Lessons-learned Report: The CFIA’s Response to the 2007 Avian Influenza Outbreak in Saskatchewan
May 2008

Management Response and Action Plan

Corporate Evaluation Directorate
Audit, Evaluation and Risk Oversight Branch
Canadian Food Inspection Agency

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• 1.0 Executive Summary
• 2.0 Introduction
  • 2.1 Background
  • 2.2 Scope and Objectives
• 3.0 Approach & Methodology
  • 3.1 Approach
  • 3.2 Methodology
• 4.0 Lessons-learned Analysis: Findings
  • 4.1 Roles and Responsibilities
    • 4.1.1 Successes
    • 4.1.2 Opportunities for Improvement
    • 4.1.3 Learning from experience
    • 4.1.4 Recommendations
  • 4.2 Communication and Information Sharing
    • 4.2.1 Successes
    • 4.2.2 Opportunities for Improvement
    • 4.2.3 Learning from experience
    • 4.2.4 Recommendations
  • 4.3 Logistics
    • 4.3.1 Successes
    • 4.3.2 Opportunities for Improvement
    • 4.3.3 Learning from experience
    • 4.3.4 Recommendations
• 5.0 Summary of Recommendations
• 6.0 Conclusion
• Annex 1: Chronology
• Annex 2: Recommendations of British Columbia Outbreak Report - 2006
• Annex 3: Glossary

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1.0 Executive Summary

In November 2007, the Evaluation Directorate of CFIA’s Audit, Evaluation and Risk Oversight Branch conducted a lessons-learned review to analyse and document the effectiveness of the CFIA’s response and overall management of the 2007 Avian Influenza (AI) outbreak in Saskatchewan.

The information was gathered for the Agency’s continuous improvement of its response and overall management of outbreaks, by learning from successes, opportunities for improvement, and from past outbreaks.

The main finding of this review was that most aspects of CFIA’s response and overall management, and those of its working partners and stakeholders, were seen to be outstanding successes, and that CFIA, its working partners and stakeholders should be commended for their accomplishments, most notably, the successful and rapid containment and eradication of the outbreak.

The objectives of this report were the assessment of the following aspects:

• The successes of CFIA’s response to the Saskatchewan outbreak;
• The issues impacting the effectiveness of the operation;
• Possible improvements required for a future outbreak; and,
• Possible continuing issues present in the Saskatchewan outbreak from the BC 2004 outbreak.

The information reported in this review is presented from the perspective of those interviewed and was gathered and organized under three themes:

1. Roles and Responsibilities
2. Communication and Information Sharing
3. Logistics

The lessons-learned approach and methodology were based on collecting observations from those directly involved in the AI outbreak. As such, this report is based on personal experiences and perspectives. In addition to CFIA staff at headquarters, areas, regions, and in the field, the perspectives of the Public Health Agency of Canada (PHAC), Public Safety Canada (PS), Public Works and Government Services Canada (PWGSC), Saskatchewan government officials, and of industry representatives were taken into consideration. A consistent data collection strategy was used to gather information from multiple sources (interviews, focus groups, document reviews) to allow for a balanced view of the response effort. This methodology was further supported by an analysis of the Avian Influenza chronology described in Annex 1, and by other background documentation.

Summary of Findings

The CFIA’s response and overall management of the Saskatchewan outbreak were widely seen as resounding successes. The listing of all the successes achieved by CFIA personnel and its working partners would be too numerous to include in this report. As a result, the portions of this report outlining Agency successes focus on the significant improvements achieved since the 2004 British Columbia Outbreak, demonstrating the Agency’s commitment to enhancing its response and overall management of outbreaks.

Roles and Responsibilities

Successes

Previous experience with the Incident Command System (ICS) among key personnel, through a combination of experience gained in the British Columbia outbreak and subsequent field exercises, was vital to the smooth functioning of operational commands during the emergency. One of the key regional successes in the outbreak was the quick response time displayed by local CFIA personnel in the handling of the initial outbreak. On-farm operations ran smoothly, and the roles and responsibilities amongst animal health partners were very clear, with CFIA playing the lead role. In addition, decision making on-site and in the Regional Emergency Operations Centre (REOC) was quick and decisive, with staff making effective use of existing and new decision documents.

Opportunities for Improvement

Key personnel involved in ongoing emergency operations were well trained and handled themselves in a professional manner. However, there were minor changes in the chain of command at the national level and uncertainty regarding the delineation of authority between the three operations centres, reducing situational awareness.

Coordination of some multi-jurisdictional roles caused additional challenges. Further challenges developed over communications triggers and messages. Occupational safety and health (OSH) protocols were not uniform during the initial investigation stages of the Saskatchewan outbreak, and OSH officers were not present at the start of containment operations.

Learning from Experience

In the wake of the 2004 Avian Influenza outbreak in British Columbia, recommendations for improvements were made in Avian Influenza Lessons Learned and Action Plans (2006). In the Saskatchewan outbreak, some of these challenges recurred. As part of the learning process, it was important to acknowledge that some challenges from the BC outbreak continue to need further attention.

These challenges include issues addressed in recommendation numbers One (Jurisdictional Issues), Two (Federal Health Linkages), Five (Information Flows), and Eight (Bio-safety Responsibilities). While much progress has been made in each of these broad areas some additional clarifications would still be beneficial.

Recommendations

The information gathered under the roles and responsibilities theme demonstrates the extent to which CFIA has learned and is still learning from its successes and opportunities for improvement from the outbreaks in BC and later in Saskatchewan. This process is an indicator of the Agency’s commitment to and capacity for continuous improvement and learning.

Lessons-learned reviews are mechanisms that support organization learning to achieve excellence. The following recommendations are intended to further support the Agency’s process of continuous improving and learning.

These recommendations are based on successes, opportunities for improvement and past outbreaks which are from both positive and more challenging experiences.

Recommendation 1: CFIA should strengthen and continue to practice roles and responsibilities in advance through increased exercises of the Incident Command System at both the national and regional level.

Recommendation 2: CFIA should work with key partners at the regional level to better coordinate inter-jurisdictional flows and triggers with other federal departments and agencies, in particular PHAC, PS, and CBSA.

Recommendation 3: CFIA should clarify and strengthen MOUs regarding existing inter-departmental links, while creating new formal agreements where necessary.

Communication and Information Sharing

Successes

Information sharing between CFIA and industry was successful, and public communications to Canadians helped maintain consumer confidence in both the national food supply and the government authorities managing the outbreak. Once Notifiable Avian Influenza (NAI) was confirmed, regular meetings between government and industry stakeholders were established within twenty-four hours. The Foreign Animal Disease Emergency Support (FADES) agreement allowed CFIA to marshal trans-jurisdictional resources to commit to the outbreak.

