Pandemic Influenza Planning An Evolution to the Approach for National Communicable Disease Emergencies Dr. Theresa Tam Manager, Respiratory Infections

Pandemic Influenza Planning Pandemic Influenza Planning An Evolution to An Evolution to the Approach for National the Approach for National

Communicable Disease EmergenciesCommunicable Disease Emergencies

Dr. Theresa TamManager, Respiratory Infections Section

Immunization and Respiratory Infections Division

Health SantéCanada Canada Teleclass, Association of Local Public Health Agencies, October 21, 2003

Health SantéCanada Canada

OutlineOutline

Background on influenza virus and pandemicsBackground on influenza virus and pandemics Evolution of the Canadian Pandemic Influenza Evolution of the Canadian Pandemic Influenza

PlanPlan How the Canadian plan and processes were How the Canadian plan and processes were

used during the H5N1 and SARS responseused during the H5N1 and SARS response How the Plan will be modified:How the Plan will be modified:

successes, challenges and lessons learnt from SARS successes, challenges and lessons learnt from SARS model for communicable disease emergency model for communicable disease emergency

response plans response plans

Influenza VirusInfluenza Virus

The Pandemic AgentThe Pandemic Agent


Influenza Virus: Influenza Virus: orthomyxoviridaeorthomyxoviridae

RNA virus, 8 segments RNA virus, 8 segments mutate or recombine mutate or recombine resulting in new viral resulting in new viral strains strains

Lipid membrane contains Lipid membrane contains two spike glycoproteins: two spike glycoproteins: • haemagglutinin haemagglutinin • neuraminidaseneuraminidase


ABC of Influenza VirusABC of Influenza Virus

Influenza A (Influenza A (avian, avian, humans, swine, humans, swine, equine, marine equine, marine mammals) mammals) 15 hemagglutinin 15 hemagglutinin

subtypes subtypes current human current human

strains strains H1N1 (H1N2)H1N1 (H1N2) H3N2 H3N2

Influenza B Influenza B (humans)(humans) Influenza C Influenza C (humans, (humans,

swine)swine)

The natural hosts of influenza AThe natural hosts of influenza A


Antigenic Shift and DriftAntigenic Shift and Drift

Antigenic drift:Antigenic drift: a gradual change in the a gradual change in the hemagglutinin and/or the neuraminidase hemagglutinin and/or the neuraminidase proteins when the virus goes through a proteins when the virus goes through a series of minor mutations and evolves over series of minor mutations and evolves over time (Influenza A & B)time (Influenza A & B)

Antigenic shiftAntigenic shift:: an abrupt and major an abrupt and major change in the hemagglutinin and/or the change in the hemagglutinin and/or the neuraminidase proteins resulting in the neuraminidase proteins resulting in the sudden appearance of a new influenza virus sudden appearance of a new influenza virus subtype subtype (Influenza A)(Influenza A)


Influenza Pandemics:Influenza Pandemics:How Do They Occur?How Do They Occur?

Type A Type B

Annual Annual FluFlu

ANTIGENIC SHIFTANTIGENIC SHIFT

Novel virusNovel virusNo resistanceNo resistance

Human to human transmissionHuman to human transmissionIllnesses and deathsIllnesses and deaths

PANDEMIC


Pandemic InfluenzaPandemic Influenza

What is it?What is it?

Why plan for it?Why plan for it?

What can be What can be done to prepare done to prepare for it?for it?


Pandemic Influenza Pandemic Influenza HistoryHistory

Spanish Flu 1918Spanish Flu 1918 Asian Flu 1957Asian Flu 1957 Hong Kong Flu 1968Hong Kong Flu 1968

Pandemic scares:Pandemic scares: Swine Flu 1976Swine Flu 1976 Hong Kong Avian Flu Hong Kong Avian Flu

1997 and 20031997 and 2003


Each Pandemic is DifferentEach Pandemic is Different

YearYear Interval(yrs) Subtype SeverityInterval(yrs) Subtype Severity

18891889 -- -- H3N2 H3N2 moderatemoderate

19181918 29 29 H1N1 severe H1N1 severe

19571957 39 39 H2N2 severe H2N2 severe

19681968 11 11 H3N2 H3N2 moderatemoderate

19771977 9 9 H1N1 mild H1N1 mild


Pandemic InfluenzaPandemic InfluenzaWhat We Know and the What We Know and the UncertaintiesUncertainties Another influenza pandemic is Another influenza pandemic is

