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Preparing for an Influenza Pandemic:
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Dr. David Butler-Jones, Chief Public Health Officer of Canada |
Dr. Perry Kendall, Provincial Health Officer, British Columbia |
Co-chairs of the Pan-Canadian Public Health Network Council
The Government of Canada and its provincial and territorial counterparts have developed a Canadian Pandemic Influenza Plan for the Health Sector (the Plan) outlining a public health strategy on how to deal with an influenza pandemic (a worldwide outbreak of influenza affecting a large portion of the population). This national Plan, first published in 2004, was based on input from over 200 experts. It is updated on an ongoing basis as new developments and knowledge emerge.
The Plan has two main goals:
The Plan is complemented by other emergency response plans including those created by each level of government and individual health care institutions and those dealing with other important issues, such as the role and response of business in a public health emergency.
The Plan is based on what is known from science, public health principles, health care delivery and the ethical and legal implications of action. Canada is not the only country engaged in pandemic planning. Many other countries are involved in similar work. The World Health Organization (WHO) has encouraged all countries to develop plans to prepare for, and respond to, an influenza pandemic.
Canada is taking influenza pandemic preparedness very seriously. Federal and provincial/territorial governments are dedicating resources towards planning, research and ongoing surveillance in advance of a pandemic.
The following section gives you some information on influenza pandemics. There will also be presentations on the first evening where you will have the chance to hear the most up-to-date information and discuss your questions with experts. You may also wish to review the glossary at the back of this workbook.
Understanding Pandemic Influenza
An influenza pandemic is a global outbreak that occurs when a new influenza virus strain appears that can spread easily from person to person with serious and sometimes even fatal consequences. Because it is caused by a new virus, everyone is susceptible to it and that is why the impact is seen globally. The following provides a brief overview of the different types of influenza (or ‘flu’), the connection among them and how they spread. A more detailed description will be provided in the evening information session.
What is the connection between the three types of flu? A pandemic flu virus could develop from an avian flu virus that either changes slightly or mixes with a seasonal (human) flu virus and as a result, is able to spread easily from human to human.
History of PandemicsA pandemic is a widespread outbreak that affects a large proportion of the population. It is often worldwide.
People are exposed to different strains of influenza during their lives and even though the virus changes, a previous case of flu may offer some protection against an infection caused by a similar strain.
However, in the case of a flu pandemic (which tends to occur three to four times each century) a completely new strain of influenza appears. Since people have no immunity against the new strain it can spread rapidly around the world. It is impossible to predict exactly when the next pandemic will hit, but experts agree that one will come.
Pandemics are not new – the first was recorded in 412 BC. In the last century, there were three major (and very different) pandemics:
It is not possible to know when the next pandemic will occur, how severe it will be, or which groups will be most affected. Human and avian influenza viruses continue to circulate and there is always a risk that a new virus with pandemic potential could arise. It is important however to recognize that most outbreaks of avian influenza in birds will not lead to a pandemic.
Expected ImpactIn general, experts believe that a pandemic virus will behave in much the same way as seasonal flu.
It is anticipated that:
If the pandemic is “moderately severe”:
These predictions do not include the impact of vaccines, antivirals or other response measures. An actual pandemic could be more or less severe.
Canada’s comprehensive pandemic planning is recognized worldwide. As the pyramid below illustrates, the Plan is built on a foundation of basic prevention measures we all can take, such as hand washing and cough etiquette. Then we have early detection and monitoring, as well as other public health measures. Vaccines for prevention and antivirals for treatment appear near the top of this pyramid. At the very top is the question of using publicly funded antivirals for prevention. This measure is still being debated and is the focus of our dialogue.
Preparing for a Pandemic
Governments have made sure that contracts are in place to produce vaccines so that every Canadian can be vaccinated as soon as possible. Vaccines provide protection against a disease – they are not a treatment. Widespread vaccination not only protects individuals, it can also decrease the spread of disease in the population. While there will be enough vaccine for every person in Canada, it will take at least 6 months after the strain of virus causing the pandemic is identified, before the vaccine will be ready for most Canadians. Two doses would likely be required and protection may not be 100%.
The use of antiviral medication for treating people will be vital until a vaccine becomes available. A National Antiviral Stockpile of 55 million doses has been created to ensure every Canadian who needs treatment during a pandemic will get it. Currently we know that antivirals are an effective treatment for seasonal flu: people are not sick for as long as they would be without the medication and they have fewer complications. We expect that antivirals will also have this effect on a new pandemic influenza virus, although we cannot be certain until it arrives and we test the medication.
Antiviral medications come in 3 forms: pills, liquids/syrups and inhalers. Most of the supplies purchased by government (for the purpose of treatment) come in the form of a pill called “Tamiflu”. Usually antiviral medications are prescribed by physicians and other health care professionals licensed to write prescriptions.
They are most effective if taken early on in the course of the illness (within the first 48 hours of onset of symptoms). Taking 2 pills a day for 5 days can shorten flu symptoms by about one day. Treatment can also reduce the severity and complications of influenza.