Opportunities for Improvement

With respect to communications, information provided to the public was clear and consistent. However, the initial news conference and news release were slightly delayed.

With respect to information sharing, the stakeholder list at the regional level was only partially completed due to outdated contact lists for non-CFIA personnel. Compounding this was a high rate of new personnel in key positions, and some uncertainty of precisely which information needed to be shared with whom, and when.

In addition, CFIA briefings were initially not provided to the appropriate personnel at central agency and ministerial offices, although this error was quickly remedied. The complexity of laboratory testing in establishing the presence of Notifiable Avian Influenza influenced the timing of the warning regarding a potential outbreak and CFIA’s ability to rapidly deploy resources to Saskatchewan. Respondents from both provincial and federal health partners were in agreement that such challenges are opportunities for CFIA to improve for future outbreaks.

On the farm, there were challenges with hardware compatibility, especially radios. Not all communications platforms possessed the interoperability required of this operation.

Learning from experience

In the wake of the 2004 Avian Influenza outbreak in British Columbia, recommendations for improvements were made in the Avian Influenza Lessons Learned and Action Plans (2006). In the Saskatchewan outbreak, some challenges recurred, and as part of the improving and learning process it is important to CFIA to recognize its opportunities for improvement from one outbreak to another. As such, continuing challenges include challenges from recommendation numbers Four (IM/IT Capabilities) and Five (Information Flows).

Recommendations

The information gathered under the communication and information-sharing theme demonstrates the extent to which CFIA has learned and continues to learn from both successes and opportunities for improvement from the outbreaks in BC and Saskatchewan. This demonstrates the Agency’s commitment to continuous improvement and learning.

Lessons-learned reviews are mechanisms to support learning from experience. The following recommendations will further support the Agency’s process of continuous improving and learning. These recommendations are based on successes, opportunities for improvements and past outbreaks, from both positive and challenging experiences.

Recommendation 4: At the national level, CFIA should re-confirm official information sharing protocols with federal partners.

Logistics

Successes

A logistics team was quickly put in place, and contingency plans were activated and followed throughout the emergency with daily logistics calls between key federal and provincial actors. The MOU with PWGSC was activated, allowing CFIA to establish an enlarged off-site emergency operations centre should the outbreak worsen.

Regional logistical support, while improvised, was focused on supporting the on-site team and the establishment of the REOC. A private security firm was contracted to provide auxiliary personnel to enforce the quarantine perimeters and personal protective equipment (PPE) stockpiles were delivered on-site within forty-eight hours of the initial notification. In addition, CFIA personnel were moved with astounding rapidity into southern Saskatchewan from Saskatchewan and Manitoba.

Telecommunications equipment coordination was, on balance, successful. The informatics hot line and the Canadian Emergency Management Response System (CEMRS) were both in place, and served important functions.

Opportunities for Improvement

Confirmation that Avian Influenza was present was followed by further testing to confirm that the strain was Notifiable AI (either H5 or H7 subtypes). Respondents noted that the response and coordination of logistical efforts did not commence until confirmation that the strain was in fact Notifiable AI.

This observation points to a difference in positions between the Agency and its public health partners which may not have been explicitly communicated between the organizations. It is important to note that the Agency responded quickly once the presence of NAI was proven by laboratory testing. Many of the officials from public health organizations noted their preference for an early warning and would accept the possibility of a false start. The position of the CFIA is that notifications are made only when an early indication either from a CASHN laboratory or the NCFAD of a notifiable AI potential detection has been established, preferring a “safe” start to avoid the possibility of unnecessary panic and negative economic impact.

Respondents felt that financial codes for travel, overtime, and other expenses should have been prepared in advance to improve the timeliness of procurement. Medical clearances and fit testing for field staff could have been more complete. These created confusion over Occupational Health and Safety responsibilities. Respondents also stated that the supply situation in Saskatchewan should have been organized on-site with a clear procurement authority, and with a comprehensive inventory. Adding to these challenges, were jurisdictional issues regarding which supply depots would be the primary source for the necessary materiel.

The lack of sufficient geographic information system (GIS) data affected the mapping of the area surrounding the hot zone. Were CFIA to have access to reliable high-resolution images of all arable land in Canada, its capacity to respond to outbreaks would be improved. In addition, the scarcity of additional trained backups in emergency management could have influenced CFIA’s surge capacity.

Learning from experience

In the wake of the 2004 Avian Influenza outbreak in British Columbia, recommendations for improvements were made in the Avian Influenza Lessons Learned and Action Plans (2006). In the Saskatchewan outbreak, some challenges recurred, and as part of the improving and learning process it is important to CFIA to recognize its areas of improvement from one outbreak to another. These challenges recommendation number Four (IM/IT Capabilities), Eight (Bio-safety Responsibilities), and Twelve (HR, Finance, and IM/IT Support).

Recommendations

The information gathered under the logistics theme demonstrates the extent to which CFIA has learned and is still learning both from its successes and from opportunities for improvement from the BC and Saskatchewan outbreaks, demonstrating the Agency’s commitment to continuous improvement and learning.

Lessons-learned reviews are mechanisms to support learning from experience. The following recommendations will further support the Agency’s process of continuous improving and learning. These recommendations are based on successes, opportunities for improvement and from past outbreaks, which are from both positive and challenging experiences.

Recommendation 5: CFIA should increase staff training efforts to help ensure adequate succession planning for future outbreaks.

Recommendation 6: CFIA should review its Emergency Operations Centre logistics procedures and ensure that proper supply chain management pathways are followed and communicated at the regional level. At the regional level, CFIA should establish a comprehensive list of necessary telecommunications hardware for future outbreaks, as well as a plan for acquiring the equipment in the immediate future.

Recommendation 7: CFIA should propose plans for increasing internal surge capacity to handle future emergencies at both the national and regional levels, and continue to improve emergency business continuity planning.

Recommendation 8: CFIA should dedicate resources to monitor globally AI strains modifications and ensure on-going improvements to screening tests to minimise delays in notifications of future emergencies.

Recommendation 9: Additional funding should be made available for augmenting IM/IT systems, such as CEMRS and LSTS, to increase functionality and response time.

Conclusion

CFIA’s response and overall management of the outbreak was viewed as an outstanding success, with the general response being overwhelmingly positive for both CFIA and its working partners. The outbreak was rapidly contained and eradicated, and disruptions to trade and industry were minimized. It was recognized that considerable effort was made by all parties to respond to the outbreak and as a result, the spread of the disease was contained at its initial outbreak location.