INEVITABLEINEVITABLE

Timing and epidemiology Timing and epidemiology UNPREDICTABLEUNPREDICTABLE

SHORT LEAD TIMESHORT LEAD TIME presence in Canadapresence in Canada < 3 months (much < 3 months (much

shorter?)shorter?) 1st peak in illness within 5-7 months 1st peak in illness within 5-7 months

Outbreaks will occur Outbreaks will occur SIMULTANEOUSLY SIMULTANEOUSLY in multiple locations, in multiple wavesin multiple locations, in multiple waves


Influenza Pandemics: Influenza Pandemics: Then and NowThen and Now Increase in world population and changing Increase in world population and changing

demographics (e.g. immunocompromised demographics (e.g. immunocompromised hosts)hosts)

Jets may spread the disease very rapidly in Jets may spread the disease very rapidly in hours or dayshours or days

In developed countriesIn developed countries Improved medical care, antibiotics for Improved medical care, antibiotics for

secondary infectionssecondary infections Vaccines and antivirals for prophylaxisVaccines and antivirals for prophylaxis Antiviral drugs for treatmentAntiviral drugs for treatment


Pandemic InfluenzaPandemic InfluenzaEstimating the ImpactEstimating the Impact

In Canada, if vaccine is In Canada, if vaccine is unavailable, unavailable, EXPECTEXPECT:: 11,000 to 58,000 deaths11,000 to 58,000 deaths 34,000 to 138,000 34,000 to 138,000

hospitalizationshospitalizations 2 to 5 million outpatients2 to 5 million outpatients economic costseconomic costs

health care: $330M to health care: $330M to $1.4B$1.4B

societal: $5B to $38Bsocietal: $5B to $38B

SocietalDisruption

Health Resource Scarcity


Recent Experience with Recent Experience with Avian InfluenzaAvian Influenza 1997 H5N1 in Hong Kong1997 H5N1 in Hong Kong

18 cases and 6 deaths18 cases and 6 deaths Mass culling of poultry Mass culling of poultry International demand for antiviral drugsInternational demand for antiviral drugs

20032003 H5N1 in China/Hong KongH5N1 in China/Hong Kong

Two persons with confirmed infection; two Two persons with confirmed infection; two fatalitiesfatalities

H7N7 in the NetherlandsH7N7 in the Netherlands One death and > 80 cases of mild disease in One death and > 80 cases of mild disease in

humans associated with affected poultry farmshumans associated with affected poultry farms Human to human spreadHuman to human spread


Planning & preparing

to better manage tomorrow’s pandemic consequences ... today

Pandemic InfluenzaPandemic Influenza

Preparedness Activities:Preparedness Activities:InternationalInternational


Global Agenda for Influenza Global Agenda for Influenza Surveillance and Control Surveillance and Control (WHO)(WHO)

Major ThemesMajor Themes

1. Improvement in the quality and 1. Improvement in the quality and coverage of virological and coverage of virological and epidemiological influenza epidemiological influenza surveillance surveillance

2. Improvement in the understanding of 2. Improvement in the understanding of health and economic burdenhealth and economic burden of of influenza, including benefits from influenza, including benefits from epidemic control and pandemic epidemic control and pandemic preparednesspreparedness


Global Agenda for Influenza Global Agenda for Influenza Surveillance and Control Surveillance and Control (WHO)(WHO)

Major ThemesMajor Themes

3. 3. Expansion in the use of existing Expansion in the use of existing vaccinesvaccines, particularly in developing , particularly in developing countries and in high-risk groups and countries and in high-risk groups and acceleration in the introduction of new acceleration in the introduction of new vaccinesvaccines

4. Increase in national and global 4. Increase in national and global epidemic epidemic and pandemic preparednessand pandemic preparedness, including , including vaccine and pharmaceutical supplies vaccine and pharmaceutical supplies


Global Influenza Global Influenza Surveillance NetworkSurveillance Network

Virological Virological surveillancesurveillance110 national influenza 110 national influenza

laboratorieslaboratories

1 lab/country1 lab/country>1 lab/country>1 lab/country

4 regional reference 4 regional reference centrescentres

WHO Global Agenda, WHO Global Agenda, May 2002May 2002

To expand the existing laboratory surveillance To expand the existing laboratory surveillance network and increase disease surveillance for network and increase disease surveillance for influenza control and pandemic preparedness.influenza control and pandemic preparedness.