Studies have shown that antivirals can be used for prevention as well. Using antivirals to help prevent flu is relatively new–usually we use annual flu vaccines to protect large numbers of people. We do know that antivirals may be useful in controlling outbreaks of seasonal influenza in nursing homes and other facilities and they have been used in avian influenza outbreaks to protect workers whose job it is to kill infected birds. We don’t know how effective antivirals will be for prevention in a pandemic, as they have never been used in this manner.
A person needs to take 1 pill a day when antivirals are used for prevention. However the length of time a person would need to take antivirals varies considerably. It can be 1 week if the medication is taken after exposure to someone who is ill, up to a maximum of 8 weeks if it is to provide protection for the duration of the first wave.
The only licensed use for antivirals for prevention in Canada is for healthy people over 1 year of age taking Tamiflu for 1 week after exposure to an infected person. The few studies done on taking preventive therapy for longer periods have shown that antivirals can prevent influenza in healthy people if taken daily for 4-6 weeks while the flu virus is circulating in the community. However, in these studies, since over 90% of people would not have come down with the flu anyway, a large amount of antivirals were taken by many people to prevent a small number of cases (i.e. Out of the 100 people who took the antivirals, the drugs helped prevent illness in 4-7 of them). In a pandemic, where the estimated percentage of people who will get sick is higher, these numbers may vary.
Possible risks
There are significant cost and human resource implications to adding antivirals for prevention to our planning efforts. Using our resources in this way could mean there are other things we won’t be able to do, both pandemic and non-pandemic related. The Public Health Network Council is examining the potential upsides and downsides of using antivirals for prevention, including the ethical and legal implications. As part of this process, the Council wants to hear from citizens about the values, principles and other factors that you believe should guide governments as they make decisions about the use of antivirals to prevent illness during a pandemic.
You have been invited as part of a randomly chosen group of Canadians to explore the values, principles and other considerations that you believe should guide your governments as they develop policies and make decisions on how antiviral drugs should be used, if they should be used to prevent illness during an influenza pandemic and, if so, who should have priority for receiving them.
On the first evening, you will have the opportunity to listen to and ask questions of an expert on pandemic influenza and on antivirals.
The following day, you will consider three approaches that will help you think through the values and principles that governments should consider when they make decisions about whether or not to use antivirals for prevention during an influenza pandemic. These approaches stress different priorities and principles. You’ll have a chance to work through them with other participants and talk together about which values, principles and other factors you would like to see reflected in the governments’ decision-making.
By the end of the day you may think that the values and principles underlying one approach capture your views better than others. You may identify a different set of principles, you may have found common ground with others, or you may find that the group is sharply divided. We hope that, whatever the outcome, you have a good discussion and come away with a better understanding about what’s involved in considering the possible use of antivirals for prevention during an influenza pandemic.
Day 1 Evening (6:30 pm - 9pm)
Welcome and Opening
Participant Introductions
Initial Questionnaire
Presentations: Learning About Pandemics and the Use of Antivirals
Discussion
Day 2 (9am - 4:30pm)
Overview of the Process
Discussion: Personal Experiences of a Public Emergency
Dialogue Using Three Approaches:
On what basis should publicly funded antivirals for prevention be provided during an influenza pandemic?
Buffet Lunch
Elaboration of “Common Ground” (shared values and views that could guide
e decision-making)
Identification of Priority Recipients for Antivirals for Prevention:
Given your common ground, who should be the priority recipients to receive antivirals for prevention?
Final Considerations:
What else do governments need to consider in making a decision about whether or not to provide publicly funded antivirals for prevention?
Closing Questionnaire
Closing Comments – Participants
Closing Comments – Facilitators and Hosts
The discussion that you and your fellow citizens will be having is designed to be a dialogue. Dialogue is a special kind of conversation that involves learning together and working to understand different points of view to try to build on common ground. Dialogue is very different from debate, as shown in the chart below.
Debate | Dialogue |
Assumes that there is one right answer (and you have it) | Assumes that others have pieces of the answer |
Attempts to prove the other side wrong | Attempts to find common understanding |
Objective is to win | Objective is to find common ground |
Listening to find flaws | Listening to understand |
Defend your personal assumptions | Explores and tests personal assumptions |
Criticizes the other’s point of view | Examines all points of view |
Defends one’s views against others | Admits that others’ thinking can improve one’s own |
Searches for weaknesses and flaws in the other's position | Searches for strengths and value in the other’s position |
Seeks an outcome that agrees with your position | Seeks an outcome that creates new common ground |
*Adapted from the version used by the Canadian Policy Research Networks
The following ground rules* can help us engage in good dialogue.
*Adapted from the version used by the Canadian Policy Research Networks
(The following definitions are included to help citizens as they listen to presentations and read the workbook.)
Antiviral drugs: Medication used to treat (and in some cases prevent) influenza. Antivirals come in pills, syrup/liquids, and inhalers. Antivirals are not a vaccine.
Avian (bird) flu: A disease originating in birds caused by influenza virus that can occasionally spread to other animals and humans.
Canadian Pandemic Influenza Plan for the Health Sector (CPIP): A national pandemic plan produced by representatives from the federal, provincial and territorial governments. It has two main goals:
Ethics: The moral principles governing or influencing conduct that helps identify how to “do the right thing”.