The information gathered during this lessons-learned review was intended to support the Agency’s continuous improvement to its response and overall management of outbreaks by learning from their successes, opportunities for improvement and past outbreaks. This report is an example of the efforts of the Agency to strive for excellence.

As a result of continuously improving through learning, the Saskatchewan outbreak represents a significant improvement in performance for the CFIA over the 2004 outbreak in British Columbia.

2.0  Introduction

2.1 Background

Avian influenza (AI) is an infectious and contagious viral infection affecting most species of wild and domestic birds. Infrequently, certain strains of the virus have been found to cross into and cause disease in unrelated species including pigs, cats, dogs, ferrets, martens and humans. Transmission of the virus from one bird to another occurs primarily through direct contact, typically through contact with respiratory secretions or feces. Airborne transmission may occur if birds are in close proximity and with appropriate air movement. Infection with the virus may result in asymptomatic birds, as is found in many waterfowl and shorebird species, or a diversity of disease manifestations, as seen in domestic poultry, varying from sub-clinical disease, mild respiratory disease and loss of egg production to an acute and highly fatal disease. Most AI viruses found in birds have not historically posed a significant health risk to humans.

Since 1955, all highly pathogenic outbreaks in domestic poultry have been attributed to viruses of the H5 and H7 subtypes. These subtypes have repeatedly demonstrated the capacity to mutate from low pathogenicity strains to highly pathogenic forms while circulating within poultry populations. Since 2003, trade in domestic poultry and the movement of migratory birds has resulted in the spread of the H5N1 Eurasian strains to numerous countries in Asia, Africa, the Middle East and Europe. Although the number of human infections remains low, the mortality rate in those infected is high. To date, there has been no sustained, efficient human-to-human transmission of the H5N1 Eurasian strains, so direct contact with infected birds (mainly poultry) remains the greatest risk of human infection. Of particular concern is the possibility of re-assortment of genetic material between human and avian influenza A viruses when they simultaneously infect the same swine or human host. This re-assortment may result in the formation of a new influenza virus strain with pandemic potential.

Global efforts to restrict 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 prior exposure or initial immunity to these emerging pathogens. AI viruses, such as the H5N1 strain of the influenza A virus present in East Asia, may, on rare occasions, cause disease in humans. Human infection has occurred where people had prolonged contact with infected birds or heavily contaminated environments.

Notifiable Avian Influenza (NAI) is a notifiable disease according to the Terrestrial Animal Health Code of the World Organization for Animal Health (OIE).¹ Member countries have an obligation to notify the OIE within 24 hours of confirming the presence of the virus. Highly pathogenic avian influenza (HPAI) is a reportable disease under the Health of Animals Act. This means that all suspected cases of avian influenza must be reported to the Canadian Food Inspection Agency (CFIA), which represents the chief veterinary authority in Canada. In September 2007, the CFIA identified the presence of a highly pathogenic H7N3 avian influenza in a commercial poultry operation in Saskatchewan. The CFIA depopulated the infected premises on which highly pathogenic avian influenza was found.

In this context, the 2007 outbreak of AI in Saskatchewan raised concern in the public health sector as well as the agricultural community. The corresponding efforts of Canada’s federal, provincial and municipal response organizations as well as industry 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 improve and learn from experiences, including those based on successes, and from opportunities for improvement, as well as from past outbreaks.

2.2 Objectives and Scope

This report was intended to assess the following:

• The successes of CFIA’s response to the Saskatchewan outbreak;
• The issues impacting the effectiveness of the operation;
• Possible improvements required for a future outbreak; and,
• Possible continuing issues present in the Saskatchewan outbreak from the BC 2004 outbreak.

To conclude on the objectives established for this report, three themes were established to analyse and document the lessons learned from the outbreak.

1. Roles and Responsibilities;
2. Communication and information sharing; and,
3. Logistics.

The scope of this review is to assess CFIA’s response and overall management of the 2007 Saskatchewan outbreak, as well as establish whether continuing challenges affected CFIA’s ability to respond to potential future outbreaks following the outbreak in British Columbia. This lessons-learned report was initiated in November 2007 and concluded in December 2007.

3.0  Approach & Methodology

3.1  Approach

• Review of background documentation and chronology of the AI outbreak.²
• Identification of topics of study.
• Identification of regional and national participants in focus groups.
• Identification of regional and national interviewees involved in the AI outbreak who would require one-on-one interviews.
• Consistent data collection strategy for all focus groups and interviews.
• Summary of findings and lessons-learned analysis.
• Comparison between the areas of improvement for the Saskatchewan outbreak and the recommendations of the Avian Influenza Lessons Learned and Action Plans—2006 Progress Monitoring Exercise of Internal Audit Recommendations 2002-Present.³
• Development of recommendations.

The focus groups and the directed interviews were conducted with senior managers from the Canadian Food Inspection Agency (CFIA), the Public Health Agency of Canada (PHAC), Health Canada (HC), Public Works and Government Services Canada (PWGSC), Saskatchewan Health, Saskatchewan Agriculture and Food – all of which took part in the AI outbreak response – and with representatives from Chicken Farmers of Saskatchewan and Saskatchewan Broiler Hatching Egg Producers.

3.2 Methodology

The lessons-learned methodology is based on collecting observations from those directly involved in the AI outbreak. As such, the final report is based on personal experiences and perspectives. A consistent data collection strategy was used to gather information from multiple sources (that is, interviews, focus groups, documentation, etc) to allow a balanced view of the experience.

Participants were provided with preparatory material and asked to explain their involvement and role in the event. The participants were asked to provide feedback on the three topics (roles and responsibilities, communication and information sharing, and logistics) and related questions. The study was based on analyses of the observations of direct participants.

4.0 Lessons-learned Analysis: Findings and Recommendations

The findings of this lessons-learned report are grouped below according to the three themes. Feedback for each topic area is captured in three sections: 1) successes, 2) opportunities for improvement, and 3) learning from experiences.

CFIA’s response and overall management of the Saskatchewan outbreak were widely seen as a resounding success. The listing of all the successes achieved by CFIA personnel and its working partners would be too numerous to include in this report. As a result, the portions of this report outlining Agency successes focus on the significant improvements achieved since the 2004 British Columbia outbreak, which demonstrates the Agency’s commitment to enhancing its response and overall management of outbreaks.