RationaleRationale for for Strengthening Strengthening International International Influenza Influenza SurveillanceSurveillance

Areas where Areas where birds, pigs and birds, pigs and humans live in humans live in close close proximity are proximity are high risk high risk environments environments for antigenic for antigenic drift and shift.drift and shift.

Surveillance of human, wild and domestic animal Surveillance of human, wild and domestic animal populations in high risk areas is key to:populations in high risk areas is key to: vaccine developmentvaccine development development of an early warning system for development of an early warning system for

viruses with pandemic potential viruses with pandemic potential


WHO Pandemic PhasesWHO Pandemic Phases Phase 0, Level 0 - Inter-Pandemic periodPhase 0, Level 0 - Inter-Pandemic period Phase 0, Level 1 - Novel virus identification in a humanPhase 0, Level 1 - Novel virus identification in a human Phase 0, Level 2 - Human infection confirmedPhase 0, Level 2 - Human infection confirmed Phase 0, Level 3 - Human-to-Human transmission Phase 0, Level 3 - Human-to-Human transmission

confirmed confirmed Phase 1 - Pandemic confirmedPhase 1 - Pandemic confirmed Phase 2 - Outbreaks in multiple geographic areas Phase 2 - Outbreaks in multiple geographic areas Phase 3 - End of first wavePhase 3 - End of first wave Phase 4 - Second or later wavesPhase 4 - Second or later waves Phase 5 - Post-Pandemic / Recovery Phase 5 - Post-Pandemic / Recovery


International Pandemic International Pandemic PreparednessPreparedness

Development of pandemic plansDevelopment of pandemic plans Approximately 30 countries worldwide have a Approximately 30 countries worldwide have a

planplan Use of the WHO Pandemic Phases improves Use of the WHO Pandemic Phases improves

communication and consistencycommunication and consistency Requires national coordination and agreement on Requires national coordination and agreement on

goals of pandemic preparedness and responsegoals of pandemic preparedness and response

National surveillance for influenza-like illness National surveillance for influenza-like illness and influenza virusesand influenza viruses

Vaccine strategiesVaccine strategies Development of Stockpiles / Antiviral Development of Stockpiles / Antiviral

strategystrategy

Preparedness ActivitiesPreparedness Activities

CanadaCanada


Overall Goal of Pandemic Overall Goal of Pandemic Preparedness and Preparedness and ResponseResponse

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


Pandemic Planning Milestones Pandemic Planning Milestones 1998-20021998-2002 Post H5N1 outbreak in Hong Kong Post H5N1 outbreak in Hong Kong

First national meeting (Jan. 2000)First national meeting (Jan. 2000) Federal/Provincial/Territorial Working Federal/Provincial/Territorial Working

Agreement (Mar. 2001)Agreement (Mar. 2001) Pandemic vaccine contract (Sep. 2001)Pandemic vaccine contract (Sep. 2001) Pandemic Influenza Committee (PIC) (Mar. Pandemic Influenza Committee (PIC) (Mar.

2002)2002) Extensive stakeholder consultations on the Extensive stakeholder consultations on the

Canadian Pandemic Influenza PlanCanadian Pandemic Influenza Plan (Summer 2002)(Summer 2002)


Pandemic Planning in Pandemic Planning in Evolution - 2003Evolution - 2003 ““Exercised” pandemic plan structures & Exercised” pandemic plan structures &

processesprocesses H5N1 in Hong Kong and H7N7 in NetherlandsH5N1 in Hong Kong and H7N7 in Netherlands SARS outbreakSARS outbreak other emergency exercisesother emergency exercises

TOPOFF2TOPOFF2 Global Mercury – international communicationsGlobal Mercury – international communications

Incorporating SARS lessons learntIncorporating SARS lessons learnt


IV. RESPONSE SECTION Introduction (to Response Section) Phased Approach Experience to Date Key Response Activities by Pandemic Phase

Overview of the PlanOverview of the Plan Executive Summary Overview List of Annexes

I. INTRODUCTION Goal of Influenza Pandemic Preparedness and Response Overview of the Plan Roles and Responsibilities The Pandemic Influenza Committee The Pre-Pandemic Period The Pandemic Period The Post-Pandemic Period

II. BACKGROUND Epidemiology of Pandemic Influenza Estimated Impact of an Influenza Pandemic on Canadians Terminology

Pandemic Phases List of Abbreviations

Legal Issues Ethical Issues III. PREPAREDNESS SECTION

Introduction (to Preparedness Section) Components of the Preparedness Section

Surveillance and Lab Testing Vaccine Programs Antivirals Health Services Emergency Planning Emergency Services Public Health Measures Communications

