs. This was of particular concern since many of these same personnel could potentially be required to respond to a future outbreak . Health Canada has since advised that medication protocols for oseltamivir can be re-initiated after a break of two weeks.

Focus group participants raised the discrepancy between federal workers performing work on an infected farm in full bio-safety equipment while the farm owner and his/her staff had no protective gear. While the CFIA carries the responsibility for the occupational health and safety of its employees, the responsibility to protect the broader community falls on public health authorities. Representatives of the local health authority indicated that they had limited capacity to respond to the human health implications of AI. It was recognized that in future outbreaks local health authorities may require additional support from Provincial health departments, Health Canada and the Public Health Agency of Canada, particularly with respect to providing personal safety information to protect all persons working with infected poultry.

Effective bio-security protocols can prevent or minimize the spread of infectious diseases from farm to farm. They include measures such as sanitation and access or movement controls to prevent the spread of disease by people or equipment. The poultry industry does not currently have standards in place for on-farm bio-security. Industry representatives have proposed that an industry-led process be established to develop minimum bio-security standards, with technical approval by the CFIA. The CFIA has bio-security protocols in place for entering and leaving a farm and for the disposal of carcasses. Both CFIA and industry representatives identified what they believed to be breaches in bio-safety and bio-security protocols. More effective bio-security compliance measures may also be required in the future, including incentives or penalties. Additional training of CFIA and industry personnel in bio-safety and bio-security could enhance personal protection and improve the effectiveness of bio-security measures and protocols.

Compensation policies and protocols were frequently raised during the focus groups, particularly in sessions with industry representatives. In particular, industry stressed the importance of producers understanding compensation schedules and amounts prior to receiving depopulation orders. Maximum compensation amounts are set out in the schedule of values for destroyed animals included in the Compensation for Destroyed Animals Regulations. The primary concern was that these compensation amounts may not reflect current market values of various types of farmed animals (i.e. specialty birds, breeders, layers). The CFIA was also asked to review its compensation policies and protocols to support industry developed rapid containment strategies (pre-emptive culls) to limit the potential spread of future AI outbreaks.

CFIA Response: The CFIA is currently reviewing the structure and function of its area and national emergency response teams to incorporate lessons learned from both the avian influenza and BSE incidents. Public Safety and Emergency Preparedness Canada has been invited to participate in this review process, which will include an evaluation of the Incident Command System (ICS) approach. It is anticipated that updated emergency response structures and protocols will be recommended by the spring of 2005.

CFIA Response: The CFIA's upcoming review of its emergency management structures and protocols will address the identified need to formalize the Agency's advance planning function during an emergency response situation. The development of a framework with Health Canada and the new Public Health Agency of Canada regarding collaborative arrangements for response to zoonotic disease outbreaks will also help to ensure the integration of public health experts into this planning cell.

CFIA Response: The CFIA will review the applicable occupational health and safety protocols which are designed to ensure the health and safety of CFIA employees and contracted staff. The CFIA will also work with Health Canada and the Public Health Agency of Canada to identify and address biosafety issues which impact on the broader community.

CFIA Response: The CFIA will assist the poultry industry in their development of biosecurity programs by providing a technical review and assessment of the industry's proposed standards and plans. The Agency will be meeting with representatives of the poultry industry in January 2005 to discuss progress and next steps.

CFIA Response: The CFIA is currently preparing to conduct a review of elements of the compensation program, including maximum compensation amounts. It is anticipated that this review will be completed in 2005.

CFIA Response: The CFIA will conduct a review of elements of the compensation program in 2005. Included in this review will be an assessment of the periodic review process for the schedule of values included in the Compensation for Destroyed Animals Regulations.

4.4 Communications and Linkages

Aspects of communication reviewed included media and public relations; communication across organizations and risk communication.

The following types of questions were used to guide focus group/interview participants:

1. What communications processes were in place?
2. Did communications improve or deteriorate over the course of the outbreak?
3. How important and how effective were communications with partners and stake holders?
4. How were communications with the media managed?
5. How were communications with the public managed?

What Worked Well:

Overall, participants noted that the appropriate mechanisms were put into place at the outset of the emergency to allow for ongoing communication with partners and stakeholders. Examples of these mechanisms included daily situation reports, web-site updates and teleconferences. Regular conference calls were coordinated by the CFIA with federal and provincial counterparts, as well as national and provincial industry associations. The initial CFIA/industry conference calls were difficult to manage, due to the large number of participants. However, the effectiveness of these conference calls improved as representatives for the various industry associations, speciality bird producers and backyard flock owners were identified.