4.1 Roles & Responsibilities

Roles and responsibilities were identified as one of the three primary themes. Specific aspects reviewed included governance, collaborative arrangements, decision making and accountability, task identification, and allocation.

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

1. Were roles and responsibilities clear?
2. Was coordination with your organization/group managed? Was it managed effectively?
3. Were decisions, from your perspective, conducive to the efficient management and coordination of the response?
4. Were decisions made in a timely fashion?
5. Could you have had a more active and effective role in the outbreak? If so what could you have done?

4.1.1 Successes:

National:

The standout success of the Saskatchewan Outbreak was the implementation of the Incident Command System (ICS). Extra resources were identified and brought in, and both the regional (REOC) and the Area (AEOC) level Emergency Operations Centers were quickly activated in accordance with ICS principles, followed by the activation of the National Emergency Operations Center (NEOC). Both the national and area commands were able to provide excellent support to the local operations carried out on-site and at the regional command.

Previous training and experience with the Incident Command System among key personnel, through a combination of experience gained in the BC outbreak and subsequent field exercises was vital to the smooth functioning of operational commands during the emergency.⁴

Regional:

One of the key regional successes in this section is the quick response time displayed by local CFIA personnel in the handling of the initial outbreak events. Once abnormal chicken mortality was reported, samples were collected and dispatched to the National Centre for Foreign Animal Diseases (NCFAD) in Winnipeg.

On-farm operations ran smoothly, with well-trained staff handling the depopulation of the barns and subsequent disposal of the carcasses. Previous training in the use of personal protective equipment (PPE) was also crucial. This experience removed most of the learning curve associated with the tactical use of PPE gear employed in the hot zone.

The roles and responsibilities amongst animal health responders were very clear, with CFIA playing the lead role. The animal health response was unanimously viewed as a success by industry representatives.

Decision-making on-site and in the Regional Emergency Operations Centre (REOC) was quick and decisive, with staff making effective use of the Notifiable Avian Influenza Hazard Specific Plan and Standard Operating Procedures documents (for example, destruction, disposal, biocontainment). New decision documents to address special issues were created as required.

4.1.2 Opportunities for Improvement:

National:

While key personnel involved in ongoing emergency operations were well-trained and handled themselves admirably, there were minor changes in the chain of command at the national level caused by adjustments of leadership at the NEOC. The shifting of staff as a result of temporary postings made maintaining adequate situation awareness a challenge.

While linkages between the CFIA and public health partners are in place, there is an opportunity to work more closely with federal and provincial health partners to obtain a common understanding on the timing and process for notifying them of the outbreak. Further issues developed over communications triggers and the consequent messages. This highlights the need to again review the Communications Trigger and Messaging documents presented to the federal-provincial animal and human health officials in September 2006.

During interviews, it was revealed that some of these organizations would prefer an early warning of suspect situations and would accept the possibility of a false start based on an incorrect diagnosis. The position of the CFIA is that at any given time there are many samples in the laboratories being tested for a wide variety of diseases. Notifications are made only upon confirmation of tests. In the case of avian influenza, notifications are made when there is a positive Notifiable AI screening test in the provincial network laboratories (CAHSN), or pending failure of the front line screening tests until the NCFAD can have early indication of a Notifiable AI, through alternative testing approaches not available in the CAHSN. The CFIA position is that confirmed test results are necessary to avoid the possibility of unnecessary panic and negative economic actions. In addition to divergent views on notification, there was a perceived lack of clarity between federal and provincial public health roles, and their relationship with the CFIA.

Regional:

There was uncertainty regarding the delineation of authority between the three command centres, as well as the executive committee. Owing to this uncertainty, some decisions were delayed, and some issues were escalated to the national or senior executive level.

Coordination of some multi-jurisdictional roles created additional challenges. With the reinforcement of Public Safety Canada’s role in new legislation, its roles and responsibilities were not firmly understood within the CFIA command framework at the regional level. During the operation it became apparent that Public Safety Canada’s legal mandate and roles and responsibilities as compared to CFIA’s, had yet to be clearly defined and implemented for combined field operations, resulting in a potentially ambiguous decision-making process and framework.

Occupational safety and health (OSH) protocols were not specific prior to the establishment of a full quarantine perimeter by CFIA staff. During the initial phases of the investigation there were issues with differing standards of required PPE and its use by partner organizations. As a result of a lack of clearly defined and understood leadership and support roles for the various organizations involved in the response, the release of key information during the emergency was impacted, resulting in suboptimal information sharing with partner organizations.

At the commencement of the outbreak, although there were no occupational safety and health officials on site, there was no accidental exposure or additional contamination at the Saskatchewan site. In addition, industry representatives questioned the policy of assigning the responsibility of cleaning and disinfection of the contaminated premises to the farm owners.

4.1.3 Learning from experience

In the wake of the 2004 Avian Influenza outbreak in British Columbia, recommendations for improvements were made in Avian Influenza Lessons Learned and Action Plans (2006) to address challenges identified during the 2004 outbreak. In the Saskatchewan outbreak, some challenges recurred.

For example, the delineation between national and regional roles continued to be a challenge. Decision-making parameters remained only partially defined after the British Columbia outbreak. This lack of clarity may have been a factor in some operational issues still being escalated to the national level.⁵

During the British Columbia emergency, the CFIA found that links with its strategic partners at both the federal and provincial level were either weak or non-existent. While vigorous field exercises undertaken since 2004 have served to strengthen ties, liaison with other government departments still requires attention in order to expand federal emergency zoonotic capacity.⁶

General misunderstanding about respective roles and responsibilities of the stakeholders involved in the emergency response hindered effective information sharing and slowed the release of information from CFIA during the 2004 outbreak. While the process had undergone tremendous improvement since the British Columbia outbreak, some information flows and triggers were still seen as challenges by many respondents during the Saskatchewan outbreak.⁷

The lack of clarity of bio-safety responsibilities for non-federal personnel on infected premises at the regional level between CFIA, other federal agencies and provincial public health partners was cited as a recurring challenge during the Saskatchewan outbreak. Although this area was the focus of considerable improvement since 2004, with bio-safety protocols moving from an emergency ad hoc basis to formalized plans, continued attention must still be paid to this aspect of emergency operations.⁸

4.1.4 Recommendations

The information gathered under the roles and responsibilities theme demonstrates the extent to which CFIA has learned and continues to learn from its successes and opportunities for improvement from the outbreaks in BC and later in Saskatchewan. This is an indicator of the Agency’s commitment to and capacity for continuous improvement and learning.

Lessons-learned reviews are mechanisms that support organization learning to achieve excellence. The following recommendations are intended to further support the Agency’s process of continuous improving and learning.

