Preparing for the worst

Preparing for the worst
The lessons from the 2003 SARS outbreak are being put to the test in anticipation of a flu pandemic Canada earns top marks for being well ahead of the world in pandemic preparation
Jul. 8, 2006. 01:00 AM
RITA DALY
STAFF REPORTER


The threat of a flu pandemic — dubbed nature's terrorist attack — has led G-8 leaders to put it at the top of their agenda when they gather in St. Petersburg next week. It's the latest in a world that has become increasingly focused on the need for all nations and all cities to get ready for a global outbreak of infectious disease.

So three years after SARS hit Canada's largest city, is Toronto ready to tackle the big one?

According to the experts, we're leading the international pack, but it's still a long way to the finish line.

"I would say the hospitals and public health in Toronto, and the province of Ontario, have got fairly well-advanced pandemic plans," says Dr. Ron Upshur of the University of Toronto's Joint Centre for Bioethics, who recently returned from discussions on flu pandemic preparedness at the World Health Organization in Geneva.

His assessment is that most countries are much further behind. Even the United States' national pandemic plan is still a work in progress and some states, including Florida and North Carolina, have turned to Canada for guidance, he says.

The WHO has long recognized Canada as a leader in pandemic preparedness and one of the few countries in the world to have a domestic contract to produce a pandemic flu vaccine. As a member of the Group of Eight wealthy nations, Canada has lent expertise to poorer nations to help control spread of the H5N1 bird flu and is willing to sign on to further commitments to global pandemic planning at next week's summit.

Still, the front lines of health care back home tell a mix of stories on just how prepared our own system is.

At Markham-Stouffville Hospital just north of the city, Niala Kalliecharan is still recovering from Toronto's last public health disaster.

A former SARS nurse, she was recently asked to don a mask, gown and gloves for a patient admitted with respiratory symptoms during her shift on the surgical unit. It was the first time she was assigned to wear the protective gear since treating SARS patients in 2003.

"I just seized up. I couldn't do it," said the 32-year-old part-time health worker, who fell sick herself with severe acute respiratory syndrome in what became one of Toronto's worst public health crises. The illness killed 44 people and sickened hundreds more, many of them health workers.

"I didn't think it would still be so fresh in my mind, but when I was faced with putting these things on I just clammed up inside," she said. "The emotions that came up felt like SARS was yesterday."

Kalliecharan now fears a flu pandemic would paralyze her in similar fashion. She sadly acknowledges she may not be ready.


Dr. Michael Gardam, director of infection control at the University Health Network in Toronto, worries about the legal and ethical issues around who will get treated in a pandemic, when hospitals are already operating a near capacity.

"Right now everybody has access to an intensive care unit bed and that's not working all that well," he says. "So in an emergency, who do you stop giving access to? Is it people with underlying medical conditions? Do health-care workers get first access? Do politicians? These kinds of issues aren't really being discussed yet."

The H5N1 avian flu, the worst bird flu virus in history, poses the greatest threat of a human pandemic, although so far it has not been able to infect humans easily.

The federal government first released its national pandemic plan in 2004, and the Ontario government followed with a plan for the province. Toronto public health released its plan for the city late last year, and this month all city departments and agencies are supposed to have plans in place.

The plans are just that, however — plans. Despite efforts to address everything from mass vaccination to bulk disposal of bodies, officials expect major disruptions and many deaths.

Toronto public health officials estimate in a severe pandemic more than 900,000 people, a third of the city, could become infected in Toronto over the course of six to eight months; 14,000 will be hospitalized, equal to as many as 800 admissions a day. More than 4,000 are expected to die.


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`We're always working to be more ready, but is it ever going to be 100 per cent?

I don't think so'

Dr. Barbara Yaffe, Toronto public health

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A major drawback is there will be no flu vaccine to fight the new strain for at least three to six months, so anti-viral medication and supplies — including masks, gloves and gowns for nurses like Kalliecharan — are being stockpiled.

"It's hard to ask people how ready they are," says Dr. Barbara Yaffe, director of communicable disease control for Toronto public health. "We're always working to be more ready, but is it ever going to be 100 per cent? I don't think so."

It sounds surprising today, but prior to SARS there were no emergency stockpiles for infectious diseases. Ontario municipalities weren't required to have emergency plans until the end of 2004, and there was no overall strategy to deal with a major disease outbreak.

Kalliecharan recalls how in the early days of SARS, public health authorities fed conflicting information on protective measures hospital staff ought to take. First they were handed gowns to wear, then gloves, and then masks. Then plastic barriers were brought in.

"Eventually you saw the spacesuits. But by then I was a patient," she says.

Things are different now. All local public health units, hospitals and health facilities are required to stock the equivalent of four weeks' emergency infection control supplies — enough to cover half of the first wave of a pandemic. The province has agreed to buy enough supplies to get them through the remaining four weeks of the first wave.

The antiviral flu drug Tamiflu is also being stockpiled: Ottawa has purchased 40 million doses so far, enough to treat 4 million people; the province has more than 12 million doses, enough to treat 10 per cent of its population. The goal is to have enough for 25 per cent of the population.

Stockpiling, however, is only one part of the pandemic plan and there is no guarantee Tamiflu, the first line of defence in a pandemic, will be effective against the new strain.

Local health units will be responsible for distributing the drug, but another problem is where to set up temporary sites to treat flu patients and who should administer it.

"If you're going to have physicians and nurses working at these assessment centres, how are they going to get paid? What if they get sick? And liability and compensation need to be worked out. Those are the kinds of issues that have been brought to the ministry," says Yaffe.

About two months ago, Toronto's public health department mailed out letters to every licensed physician in the city, about 8,000 in total, asking for updated contact information in the event of an emergency. At the same time it asked doctors if they'd be willing to help out at pandemic treatment centres.

"Last time I checked we had a 20 per cent response rate. Not bad, I suppose, for doctors," Yaffe laughs, then soberly adds: "This will be an issue. There will be a shortage of staff."

Toronto has, however, made progress in its mass vaccination plan. The public health department recently obtained permission from the city's two school boards to use approximately 30 schools as vaccination clinics in a pandemic, said Yaffe.

Pills and needles aside, ultimately the two main goals in pandemic planning are: finding ways to protect health workers from getting sick and deciding who among the thousands of sick and dying patients get treated.

The Ontario government recently angered doctors and nurses when it introduced Bill 56, sweeping new emergency powers that could force health workers into service in a pandemic. While most have a natural inclination to work, they fear being conscripted to work in unsafe situations or face fines and jail terms. The government says no one will be forced to work.

Marilyn Reddick, vice-president of human resources for Sunnybrook Health Sciences Centre, said it's expected some staff will remain home if they're sick or caring for family members. The right to refuse to work, however, is another issue and "we'd have to go through a negotiating process," she says.

The hospital is currently deciding who among its 8,500 employees will be reassigned to other jobs in a pandemic. It is also asking retired employees, students and its 1,200 volunteers to help carry the load.

"This will be a living hell like SARS. But we have an attitude that we're professionals and we'll deal with it," she says.