The International Day of Epidemic Preparedness was marked on 27 December. The UN General Assembly called for this day in 2020 to advocate for the importance of preventing and preparing for epidemics, in addition to creating local and global partnerships against epidemics. The UN emphasizes that “[t]here is great need of raising awareness, the exchange of information, scientific knowledge and best practices, quality education and advocacy programmes on epidemics at the local, national, regional and global levels as effective measures to prevent and respond to epidemics”.
We have now observed the second annual International Day of Epidemic Preparedness, and many countries are facing yet another wave driven by an emerging variant of COVID-19. Jurisdictions like Ontario, Canada have begun implementing preventative measures as cases rise to unprecedented numbers. It is a solemn reminder that as a global community, we remain very much in the middle of a global pandemic that is now in its third calendar year.
Dr. Leanne Tran has been on the frontlines of the fight against COVID-19 in Toronto since the beginning. She is currently the Managing Research Counsel and Head of the Health Law, Innovation and Policy (HLIP) Lab at the Lunenfeld-Tanenbaum Research Institute (LTRI), part of the Sinai Health System (SHS). She is also principal at JD MD Solutions, which offers services at the interface of law, medicine, science and research. With more than 20 years of experience in the health and legal industries, Dr. Tran also serves on the boards of several non-profit healthcare organizations. She has authored numerous papers and books, including Outbreaks: A Practical and Legal Risk Management Primer for the Healthcare Sector, published in December 2021, which is a first-of-its-kind legal text that explores the past, present and future of epidemic and pandemic preparedness, with a focus on the COVID-19 pandemic, in Canada and beyond.
Dr. Tran wrote Outbreaks as the pandemic evolved over the last two years. During this time, she also managed a team of lawyers and legal professionals that focused on prioritizing research on COVID-19, resulting in new diagnostics and vaccine testing. Recognizing the need to be flexible through the various waves, her work and priorities evolve as the pandemic does, and she provides whatever support is necessary to researchers and clinicians in the hospital and institute for which she works.
Dr. Tran discussed epidemic preparedness with UNACTO in the context of her experiences on the ground in Toronto. Education and awareness of the impact of epidemics and pandemics on societies are crucial for being prepared for the future. Dr. Tran says “we need to learn from our past and from other countries. COVID-19 has impacted, tested, and in some cases, improved our health systems. We need leadership, public education, research and funding. The concern is that after five to ten years, just like SARS [Severe Acute Respiratory Syndrome], this COVID-19 pandemic experience will be forgotten with no long-lasting and sustainable changes, and funding being cut from public health once again”.
The following responses were provided by Dr. Tran in an interview conducted on 15 December 2021.
Let us dive right into your reflections on the current pandemic. Given your line of work, did you see the COVID-19 pandemic, or something like it, coming?
Yes. In talking, interviewing and working with contributors for Outbreaks, as well as learning from our clinicians and scientists in the infectious diseases and public health space, many experts saw this pandemic or something similar coming. Recall that we were hit hard by SARS in Toronto. In the words of Dr. David Naylor, the co-chair of the Canadian COVID-19 Immunity Task Force (CITF), during his interview for the book, “the epidemic was on the radar screen of many other nations”, “we basically sleepwalk between pandemics”, and “SARS was a dress rehearsal that went away fast and only hit a small part of the country. We now have the ‘big one’ that everyone has talked about for decades and it is brutal”. However, SARS was limited to hospitals, whereas COVID-19 was unexpected in its global scope, scale, and duration.
Did previous epidemics, like SARS, prompt any preparedness that assisted us in managing the COVID-19 pandemic? If so, how? If not, why?
As a result of SARS, Infectious Disease Prevention and Control (IPAC) became integral to hospitals and thus made them better prepared for COVID-19. There was also a stockpile of PPE [personal protective equipment] in some hospitals that made supply chain shortages due to COVID-19 less catastrophic for them. Also, hospitals had emergency preparedness and business continuity plans and ran simulations. Due to SARS, we have a Public Health Agency of Canada (PHAC) and a strong National Microbiology Lab (NML). There is also some committee infrastructure to allow for coordination between the provinces and the federal government and a flu pandemic plan which guided some provinces in their responses.
Additional funding and resourcing were made available because of SARS, but then people forgot, and budgets were cut in hospitals and public health. Similarly, the Global Public Health Intelligence Network (GPHIN), which was very active and helped detect SARS in 2003, was decommissioned as we entered the COVID-19 outbreak. Dr. Naylor suggested it was symbolic of the lack of resources, loss of focus, and erosion of scientific leadership.
The need for clarity, collaboration, and coordination locally, provincially, nationally, and internationally is recognized, as is the need for one integrated health system to include primary care, hospital care, and social services. Translating these to implementation, however, has proven more difficult. We need to keep the committees and infrastructure for emergency times in ‘normal times’ so we can respond quickly and nimbly to a future epidemic or other health emergency.