These recommendations are based on successes, opportunities for improvement and past outbreaks which are from both positive and more challenging experiences.

Recommendation 1: CFIA should strengthen and continue to practice roles and responsibilities in advance through increased exercises of the Incident Command System at both the national and regional level.

Recommendation 2: CFIA should work with key partners at the regional level to better coordinate inter-jurisdictional flows and triggers with other federal departments and agencies, in particular PHAC, PS, and CBSA.

Recommendation 3: CFIA should clarify and strengthen MOUs regarding existing inter-departmental links, while creating new formal agreements where necessary.

While positive steps were taken in the wake of the 2004 British Columbia outbreak, it is vital that field exercises of the Incident Command System continue to be performed jointly with national and regional staff. During these field exercises, roles and responsibilities of all parties should be clarified and practiced.

4.2 Communication and information sharing

Elements of communication and information sharing that were assessed include frontline feedback, media and public relations, intergovernmental co-operation, and risk communication. The following types of questions were used to guide focus group and interview participants:

1. What communication and information sharing processes were in place? Did you feel said processes were sufficient/insufficient and why/why not?
2. Did communication and information sharing improve or deteriorate over the course of the outbreak? How?
3. How important and how effective were communication and information sharing with other departments/agencies?
4. How and when were you advised of suspected cases?
5. Who and when would/did you advise of suspected cases?
6. Was key messaging timely and well coordinated?

4.2.1 Successes:

National:

The initial press releases on September 27, 2007 by the CFIA and the Hon. Gerry Ritz, Minister of Agriculture and Agri-Food, contained pertinent information and proved useful in both alerting and reassuring the general public. Additional information provided by the CFIA regarding potential food safety issues as well as a fact sheet on Avian Influenza were also timely, coming as part of the announcement of the outbreak. This helped to maintain consumer confidence in both the national food supply and in the government authorities managing the outbreak.

Once Notifiable Avian Influenza (NAI) was confirmed on September 26, 2007 regular meetings between government and industry stakeholders were established within twenty-four hours. This facilitated communication by allowing key stakeholders to reliably share information between organizations.

Regional:

The Foreign Animal Disease Emergency Support (FADES) agreement between CFIA and the province of Saskatchewan allowed CFIA to direct trans-jurisdictional resources to commit to support CFIA’s management of the outbreak. In the BC outbreak in 2004 there was scant awareness of the FADES plan among industry and provincial representatives as a result of it never having been exercised. However, in Saskatchewan, the FADES agreement was in place and signed by key stakeholders, with positive feedback on the effectiveness of the FADES agreement coming from all participants.

Information sharing between CFIA and industry was successful, with the Saskatchewan Poultry Industry informed in a timely fashion. In addition, the Saskatchewan Poultry Industry Emergency Management Team (SPIEMT) was contacted rapidly and engaged to provide support to CFIA on-site and regional operations.

4.2.2 Opportunities for Improvement

National:

While the public messaging was clear and consistent, the initial communications briefing and news release were slightly delayed for technical reasons.

Laboratory testing is an iterative process which requires a series of checks to ensure the validity of the results. The time involved to conduct the required testing, particularly if initial results are not entirely consistent with subsequent tests, can be a source of frustration for those seeking clear and timely information. Establishing that the Avian Influenza detected was in fact Notifiable Avian Influenza took several days and therefore influenced the timing of the response. Rapid screening tests did not detect Notifiable Avian Influenza, resulting in many partner organizations ordering their emergency teams to stand down. Confirmation of highly pathogenic Avian Influenza came from NCFAD two days after the original screening was deemed inconclusive. It was only at that point that the response effort could be mobilized.

The position of the CFIA is that notifications be made only after there is an early indication either from a CASHN laboratory or the NCFAD of a Notifiable Avian Influenza potential detection, preferring to have accurate results before implementing the response. However, many of CFIA’s working partners in public health and safety ordered their emergency teams to stand down before the diagnosis was confirmed as Notifiable Avian Influenza.

Both provincial and federal health partners were in agreement that the absence of an early warning regarding a potential outbreak was a challenge. Discussions are required to develop a better understanding of the challenges CFIA and public health partners face in responding to animal disease outbreaks. CFIA briefings were not initially provided to the appropriate personnel at central agency and ministerial offices affecting the timing of the transmission of information, although this issue was quickly remedied.

Regional:

The information sharing between CFIA, other government departments, and industry stakeholders was coordinated. However, the stakeholder list was partially completed, leaving many organizations, such as Public Safety Canada, either partially or completely out of the information loop at the regional level. Resolution of this challenge requires clearly identifying and documenting contact individuals in stakeholders organizations who are responsible for disseminating information received from CFIA through their organization.

Another challenge to information sharing was the employment of outdated contact lists for many non-CFIA personnel. Phone numbers were out of service, or the listed personnel had moved on to different positions in the organization. Adding to this challenge was a number of new personnel in key positions, as a result of staffing changes or planned absences such as vacations. These factors created a minor challenge. These shifts in personnel were often accompanied by a new telephone contact number, making consistent information sharing difficult.

On the farm, there were issues with hardware compatibility. Not all communications platforms possessed the interoperability required by CFIA staff and their partners. For example, as short-range radios broke down, replacements were often incapable of matching the selected frequency band. In addition, the plethora of dissimilar communications hardware made inter-service cooperation difficult, as the numerous frequencies employed by Agency staff, other government departments, as well as local law enforcement and security personnel often interfered with one another.

4.2.3 Learning from experience

In the wake of the 2004 Avian Influenza outbreak in British Columbia, recommendations for improvements were made in the Avian Influenza Lessons Learned and Action Plans (2006). In the Saskatchewan outbreak, some challenges recurred, and as part of the improving and learning process, it is important to CFIA to recognize its areas of improvement from one outbreak to another.

One of the key factors leading to communication and information sharing challenges during the Saskatchewan outbreak was the absence of sufficient IM/IT capabilities. The paucity of communications infrastructure, such as the technical issues reported with the press teleconference at the regional level, affected the timely release and efficient transmission of important data.⁹ Information sharing improved significantly as the outbreak progressed. A notable improvement from the British Columbia outbreak was that the above mentioned issues were extremely short-lived during the Saskatchewan outbreak. While assessments of the effectiveness of CFIA information sharing were on balance positive, feedback was mixed across organizations, indicating inconsistency either in the structure or the application of CFIA’s information sharing and liaison strategy.¹⁰

4.2.4 Recommendations

The information gathered under the communication and information-sharing theme demonstrates the extent to which CFIA has learned and continues to learn from both successes and opportunities for improvement from the outbreaks in BC and Saskatchewan. This demonstrates the Agency’s commitment to continuous improvement and learning.