Planning Activities by Components Pandemic Planning Checklists

V. RECOVERY SECTION In development

VI. ANNEXES

WHO PhasesWHO Phases


Resource ManagementResource Management Non-Traditional Sites and Workers Non-Traditional Sites and Workers Mass fatalitiesMass fatalities Clinical CareClinical Care Infection ControlInfection Control

NationalNational Working GroupsWorking Groups Pandemic Influenza Pandemic Influenza SARSSARS

Surveillance and epidemiologySurveillance and epidemiology LaboratoryLaboratory testingtesting VaccinesVaccines Antivirals Antivirals (Special Access Program) (Special Access Program) Public Health MeasuresPublic Health Measures CommunicationCommunication Health ServicesHealth Services


SARS: Recognition and SARS: Recognition and ResponseResponse 14 Feb: Official confirmation of outbreak of atypical 14 Feb: Official confirmation of outbreak of atypical

pneumonia with 305 cases and 5 deaths, Guangdongpneumonia with 305 cases and 5 deaths, Guangdong

19 Feb: Hong Kong SAR, 2 cases of influenza A/H5N119 Feb: Hong Kong SAR, 2 cases of influenza A/H5N1

Canada’s Pandemic Influenza Committee activated Canada’s Pandemic Influenza Committee activated FluWatchFluWatch surveillance system on alert surveillance system on alert Pandemic surveillance protocol developed Pandemic surveillance protocol developed Communications strategy and fact sheetsCommunications strategy and fact sheets

12 March: 1st WHO global alert for atypical pneumonia12 March: 1st WHO global alert for atypical pneumonia

13 March: Health Canada advised of cases of atypical 13 March: Health Canada advised of cases of atypical pneumonia in Ontario and British Columbiapneumonia in Ontario and British Columbia

Issues, What Issues?Issues, What Issues?



SuccessesSuccesses Pandemic influenza structures and processes were Pandemic influenza structures and processes were

successfully translated to respond to SARS successfully translated to respond to SARS Early phases of the national pandemic influenza Early phases of the national pandemic influenza

response tested and applied to another emerging response tested and applied to another emerging infectious diseaseinfectious disease

Disease control measures, despite uncertainties, Disease control measures, despite uncertainties, appear to have been largely effective appear to have been largely effective

Rapid knowledge generation and translation through Rapid knowledge generation and translation through existing networks for influenza and new partnerships existing networks for influenza and new partnerships

international and national international and national laboratory, epidemiology laboratory, epidemiology and clinical care experts worked together and clinical care experts worked together

National health crisis communications network worked National health crisis communications network worked wellwell


Key ChallengesKey Challenges Insufficient public health infrastructure, Insufficient public health infrastructure,

policies, procedures and legislation to support policies, procedures and legislation to support public health action at all levelspublic health action at all levels

Lack of infrastructure and processes for real Lack of infrastructure and processes for real time data sharing time data sharing

Time lag in epidemiologic data generation and Time lag in epidemiologic data generation and application of evidence to public health actionapplication of evidence to public health action

Making decisions on public health measures Making decisions on public health measures with insufficient evidencewith insufficient evidence e.g. travel-related interventionse.g. travel-related interventions


Key ChallengesKey Challenges Laboratory testingLaboratory testing

over-testing and inability to prioritise specimensover-testing and inability to prioritise specimens research versus public health needsresearch versus public health needs

Use of surveillance case definitions for Use of surveillance case definitions for clinical purposesclinical purposes

Retrospective epidemiologic linkage of casesRetrospective epidemiologic linkage of cases Communicating the progress and impact of Communicating the progress and impact of

the epidemic to decision makers and the the epidemic to decision makers and the publicpublic National and international inconsistency in case National and international inconsistency in case

definitionsdefinitions


Lessons Learned: Lessons Learned: Coordination and Coordination and OperationsOperations Clear command structure requiredClear command structure required

Provinces without well developed pandemic Provinces without well developed pandemic plans had to create structures immediately plans had to create structures immediately to deal with health emergencyto deal with health emergency

Dedicated team leadership is essentialDedicated team leadership is essential Need to strengthen human resource Need to strengthen human resource

planning and surge capacity in planning and surge capacity in emergency plansemergency plans