Flu (Influenza): A popular term for influenza often misused to describe a cold (see Influenza).
Health care sector: Those agencies, organizations and practitioners who offer health services both at an individual level (patient care) and at a population level (public health).
Health care worker: Persons who work in settings where health care services are provided.
Influenza: A severe respiratory infection caused by an influenza virus usually associated with fever, cough and other symptoms such as sore throat or muscle aches.
Pandemic flu: A worldwide outbreak of influenza that affects a large portion of the population.
Population-based health: A type of health service that focuses on the health of populations through health promotion (how to make communities healthy), health protection (preventing infectious diseases and other health risks) and gathering health information (see Surveillance).
Priority recipients: Individuals or groups of people who would receive something before others (such as vaccines or antivirals for treatment or prevention).
Prophylaxis: Prevention. For the purposes of our dialogues, prophylaxis refers to the use of medication to prevent a disease (rather than treatment of a disease).
Public health: Public health focuses on the health of the population. It is made up of a range of efforts to protect and promote peoples’ health. It includes activities like immunization; healthy eating and physical activity programs; infection control measures; and gathering information on both health and risk factors (see Surveillance). Public health interventions can relieve some of the pressure on the health care system.
Public health emergency: An imminent and serious threat to the public’s health that is posed by a dangerous disease or health hazard. This can include natural disasters such as a tsunami, a widespread outbreak of an infectious disease or a large terrorist event.
Public health measures: Non-medical interventions (such as quarantine or nonsmoking legislation) that may be used to slow or stop the spread of the disease or promote a population’s health.
Publicly funded: Paid for by the government. This money comes from individual taxpayers and other sources of income for governments (e.g., interest, corporate tax).
Quarantine: A public health measure that involves keeping people (or animals) who have been exposed to an infectious disease away from others for a short period of time to help prevent the spread of infection.
Surveillance: This is the intelligence-gathering function of public health. It involves the collection of data to describe the health of a population and identify patterns of disease, outbreaks and health risks. This information is then used to assess responses to diseases.
Vaccine: A preparation of a weakened or killed form of an infectious agent given in order to create antibody production and immunity. Vaccines are given to prevent disease. The vaccine itself does not cause the disease.
Virus: A microscopic particle that can infect the cells of a biological organism and cause an infectious disease. Colds and flus are caused by viruses. They do not respond to antibiotics.
Q: Why are citizens and stakeholders being consulted about antivirals for prevention?
A: These dialogues are part of a robust process to develop a pan-Canadian policy recommendation on the potential use of antivirals for prophylaxis during a pandemic influenza. Information gathered at these sessions will be considered along with information provided by scientific legal, ethical, and economic researchers as well as advice from other groups and international bodies.
Q: Which governments are involved in this public consultation?
A: The federal government, through the Public Health Agency of Canada, is working together with the provinces and territories, to engage citizens and stakeholders in a dialogue on the potential use of antivirals for prophylaxis (prevention) during a pandemic influenza.
Q: What is a deliberative dialogue?
A: Deliberative Dialogue is a research process that is designed to foster an informed dialogue among a small group (20-25) of randomly-recruited participants, on the scope of a value-laden issue, and the tradeoffs that must be considered in weighing different decision options.
Q: Why was the deliberative dialogue process chosen?
A: The Deliberative Dialogue methodology has been chosen because it not only includes an education session for all participants, but also generates discussion that will allow governments to have qualitative data (values, principles, ethics) about the priorities and values Canadians consider in making such decisions.
Q: Where are these consultations taking place?
A: Dialogues are taking place in British Columbia (with representation from Yukon and Alberta), Manitoba, Ontario, Nunavut, Quebec (to be confirmed), Halifax (with Atlantic representation) and Ottawa.
Q: How are participants chosen for the dialogues?
A: Participants at the citizen sessions are randomly chosen by phone through a research company to reflect a cross-section of demographics including gender, ethno-cultural, socio-economic, education and age.
Q: Are Aboriginal people included in the sessions?
A: The dialogues will include Aboriginal representation to ensure an appropriate Aboriginal perspective is brought to bear on the broad process of review and reflection.
Q: Will the results from the consultation be made public?
A: Results from the citizen dialogues will be made available to the participants as well as to the public through the Public Health Agency of Canada website.
Q: What's the difference between vaccines and antivirals?
A: Vaccines are the primary means to prevent illness and death from influenza. They stimulate the production of antibodies against the flu virus components included in the vaccine, providing immunity against the virus.
Antivirals are drugs used for the prevention and early treatment of influenza. If taken shortly after getting sick (within 48 hours), they can reduce influenza symptoms, shorten the length of illness and potentially reduce the serious complications of influenza. Antivirals work by reducing the ability of the virus to reproduce but do not provide immunity against the virus.
For additional information on pandemic influenza, please visit:
For more information about the dialogue process, please contact:
Natasha Manji
Senior Communications Advisor, Public Involvement
Public Health Agency of Canada
Email: natasha_manji@phac-aspc.gc.ca
Telephone: 613 957-4257
Last Updated: 2006-11-17 |