Lessons-learned reviews are mechanisms to support learning from experiences. The following recommendations will further support the Agency’s process of continuous improving and learning.

These recommendations are based on successes, opportunities for improvements and past outbreaks, which are from both positive and challenging experiences.

Recommendation 4: At the national level, CFIA should re-confirm official information sharing protocols with federal partners.

4.3 Logistics

Logistics issues addressed included surge capacity and support systems, logistics protocols and procedures, and operational flexibility. The following types of questions were used to guide focus group and interview participants:

1. Were logistical support requirements clearly articulated?
2. Were the teams well-supplied and was the requested material able to arrive promptly?
3. Were logistical support roles and responsibilities clear?
4. Were support functions able to meet the surge in demand?
5. Were logistics plans in place? Also, were the plans followed? Or was there improvisation?
6. Were the plans sufficiently flexible to meet changing needs?

4.3.1 Successes:

National:

In terms of coordination, national CFIA operations had notable successes. A logistics team was quickly put in place, and supply plans were activated and followed throughout the emergency. Daily logistics calls between key partners at both the federal and provincial level helped to straighten out logistical issues and maintain open supply lines with the on-site team in Saskatchewan. As well, the MOU with PWGSC was activated, allowing CFIA to establish an enlarged off-site emergency operations centre should the outbreak worsen.

Regional:

Logistical support for the outbreak, while largely improvised and pursued on an ad hoc basis, was focused on supporting the on-site team and the establishment of the REOC. A private security firm was contracted to provide additional staff to enforce the quarantine perimeters. PPE stockpiles were delivered on-site within forty-eight hours of the initial mortality report, allowing staff to work within the hot zone.

In addition, CFIA personnel were moved with astounding rapidity into southern Saskatchewan from Manitoba and Saskatchewan, with the limited flight availability into Regina being well coordinated.

Telecommunications equipment coordination was on balance, successful. Emergency provision of Blackberries, cell phones, and PKI/VPN access to the CFIA network was adequate, with most devices reaching their intended users with a minimum of delay. The informatics hot line and the Canadian Emergency Management Response System (CEMRS) were both in place, and played an important role in the dissemination and storage of data.

4.3.2 Opportunities for Improvement:

National:

Confirmation that Avian Influenza was present was followed by further testing to confirm that the strain was Notifiable AI (either H5 or H7 subtypes). Respondents noted that the response and coordination of logistical efforts did not commence until confirmation that the strain was in fact Notifiable AI.

This observation points to a difference in positions between the Agency and its public health partners which may not have been explicitly communicated between the organizations. It is important to note that the Agency responded quickly once the presence of NAI was proven by laboratory testing. Many of the officials from public health organizations noted their preference for an early warning and would accept the possibility of a false start. The position of the CFIA is that notifications are made only when there is an early indication either from a CASHN laboratory or the NCFAD of a Notifiable AI potential detection, preferring a “safe” start to avoid the possibility of unnecessary panic and negative economic impact.

Respondents felt that financial codes for travel, overtime, and other expenses should have been prepared in advance, in order to improve the timeliness of procurement. Medical clearances and fit testing forms for field staff could have been more complete. These created confusion over OSH responsibilities and influenced CFIA’s ability to deploy staff to the hot zone.

Regional

Respondents also stated that procurement authority on-site in Saskatchewan could have been better defined. In the absence of a single relay point for logistical requirements, multiple individuals requested supplies simultaneously, resulting in surplus of some materiel, and shortages of others. Another challenge was the unavailability of a comprehensive on-site inventory, which also contributed to the supply situation.

Adding to the supply difficulties were jurisdictional issues. A lack of clarity existed with the on-site staff regarding which supply depots would be the primary source for the necessary materiel. Some orders were mistakenly sent to the regional operations centre when they should have been dispatched to the NCR, and vice versa. As available materiel was not perfectly mirrored at both sites, this resulted in extraneous re-routing of supply requests.

The lack of sufficient GIS (Geographic Information Systems) data affected the mapping of the area surrounding the hot zone. A mix of geographic imaging data, including the Dominion Land Survey (DLS), resulted in a non-functional data set requiring the reformatting and re-entering of virtually all data to create a working model. GPS (Global Positioning System) units were not widely available to CFIA staff, forcing field staff to rely on DLS data sets, many of which were unavailable for the quarantine area in sufficient topographical detail. A wider use of GPS would have allowed for more rapid and accurate mapping of potential outbreak locations around the hot zone.

While sufficient personnel were deployed to contain the Saskatchewan outbreak, this operation consumed most of the CFIA’s experienced AI staff in the Western Area. The scarcity of additional trained backups in emergency management could have influenced CFIA’s surge capacity.

There were issues with personnel rotation in regards to PPE. To increase efficiency, there should be adequate staff for a rotation through the hot zone, including a rotation of heavy equipment operators.

4.3.3 Learning from experience

In the wake of the 2004 Avian Influenza outbreak in British Columbia, recommendations for improvements were made in the Avian Influenza Lessons Learned and Action Plans (2006). In the Saskatchewan outbreak, some challenges recurred, and as part of the improving and learning process it is important to CFIA to recognize its areas of improvement from one outbreak to another.

Lack of IM/IT infrastructure reduced CFIA capacity to manage and acquire necessary information during the 2007 outbreak. Lack of GIS mapping tools and satellite imagery forced CFIA and its partners to rely on an amalgam of suboptimal systems. The case was similar in British Columbia, where inconsistent GIS mapping, as well as the anachronistic LSTS system for lab testing reduced IM/IT capacity.¹¹

Unclear bio-safety responsibilities between CFIA and other public health partners reduced the Agency’s ability to tap additional resources from other organizations during the British Columbia outbreak, with industry and other federal and provincial departments indicating that better use of personnel and equipment could have been made. This was repeated in Saskatchewan at the regional level, though in a less severe form due to reinforced FADES protocols, with external logistical capacity remaining underutilized.¹²

Logistics and surge capacity continued to be a problem in the Saskatchewan outbreak. While a much smaller emergency, CFIA resources were still put under stress to maintain the deployment in Saskatchewan and continue with regular Agency business. The operational requirements of CFIA field forces were underestimated, and as a result staff resorted to informal channels to acquire the necessary materiel as there is no clearly defined protocol in place. As in British Columbia, lack of or failure to implement surge capacity proved a hindrance, as it is critical to CFIA’s ability to assemble and deploy a rapid reaction force to any bio-security area.¹³

4.3.4 Recommendations

The information gathered under the logistics theme demonstrates the extent to which CFIA has learned and is still learning both from its successes and from the opportunities for improvement from the BC and Saskatchewan outbreaks.