Psycho-social support: post traumatic Psycho-social support: post traumatic stressstress


Lessons Learned: Advance Lessons Learned: Advance PlanningPlanning

Incident management structure used at Incident management structure used at Health CanadaHealth Canada Coordination and Operations Coordination and Operations Technical (surveillance, epidemiology, Technical (surveillance, epidemiology,

public health guidelines etc.)public health guidelines etc.) LogisticsLogistics Crisis communicationsCrisis communications

Advance Planning GroupAdvance Planning Group needed needed


Lessons Learned: Disease Lessons Learned: Disease ControlControl Quarantine and isolation measures were Quarantine and isolation measures were

generally acceptable to the public generally acceptable to the public

Cancellation of public gatherings will Cancellation of public gatherings will happen regardless of public health happen regardless of public health recommendationsrecommendations

Multiple partners need to be involved in Multiple partners need to be involved in the implementation of public health the implementation of public health measures measures Education and information dissemination Education and information dissemination

media, NGOs, professional societies, businesses, media, NGOs, professional societies, businesses, schools…schools…

Blood and border issues will arise quicklyBlood and border issues will arise quickly


Lessons Learned: Lessons Learned: SurveillanceSurveillance Lack of integrated mechanisms and processes for Lack of integrated mechanisms and processes for

surveillancesurveillance Strengthen interface between hospital and public healthStrengthen interface between hospital and public health Epidemiological, clinical and laboratory data linkage Epidemiological, clinical and laboratory data linkage

Establish case definitions with rationaleEstablish case definitions with rationale Consistent use of definitions nationally AND strive for Consistent use of definitions nationally AND strive for

international consistency international consistency

Pre-establish minimum dataset and data sharing Pre-establish minimum dataset and data sharing agreements for emerging infectious diseasesagreements for emerging infectious diseases

Establish mechanism and processes for alerting Establish mechanism and processes for alerting public health and health care providers in real public health and health care providers in real time time


Lessons Learned: Outbreak Lessons Learned: Outbreak InvestigationInvestigation Enhance epidemiological capacity at all levelsEnhance epidemiological capacity at all levels

multi-disciplinary outbreak investigation teamsmulti-disciplinary outbreak investigation teams

Improve ability to mobilize resources across Improve ability to mobilize resources across jurisdictionsjurisdictions Clarify or establish roles and responsibilities and Clarify or establish roles and responsibilities and

collaboration mechanisms for a multi-jurisdictional collaboration mechanisms for a multi-jurisdictional responseresponse

Increase training programs, including short Increase training programs, including short courses that can be rapidly implementedcourses that can be rapidly implemented


Lessons Learned: Lessons Learned: CommunicationCommunication

Pre-established national networks Pre-established national networks worked; need to strengthen international worked; need to strengthen international networksnetworks

Establish communication processes that Establish communication processes that permit optimal use of all participants permit optimal use of all participants timetime

Human resources needed to translate Human resources needed to translate science (particularly epidemiology) into science (particularly epidemiology) into public informationpublic information

Potential for case counts to become Potential for case counts to become politicizedpoliticized

Perception IS realityPerception IS reality


Lessons Learned: Infection Lessons Learned: Infection Control in Acute Care Control in Acute Care SettingsSettings

Lack of trained infection control personnel Lack of trained infection control personnel Varying capacity for surveillance and need to Varying capacity for surveillance and need to

coordinate with public healthcoordinate with public health Negative impact of intensive SARS infection Negative impact of intensive SARS infection

control measures control measures Health care worker well-beingHealth care worker well-being Increase in other nosocomial infections e.g. MRSA, VREIncrease in other nosocomial infections e.g. MRSA, VRE Missed or not reported tuberculosis casesMissed or not reported tuberculosis cases

Ongoing training needed e.g. how to put on / Ongoing training needed e.g. how to put on / remove personal protective equipmentremove personal protective equipment


Lessons Learned: Health Lessons Learned: Health ServicesServices

Pandemic influenza guidelines useful Pandemic influenza guidelines useful

Resource managementResource management Managing hospital triaging and transfersManaging hospital triaging and transfers Dedicated SARS unitsDedicated SARS units Lack of suppliesLack of supplies Staff exhaustionStaff exhaustion Security requirementsSecurity requirements

Non-traditional sites / workers Non-traditional sites / workers Sites administered through acute care settingSites administered through acute care setting City buses as screening units outside hospitalsCity buses as screening units outside hospitals Lack of volunteers, no medical/nursing students Lack of volunteers, no medical/nursing students