The CFIA's external communication approaches were comprehensive and well received. They included activities such as press conferences and news releases, information-sharing meetings (open houses), web-site updates, information brochures, and advertising. Focus group participants indicated that these activities were well managed, and particularly noted the effectiveness of the "open house" information sessions held by the CFIA in Abbotsford. Risk communication was viewed as being appropriate to the circumstances. It was noted the Agency's effective risk communication approach likely contributed to conserving public confidence.

Protocols were also in place to communicate with international counterparts. Two USDA liaison officers were located in the Abbotsford EOC during the outbreak. In the past, Canada has similarly sent observers to the U.S. during foreign animal disease investigations. Liaison with the OIE and the Agency's international counterparts took place via the CFIA's Chief Veterinary Officer and International Affairs Directorate. In July 2004, representatives of the European Commission's (E.C.) Food and Veterinary office visited Canada, pursuant to the E.C./Canada Veterinary Agreement, to review Canada's control of the AI outbreak. The findings of the E.C. team (Annex 2) have been reviewed and incorporated into this lessons learned analysis. In addition, the CFIA's medical advisor participated with Health Canada in briefings of the World Health Organization (WHO), to reassure the international agency on the appropriateness of surveillance and control measures aimed at protecting public health.

Areas for Improvement:

Several meetings/teleconferences were held daily to coordinate and inform stakeholders and to facilitate communication between headquarters and the local area. Some CFIA staff were required to attend multiple 1-2 hour meetings daily. Improved meeting coordination may have enhanced efficiency and reduced duplication. However, it was also recognized that the multiple meetings and conference calls were required to effectively coordinate response activities, inform partners and stakeholders and meet escalating demands for information.

The Abbotsford EOC had numerous enquiries for information from the public as well as the media. While media calls were directed to the appropriate spokespersons, calls from the public were not handled in a similar systematic fashion. These calls usually concerned the circumstances of individual poultry owners and were directed to available personnel. Focus group participants suggested that it may have been useful to have a dedicated person (e.g. a District Veterinarian) identified to respond to public enquiries. It was also suggested that EOCs should have a designated switchboard to handle and direct incoming calls.

Industry representatives indicated that regular interface between the CFIA and the national industry associations has declined in recent years. Maintaining an ongoing interface was identified as critical to building relationships and maintaining a knowledge of key contacts. Several industry representatives indicated that, at the outset, they did not know who to contact within the CFIA for information. Industry representatives also complained that teleconferences were too large, and not regularly scheduled. Those participating in the conference calls had different levels of need for information (i.e. sector vs. individual farm information). It was suggested that participation in the industry conference calls should be limited to representatives of associations.

Assessments of the effectiveness of CFIA communication with federal and provincial partners varied. Most agreed that these linkages improved as the outbreak progressed. Representatives from the Privy Council Office indicated that the CFIA communication with their office was immediate and thorough. Health Canada representatives indicated that while there was some initial confusion regarding appropriate contacts, communication worked well once linkages were established. Representatives from emergency management organizations such as PSEPC and the B.C. Provincial Emergency Program were not satisfied with the CFIA's inter-agency communications, indicating that much of the information being shared with them was either outdated or not relevant. Representatives of provincial ministries such as B.C. MAFF and B.C. Health also complained of inadequate information sharing. Some of these concerns may have been due to CFIA protocols which were in place to avoid the dissemination of preliminary or inconclusive results. CFIA participants indicated that it was sometimes difficult to determine when information could be shared externally. They also indicated that there was some confusion about whether information should be shared directly with provincial public health authorities, or indirectly through Health Canada.

Recommendation:

See recommendation #5, under intelligence and information management.

4.5 Capacity

Specific aspects of capacity reviewed included training, surge capacity, staff well-being, and logistics. The following types of questions were used to guide focus group/interview participants:

1. Was a plan in place for ramping up capacity to handle response activities in advance of the outbreak?
2. What actions were taken to ramp up capacity for response activities and when?
3. Were extra pre-trained resources available to handle the surge in activity?
4. Were trained and qualified people available to do what was required during all phases of the outbreak?
5. Was it necessary to provide specific training as a result of AI – to whom and what type of training?
6. Was the necessary equipment available and provided to perform duties?
7. Were there any personal safety issues?
8. How well were personal "well-being" needs met during the response period and after?