Lessons-learned reviews are mechanisms to support learning from experiences. The following recommendations will further support the Agency’s process of continuous improving and learning.

These recommendations are based on successes, opportunities for improvement and from past outbreaks, which are from both positive and challenging experiences.

Recommendation 5: CFIA should increase staff training efforts to help ensure adequate succession planning for future outbreaks.

An enlarged personnel buffer is required to maintain routine functionality during an emergency situation. With critical staff absent from the chain of command during an emergency, it is vital that junior team members be trained for positions above them to ensure the smooth continuation of business.

Recommendation 6: CFIA should review its Emergency Operations Centre logistics procedures and ensure that proper supply chain management pathways are followed and communicated at the regional level. At the regional level, CFIA should establish a comprehensive list of necessary telecommunications hardware for future outbreaks, as well as a plan for acquiring the equipment in the immediate future.

In the event of an outbreak, CFIA requires adequate resources to handle all immediate demands, until additional supply contracts can be drawn up, or other stockpiles tapped for resources. It should be made clear in all operational plans that EOC stockpiles are to be the primary source for materiel.

Recommendation 7: CFIA should propose plans for increasing internal surge capacity to handle future emergencies at both the national and regional levels, and continue to improve emergency business continuity planning.

Increased staffing will be required, particularly at the regional level, to handle future outbreaks. With daily operations consuming close to one hundred percent of available staff, CFIA has no surplus personnel to deploy for emergencies. As well, increasing preparedness for future bio-security emergencies that could jeopardize the organization's core mission and long-term health is crucial. While the Saskatchewan outbreak was handled smoothly, this opportunity should be taken to expand existing plans.

Recommendation 8: CFIA should dedicate resources to monitor globally AI strains modifications and ensure on-going improvements to screening tests to minimise delays in notifications of future emergencies.

In particular, the Agency must ensure that it has the capacity to keep abreast of advances in science that would support the earliest possible and most accurate detection of disease.

Advances in scientific developments are moving rapidly. The Agency will benefit from monitoring these developments and integrating them in all aspects of emergency responses.

Recommendation 9: Additional funding should be made available for augmenting IM/IT systems, such as CEMRS and LSTS, to increase functionality and response time.

5.0 Summary of Recommendations

This review has identified a number of areas in which additional focus by the CFIA may improve the effectiveness of future responses.

Roles and Responsibilities

Recommendation 1: CFIA should strengthen and continue to practice roles and responsibilities in advance through increased exercises of the Incident Command System at both the national and regional level.

Recommendation 2: CFIA should work with key partners at the regional level to better coordinate inter-jurisdictional flows and triggers with other federal departments and agencies, in particular PHAC, PS, and CBSA.

Recommendation 3: CFIA should clarify and strengthen MOUs regarding existing inter-departmental links, while creating new formal agreements where necessary.

Communication and Information Sharing

Recommendation 4: At the national level, CFIA should re-confirm official information sharing protocols with federal partners.

Logistics

Recommendation 5: CFIA should increase staff training efforts to help ensure adequate succession planning for future outbreaks.

Recommendation 6: CFIA should review its Emergency Operations Centre logistics procedures and ensure that proper supply chain management pathways are followed and communicated at the regional level. At the regional level, CFIA should establish a comprehensive list of necessary telecommunications hardware for future outbreaks, as well as a plan for acquiring the equipment in the immediate future.

Recommendation 7: CFIA should propose plans for increasing internal surge capacity to handle future emergencies at both the national and regional levels, and continue to improve emergency business continuity planning.

Recommendation 8: CFIA should dedicate resources to monitor globally AI strains modifications and ensure on-going improvements to screening tests to minimise delays in notifications of future emergencies.

Recommendation 9: Additional funding should be made available for augmenting IM/IT systems, such as CEMRS and LSTS, to increase functionality and response time.

6.0 Conclusion

CFIA’s response and overall management of the outbreak were viewed as outstanding successes, with the general response being overwhelmingly positive for both CFIA and its working partners. It was recognized that considerable effort was made by all parties to respond to the outbreak and as a result, the spread of the disease was contained at its initial outbreak location.

The information gathered during this lessons-learned review was to see how the Agency can continuously improve its response and overall management of outbreaks, by learning from their successes and opportunities for improvement. This report is an example of the efforts of the Agency to strive for excellence.

As a result of continuously improving through learning, the Saskatchewan outbreak represents a significant improvement in performance for the CFIA over the 2004 outbreak in British Columbia. The recommendations issued in this report represent almost a fifty percent decrease from the recommendations tabled in the BC outbreak report.

Also, 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 of the outbreak was accepted by both the EU and the USA, allowing poultry trade to continue from unaffected areas.

Annex 1: Chronology¹⁴

September 22 - Saturday

• Poultry Extension Agrologist takes routine samples for vaccination titres.
  • Contacted the owner to report sick roosters in Barn #11
  • Owner arranged for Poultry Extension Veterinarian visit.

September 23 - Sunday

• Poultry Extension Veterinarian calls CFIA, reports illness suspicious of AI in Barn #11, and roosters in Barns 12 and 13.
• CFIA District Veterinarian visits farm and takes samples
  • Mortality also reported in Barns #12 and #13
  • Samples driven to Prairie Diagnostics and NCFAD
• Farm quarantined
  • Farm owner notified of employees’ need for respiratory and eye protection
  • One commercial poultry farm identified in a 10 km radius
• Communication as per Animal Health Functional Plan
  • Including CFIA Management in Calgary, Winnipeg and Ottawa, laboratories in Saskatoon (Prairie Diagnostic) and Winnipeg (NCFAD)
• Saskatchewan Poultry Industry Emergency Management Team (SPIEMT) notified
• Logistics team notified and mobilized

September 24 - Monday

• OGD and provincial counterparts notified of suspected outbreak
  • Some delay due to key personnel out of province
• Key internal actors notified
  • Return to Saskatchewan soon as possible
• Laboratory test results
  • Positive for Type A influenza
  • Negative on RT-PCR for H5, H7, and Newcastle disease
• Destruction and Disposal planning initiated for worst case scenario
• REOC ready