Response to SARS vs Response to SARS vs Influenza PandemicsInfluenza Pandemics

SARSSARS Goal = ContainmentGoal = Containment

Flu Pandemic Flu Pandemic Goal = Reducing Morbidity and Goal = Reducing Morbidity and

MortalityMortality Major challenge to national capacityMajor challenge to national capacity


Looking into the Future Looking into the Future Canadian Pandemic Influenza Plan 2003Canadian Pandemic Influenza Plan 2003 ““Exercising” of the PlanExercising” of the Plan Generic approach to communicable disease Generic approach to communicable disease

emergency plansemergency plans Phase approach for advance planningPhase approach for advance planning

Antiviral stockpile Antiviral stockpile Strengthening pandemic preparedness in Strengthening pandemic preparedness in

special populations: First Nations and Inuit, special populations: First Nations and Inuit, isolated communitiesisolated communities

Preparedness Preparedness Activities:Activities:

Regional and Local Regional and Local LevelsLevels


Within Canada…Within Canada… Most Provinces and Territories Most Provinces and Territories

have developed plans for have developed plans for pandemic influenzapandemic influenza

Some provinces and territories are Some provinces and territories are at the stage where they are testing at the stage where they are testing their planstheir plans

Local level planning is occurringLocal level planning is occurring Post-SARS high level of recognition Post-SARS high level of recognition

for need for plans to mitigate the for need for plans to mitigate the impact of pandemic influenzaimpact of pandemic influenza


Strategies for Local Strategies for Local PlanningPlanning

Get all stakeholders involvedGet all stakeholders involved Agree upon goals and objectivesAgree upon goals and objectives Divide and conquer suing existing expertiseDivide and conquer suing existing expertise Consolidate and re-assessConsolidate and re-assess Incorporate lessons learned from other Incorporate lessons learned from other

experiences that have “challenged” the experiences that have “challenged” the system or facility – e.g. SARSsystem or facility – e.g. SARS

Test and evaluate plan and revise as Test and evaluate plan and revise as necessarynecessary

Ongoing education of stakeholders, Ongoing education of stakeholders, potential partners and publicpotential partners and public


ReferencesReferences The BC Pandemic Influenza Preparedness Plan The BC Pandemic Influenza Preparedness Plan

http://www.bccdc.org/content.php?item=150http://www.bccdc.org/content.php?item=150

Minnesota Pandemic Influenza Prevention and Minnesota Pandemic Influenza Prevention and Control Guidelines Control Guidelines http://www.health.state.mn.us/divs/idepc/diseases/flu/http://www.health.state.mn.us/divs/idepc/diseases/flu/

pandemic.htmlpandemic.html (includes Guide to Local Planning) (includes Guide to Local Planning)

WHO website on Global Agenda for Influenza WHO website on Global Agenda for Influenza Surveillance and Control Surveillance and Control <http://www.who.int/csr/disease/influenza/glob<http://www.who.int/csr/disease/influenza/globalagenda/en/>alagenda/en/>


ReferencesReferences Health Canada: FluWatch and SARS Health Canada: FluWatch and SARS

<http://www.hc-sc.gc.ca/><http://www.hc-sc.gc.ca/> Special Issue: Influenza Vaccine.Vaccine Special Issue: Influenza Vaccine.Vaccine

Volume 21 (16) 1 May 2003. Volume 21 (16) 1 May 2003. ““The State of Infection Surveillance and The State of Infection Surveillance and

Control in Canadian Acute Care Hospitals” Control in Canadian Acute Care Hospitals” Zoutman et al., AJIC, August 2003Zoutman et al., AJIC, August 2003


AcknowledgementsAcknowledgements The many Canadian experts in public health, The many Canadian experts in public health,

epidemiology, infection control, infectious disease, epidemiology, infection control, infectious disease, laboratory sciences and communications who laboratory sciences and communications who continue to contribute their time and expertise to continue to contribute their time and expertise to - developing, implementing and evaluating our - developing, implementing and evaluating our national SARS responsenational SARS response- developing, reviewing and evaluating the - developing, reviewing and evaluating the Canadian Pandemic Influenza PlanCanadian Pandemic Influenza Plan

Thank youThank you

Documents

Pandemic Influenza Planning An Evolution to the Approach for National Communicable Disease Emergencies Dr. Theresa Tam Manager, Respiratory Infections