What Worked Well:

The CFIA was able to collapse organizational barriers and employ staff from across Canada to respond to the outbreak. Agency partners and stakeholders became key team contributors, particularly within the Abbotsford EOC. Professionalism was displayed by staff, allowing the Agency to maintain organizational credibility during the crisis. Agency and other personnel worked long hours, demonstrating a high level of dedication in responding to the outbreak. Participants also recognized that the technical knowledge and expertise of the Agency personnel contributed to the successful response effort.

Despite some initial delays, the Agency was successful in securing and increasing laboratory capacity through collaborative arrangements with the province of B.C. and by acquiring new equipment and technology. Five CFIA scientists were assigned to work on-site with their provincial colleagues at the B.C. testing laboratory.

Areas for Improvement

Protocols for engaging the support of partner organizations (e.g., municipal, provincial, federal or industry) can be better planned and exercised. In particular, laboratory testing and disposal were cited as examples of areas where pre-established strategies or agreements may have assisted response efforts. Representatives of the federal and provincial emergency preparedness organizations (PSEPC and the B.C. Provincial Emergency Program) indicated that CFIA requests for support were limited. Industry representatives also indicated that the CFIA can make better use of industry personnel and resources.

It was perceived by Health Canada that the CFIA epidemiology capacity was inadequate. While the CFIA has a core group of veterinary epidemiologists, they are located across the country. One proposal was that the CFIA assign trained teams of disease investigation specialists to be prepared to respond to animal disease outbreaks. It was also proposed that zoonotic disease scenarios be exercised with the involvement of disease control specialists from both the CFIA and the Public Health Agency of Canada.

Management of human resources was identified as an area for improvement. Better planned personnel rotation and replacement protocols were required to reduce employee stress and prevent "burn out". More structured personnel rotation may have also reduced the requirement for overtime. It was proposed that assignments to the EOC be limited to a set period of time (e.g. 3-6 weeks). In some cases, personnel assigned to the EOC became very involved in the crisis and did not wish to leave for a rest period. The Agency did not have a formalized succession plan in place to ensure the capacity to sustain a prolonged response. This would have entailed maintaining a roster of critical positions and identified replacement staff. Better employee orientation, including briefings and overviews of assigned responsibilities and reporting protocols, was required for new staff deployed to the EOC.

Planning to support the financial and administrative functions of an EOC can be improved. Logistical support requirements for the Abbotsford EOC were initially underestimated. The situation improved once support staff in areas such as finance (procurement) and IM/IT were identified and deployed to the EOC. These emergency support functions were identified as being critical to the Agency's ability to quickly "ramp up" response capacity. Based on the experience gained from BSE and AI, it was suggested that rapid response teams be identified to support the HR, financial and administrative functions of an EOC.

Recommendation:

CFIA Response: The CFIA's Human Resource and Corporate Services Branches have each initiated reviews of their emergency response support procedures. It is anticipated that both branches will have standard operating procedures in place by the spring of 2005.

5.0 Findings of Other Avian Influenza Reviews

5.1 Scientific Peer Review of CFIA Epidemiology Report

In August, 2004 the CFIA initiated a scientific peer review of the Agency's AI epidemiology report. The final evaluation report which summarises the results of this peer review process is attached as Annex 1. Four internationally recognized experts on AI were asked to review the science which supported Canada's response to the outbreak and to assess how it compared to other countries which have experienced similar outbreaks and generally accepted international standards. A copy of the CFIA's outbreak summary report is available at: http://www.inspection.gc.ca/english/anima/heasan/
disemala/avflu/2004sum/summaryhpaie.shtml

The peer review panel determined that, overall, the disease control actions taken by Canada were consistent with internationally accepted principles for HPAI control. Observations were made concerning both strengths and areas where Canada's response may have been improved. For example, the reviewers noted that Canada has an appropriate veterinary infrastructure and legislative authorities in place to respond to an outbreak of HPAI at an internationally recognized standard. It was also noted that, with hindsight, an earlier declaration of the control area with strict movement controls may have contributed to a better outcome. Timely reporting of laboratory results was also noted as an area for improvement. The surveillance plan and protocols conducted during the outbreak were found to be at the upper end of international standards and effectively executed. In addition, procedures for movement restrictions, depopulation, disposal, and cleaning and disinfection were found to be appropriate and consistent with international standards.

The recommendations provided by the peer review panel are largely consistent with those identified through the CFIA's lessons learned analysis and will be addressed by the Agency as described in this report. The peer review panel also recommended the development of a national AI surveillance strategy, as well as further epidemiological studies to determine how the AI virus was introduced and spread.