September 25 - Tuesday

• On-site disposal preparation initiated
• Conference call initiated by CFIA with
  • Four federal agencies
  • Two industry representatives
  • Saskatchewan Agriculture
• Sampling in barns continues
• Molecular typing indicates H7 subtype
• REOC activated

September 26 - Wednesday

• CFIA VP Operations notified of Notifiable Avian Influenza (NAI) confirmed
• Industry called to confirm H7N3
  • Unofficially highly pathogenic avian influenza, field unofficial
  • Mortality rate: 90 of 150 birds left in Barn #11 died in 2 days (60%, total mortality 84.6%)
• Identification of premises within the 3 km zone begins
• AEOC activated
  • Key personnel moved to Regina
• PHAC notified of NAI outbreak

September 27 - Thursday

• Situation declared emergency by CFIA President
  • Media release and conference
  • Conference call with PHAC
  • International notification OIE, EU, Mexico
• Issues arise with Canadian Border Services Agency (CBSA)
• Destruction Disposal and Biocontainment teams on site for planning
  • Mortality rate: 40 of 60 remaining birds in Barn #11 died overnight
• NEOC activated

September 28 - Friday

• Saskatchewan Health added to REOC
• Declaration of control area perimeter
  • Restriction of bird movement within the affected zones
• Destruction started on index farm
  • Destruction complete for Barns #12, #13, #14, #15
  • Consulting with OGDs on environmental and transport issues
• CFIA completed identification of non-commercial premises within the infected zone
  • Started identification of non-commercial premises within restricted zone
• Vaccines and antivirals administered to CFIA staff and farm workers

September 29 - Saturday

• Started to sample non-commercial premises in the infected zone
• Depopulation of Barns #7 and #10 complete
• On-site burial approved
• OSH representative arrived at EOC

September 30 - Sunday

• Depopulation of farm complete
• Burial started
• Completed surveillance testing of non-commercial premises in the infected zone
• EOD institutes regular calls with emergency response teams

October 3 - Wednesday

• News release
• Saskatchewan surveillance plan

October 5 - Friday

• All carcasses and litter disposed of by deep burial

October 6 - Saturday

• All equipment cleaned and disinfected off the premises
• Cleaning and disinfection of barns by the owner started

October 30 - Tuesday

• Movement restrictions lifted

Annex 2: Recommendations of British Columbia Outbreak Report - 2006

Recommendations of the Avian Influenza Lessons Learned and Action Plans—2006 Progress Monitoring Exercise of Internal Audit Recommendations 2002–Present

1. The CFIA should review protocols associated with the activation of local, area and national emergency response teams and formalize the roles and responsibilities, and decision-making accountabilities at each level.

2. The CFIA should develop collaborative arrangements with Health Canada and the new Public Health Agency of Canada (PHAC) to increase federal capacity to respond to zoonotic disease outbreaks.

3. The CFIA should engage stakeholders in the ongoing development and exercising of FADES plans in all provinces/territories.

4. The CFIA should develop the relevant IM/IT capabilities to ensure more timely and efficient management and transmission of field and laboratory data (including geographic information) during an animal disease response.

5. The CFIA should improve information flow during an emergency response by:

• Identifying a functional cell within the Agency's emergency response structure to anticipate and manage information needs and reporting;
• Developing and implementing protocols for the appropriate release of key information (for example, laboratory results) at both the national and field level; and
• Addressing information sharing issues through pre-established agreements or protocols.

6. The CFIA should review its emergency management approach to incorporate the lessons learned from Al and, where appropriate, best practices used by partner agencies (for example, Incident Command System).

7. The CFIA should formalize the advance planning function within its emergency management structure and ensure the integration of disease control experts (including public health experts) within this planning cell.

8. The CFIA should clarify the respective bio-safety responsibilities of the Agency and public health partners in the response to zoonotic disease outbreaks.

9. The CFIA should encourage the poultry industry's development of bio-security programs.

10. The CFIA should conduct a review of compensation policies under the Health of Animals Act.

11. The CFIA should maintain a periodic review process for the schedule of values included in the Compensation for Destroyed Animals Regulations.

12. The CFIA should review the procedures for providing HR, finance, IM/IT and administrative support to EOCs and develop standard operating procedures to support each of these functions.

13. Convene the first animal health/public health forum. (CFIA/Public Health Agency of Canada)

14. Implement a national Al survey for domestic poultry. Co-ordinate surveillance of wild fowl with the Canadian Wildlife Service. (CFIA/Canadian Wildlife Service).

15. Examine the feasibility of establishing a pre-emptive cull program for suspect cases of Al to limit the potential spread of the disease. (CFIA/Poultry Industry)

16. Develop a national disposal strategy for all livestock species. (CFIA/Livestock Industries).

Annex 3: Glossary

• AEOC
  • Area Emergency Operations Centre
• CEMRS
  • Canadian Emergency Management Response System
• CFIA
  • Canadian Food Inspection Agency
• DLS
  • Dominion Land Survey
• EOC
  • Emergency Operations Centre
• FADES
  • Foreign Animal Diseases Emergency Support
• GPS
  • Global Positioning System
• ICS
  • Incident Command System
• NCFAD
  • National Centre Foreign Animal Diseases
• NEOC
  • National Emergency Operations Centre
• OSH
  • Occupational Safety and Health
• PHAC
  • Public Health Agency of Canada
• PPE
  • Personal Protective Equipment
• PS
  • Public Safety Canada
• PWGSC
  • Public Works and Government Services Canada
• REOC
  • Regional Emergency Operations Centre
• SPIEMT
  • Saskatchewan Poultry Industry Emergency Management Team

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¹ The conditions under which avian influenza viruses are subject to OIE notification are set out in Chapter 2.7.12 of the OIE Terrestrial Animal Health Code.

² Chronology of the 2007 Saskatchewan Outbreak is included in this report. Please see Annex 1.

³ The complete report, including a summary of recommendations issued, is included as Annex 2.

⁴ After the British Columbia outbreak, responsibility for the Incident Command System was moved to the Office of Emergency Management reporting to the Vice-President, Operations.

⁵ Annex 2. Avian Influenza Lessons Learned and Action Plans—2006 Progress Monitoring Exercise of Internal Audit Recommendations 2002-Present. Recommendation #1.

⁶ Ibid., Recommendation #2

⁷ Ibid., Recommendation #5

⁸ Ibid., Recommendation #8

⁹ Ibid., Recommendation #4

¹⁰Ibid., Recommendation #5

¹¹ Ibid., Recommendation #4

¹² Ibid., Recommendation #8

¹³ Ibid., Recommendation #12

¹⁴ The events are presented on the days they occurred, but not necessarily in sequence.