Also, we struggle with disease surveillance and data sharing across institutions and jurisdictions. We often need to have data-sharing agreements in place and must consider privacy concerns when dealing with sensitive personal health information.
What are your thoughts regarding how prepared the healthcare sector in Canada was for the COVID-19 pandemic?
I think the hospitals were relatively well-prepared in that they had IPAC, strong microbiology labs, and a stockpile of PPE from the SARS experience upon the recommendations of infectious diseases physicians. Hospitals run simulations and have legal, logistical, operational, and clinical leadership and academic infrastructure to launch a more comprehensive approach to respond to catastrophes. There are also emergency preparedness and business continuity plans and guidebooks.
However, community healthcare organizations were not prepared in that they had limited access to this information and experts. The long-term care homes (LTCHs) were unfortunately very ill-prepared.
Generally, some provinces did or are doing better than others. For example, British Columbia has been quite good with its public health communications compared to Alberta and even Ontario. Governance structures and leadership in the different provinces impact provincial response.
Most people would rank Canada somewhere in the middle for our preparedness. We could have (a) done much better with contact tracing and testing; (b) been clearer in our public health guidance, especially at the beginning, on mandating face masks and questions regarding aerosol transmission; and (c) moved away from reactive leadership.
What do you think are the most prominent weaknesses in epidemic/pandemic preparedness in Canada displayed by the response to the COVID-19 pandemic?
Prominent and systematic weaknesses include insufficient funding and resourcing of public health, prevention, and our healthcare system, which has caused inadequate redundancy, resiliency, flexibility, and adaptability in our response to the COVID-19 pandemic. There is disjointed communication and collaboration between different parts of the healthcare system; for example, hospitals not communicating with community health organizations, partly leading to the devastation in LTCHs.
Furthermore, healthcare is not collaborating with social services and public education. It is a very reactive system that is short-sighted. As expressed by Dr. Allison McGeer, an infectious diseases physician and researcher at LTRI, SHS, in her interview for Outbreaks: “In New York City in the 1970s, there was a tuberculosis [TB] programme which resulted in very low rates of TB, so they took it apart. The Ministry of the Environment’s spending on water testing before Walkerton was questioned because there were no problems. In the good days, nothing happens, but when nothing happens for years, people say, why am I paying for this? It’s a cycle and an issue that is difficult to change”.
The lines of communication between health institutions, public health units, and government were/are not clear and open, especially at the start, resulting in reactive and disjointed leadership. As Dr. Jennie Johnstone, SHS Physician Lead of IPAC and an LTRI researcher, discusses in her interview for Outbreaks, there is a need for more health system integration and standardization - a ‘system approach’. Perhaps there should be a centralized body that the medical officers of health report to rather than the various municipalities, which could resolve some confusion as to who is responsible for decision-making and who is held accountable.
There is limited real-time access to data due to archaic IT infrastructure in the healthcare system. In 2020, faxes were still being used, and manual data entry in many communications between hospitals, LTCHs, and public health units resulted in a heightened risk for errors.
Sharing data allows us to have evidence-based decision-making and policymaking in healthcare. As Dr. Johnstone aptly remarked, for longstanding changes, “relying on additional funding is not enough. People forget. We need to do as much as possible to embed structural changes into the healthcare system that cannot be easily reversed, such as introducing legislation that requires pandemic stockpiling at all healthcare organizations”.
You wrote and edited Outbreaks: A Practical and Legal Risk Management Primer for the Healthcare Sector. Can you discuss your inspiration for the text?
The inspiration for the text was that my colleagues and I were struggling with how to deal with the pandemic at our hospitals and research institute. We were encountering legal, ethical, scientific, and practical issues that I wanted to share with other healthcare organizations to help them navigate through similar public health crises based on any learnings, missteps, policies, and best practices we encountered and implemented.
How did you go about writing and editing the text? What was important for you in terms of (a) what was covered in the text and (b) the contributors to the text?
I realized very early on that I could write certain legal aspects of the text but needed the help of experts on the frontlines fighting the pandemic, be it clinicians, researchers, or health thought leaders, to flesh out the practical issues that arise and how these were resolved.
I wanted the text to be multidisciplinary (covering the law, but also the ethics and science). I wanted to focus on local, provincial, and Canadian circumstances, but also look at what international jurisdictions have done. I also wanted it to be a practical resource dealing with on-the-ground issues and suggestions for best practices, policies, etc. Hence, there is an appendix with sample policies, checklists, forms, agreements, guidelines and best practices.
With this lens, I reached out to the experts to provide written contributions or be interviewed. At the core, I wanted to highlight the day-to-day challenges they were facing and their recommendations on how to make things less challenging.
What is the key message that you hope your readers will gain from 'Outbreaks'?