5.2 European Commission Report

In July 2004, representatives of the European Commission's (EC) Food and Veterinary Office visited Canada pursuant to the EC/Canada Veterinary Agreement and conducted an evaluation of Canada's response to the AI outbreak. A final report of this mission was provided to the CFIA in December 2004 and is attached as Annex 2.

The report concluded that significant efforts were made to control the AI outbreak and that great commitment, innovation and technical ability were demonstrated during the response. There is a great deal of consistency between the findings and recommendations of the EC and the CFIA review. For example, both studies identified the need to update current contingency plans to incorporate the lessons learned from AI and to improve the Agency's emergency information management capabilities. The EC report also recommended that the full assistance of provincial authorities be assured at an earlier stage to allow the Agency to react more swiftly and effectively in the future.

In addition, the EC report contained some findings concerning the need to standardize some of the terminology used by the CFIA during the outbreak to be more consistent with international (OIE) definitions. The terminology used by the CFIA during the AI outbreak reflects the current Canadian legal framework. The discrepancies relative to the international terminology are recognized and attempts will be made by the CFIA to rectify the situation by means of a regulatory change.

Finally, the EC report recommended that the CFIA formalize the co-operation developed between the federal and B.C. laboratories, and use this as a model to establish a laboratory network within Canada with the necessary capability to assist fully in any future outbreak of notifiable avian disease. Bilateral arrangements currently exist between CFIA laboratories and provincial and private laboratories regarding testing for animal diseases. However, the importance of having a similar diagnostic network for avian diseases that operates under a defined quality assurance system (ISO) has been recognized and the CFIA is undertaking steps towards that objective.

The CFIA's full response to the recommendations of the European Commission is also included in Annex 2.

5.3 Canadian Poultry Industry Forum

On October 27 & 28, 2004, with the outbreak of AI in the Fraser Valley of B.C. entering the recovery phase, a lessons learned forum was jointly convened by the B.C. MAFF, the CFIA and the B.C. Poultry Industry. Approximately 190 participants, including representatives of the poultry industry (B.C. and national associations) and allied trades, as well as federal, provincial and municipal governments involved in the response to AI attended the two-day meeting. A summary of the proceedings, agreed-upon action items and follow-up leads is attached as Annex 3.

While the forum identified many of the same recommendations as those which have been described in this report, four additional recommendations were brought forward and accepted by the CFIA for follow-up. These include:

CFIA Response: The CFIA supports this recommendation, and will be initiating discussions early in 2005 with the Public Health Agency of Canada to discuss this forum, develop objectives and proposed outcomes and determine how to organize.

CFIA Response: The CFIA's development and implementation of a small scale AI surveillance plan is well under way. The expectation is that samples will be collected in the spring of 2005. The development of a longer term plan for the active and ongoing surveillance of the commercial poultry industry is also underway.

The CFIA will be undertaking consultations with the Canadian Wildlife Service, Parks Canada and the Canadian Cooperative Wildlife Health Center to define the potential costs and benefits of wildlife surveillance.

CFIA Response: The CFIA will work with industry to examine proposals for pre-emptive slaughter. A preliminary meeting with national poultry representatives is scheduled for January 2005. The CFIA will also investigate vaccination protocols as an alternative to pre-emptive culls.

CFIA Response: The CFIA will continue to work with provincial and territorial governments, AAFC and livestock industries towards the development of a national disposal strategy for all livestock species. Disposal options in all areas of Canada are currently being examined by a federal/provincial/territorial agri-food inspection committee. The findings of this committee will support the development of a national disposal strategy.

6.0 Conclusion

This review has identified a number of areas where additional focus by the CFIA may bring about improvements in the effectiveness of future responses to foreign animal disease incursions. The identified areas for improvement pertain primarily to emergency planning and preparedness, as well as strategies to improve data management and information flow. However, it important to note that overall, the effort to control the outbreak of AI was widely viewed as being successful. It was recognized that considerable effort was made by all parties to respond to the outbreak, and that as a result, the spread of the disease was contained within the Fraser Valley of B.C. Innovative measures and improved procedures were developed to respond to problems that were not foreseen in the contingency plans. Consumer and market confidence in poultry products was maintained and movement of risk-free product out of the control zone continued. And finally, the effectiveness of Canada's control measures was recognized by our trading partners, as evidenced by the fact that regionalisation was accepted by both the E.U. and the U.S.

Lessons Learned Review | Annex 1 | Annex 2 | Annex 3