There is a need to learn from our past and from the experiences of other countries to better prepare for the next inevitable pandemic and build a better future for our most vulnerable individuals, communities, and countries. We need to prioritize changes to public health and look at how to do this in tandem with potential changes to our healthcare system. We need to respond to public health threats in a more coordinated and collaborative manner locally, regionally, provincially, nationally, and internationally, as these are global crises. Finally, we need to emphasize that it is not ‘health vs economy’, but rather that a healthy population drives a strong economy. Hence, a more holistic understanding of outbreaks, epidemics, and pandemics is needed, which includes the science, medicine, law, ethics, etc., and how they intersect.
Do you have any examples of a state, society, community and/or healthcare sector, whether locally or internationally, that you believe displayed one or more best practices when it comes to epidemic/pandemic management at any point throughout the last two years?
The hospitals in Ontario were relatively prepared with best practices and emergency preparedness plans and policies. They tried to work with each other and proactively made plans for transfers from overwhelmed ICUs [intensive care units] to those less so. Similarly, I helped create data and material transfer agreements used by many Ontario hospitals and Public Health Ontario to expeditiously transfer COVID-19 biosamples and associated data for research purposes.
In terms of countries that managed COVID-19 well, most people would agree New Zealand had good leadership politically and scientifically. New Zealand contained the spread of COVID-19 early on through public health measures such as physical distancing and masking, lockdown, quarantine, contact tracing, and testing. There were significantly fewer deaths per million than in most other countries. New Zealand learned from its past failures in the fight against the H1N1 pandemic (popularly known as the ‘swine flu’), revising its pandemic response plan in 2017. New Zealand’s prime minister held daily conferences to keep the public updated. The country was criticized, however, for its slow vaccine rollout. The delay might have been due to delaying its infrastructure preparation for vaccines as there did not seem to be urgency given its other successes.
Some Asian countries such as Vietnam followed a similar path to New Zealand and were able to contain the spread. Vietnam was also successful in stopping the SARS pandemic within its borders through prompt and comprehensive identification and isolation, effective protection of health workers, and timely reporting. Vietnam prioritized the health of its citizens over the wellbeing of its economy during this pandemic by banning travel, closing borders, and increasing health checks months before other countries did so. Its government also communicated information to the public.
It remains to be seen how countries adapt and manage through waves caused by the Delta and Omicron variants, which are formidable. It is likely that responses will need to be different to deal with the significantly increased infectivity of these variants.
Let’s talk about the future. What can we expect to see in our generation in terms of epidemics/pandemics?
The experts expect that COVID-19 will remain a threat for years and that we will see another epidemic/pandemic in the next decade or so. We need to be prepared that it will likely be a virus that will mutate quickly. Also, we need to be prepared that we may not be as lucky in creating a vaccine that is so effective. Therefore, focusing on the infrastructure needed to minimize the effects and spread of the next epidemic/pandemic are crucial. This means that after we get COVID-19 under control, we need to remain vigilant and not forget. We need to continue to dedicate funding and appropriately resource public health bodies to continue surveillance efforts and effective emergency responses as required. Also, there should be more international cooperation and coordination of responses and not just every country for itself.
The United Nations strongly advocates for international cooperation and multilateralism in responding to epidemics. How important do you believe local and international cooperation will be in responding to epidemics in the future?
International cooperation and multilateralism are critical as epidemics/pandemics will be global in nature and, as such, will require a global response. Given the movement of people across borders, we need to cooperate locally and internationally. If we cannot control the epidemic in one part of the world, it will spread quickly, as we are currently seeing.
A prime example of multi-sectoral and international cooperation is the rapid development of COVID-19 vaccines. The timeframe in which these vaccines were developed, tested in clinical trials and cleared by regulatory agencies is unprecedented and a great triumph. The international community must now put similar or even increased efforts into creating a globally sufficient supply by rapidly scaling up vaccine production.
What do you believe are some ways that we, as a society, but also as individuals, can prepare for future epidemics?
Awareness and education are key. We need to understand epidemics, how they spread, and how we can do our part as individuals and communities to contain them by following public health guidance. We need to keep an open mind and listen to science. We need to analyze the data and make evidence-based decisions and policies. We need to be better communicators and have a community mindset. We need to learn from our past and other countries’ challenges and best practices.
Importantly, we must continuously invest funding and resources into public education and public health governance and the workforce. We can utilize new research and artificial intelligence-based pandemic modelling to manage pandemics. We also need to assess whether our current legislative, regulatory and governance frameworks for public health and healthcare make sense, and we must be willing to make appropriate changes.
There is likely not a one-size-fits-all approach that will work for all jurisdictions, cultures and societies. Hence, pandemic preparedness is a complex and difficult task, but well worth investing in on a long-term basis.
Edited by Ali Shahrukh Pracha