Pandemic daze
After the World Health Organization (WHO) declared on Jun. 11 that A(H1N1) swine flu is the first pandemic in 41 years, focus shifted sharply to the production and availability of a vaccine.
In mid-June, vaccine experts indicated to the WHO that they were having difficulty growing the “seed stock” for a swine flu vaccine in labs, making it difficult to reach full-scale production and make enough vaccine for the world’s 6.8 billion people.
But Canada’s Chief Public Health Officer Dr. David Butler-Jones sought to reassure Canadians that a vaccine would be ready before the winter flu season.
“Canada is well-prepared for these events, thanks to years of advanced planning,” Butler-Jones told reporters. Canada has a contract with Glaxo-SmithKline to produce new vaccine when it is developed.
Meanwhile, the federal government announced that it would spend $10.8 million over 3 years to establish a national influenza research network. Health Minister Leona Aglukkaq said the network will focus on evaluating pandemic vaccines.
The network being established by the Canadian Institutes of Health Research and the Public Health Agency of Canada will “test methodologies for the performance of rapid clinical trials, assess the safety and immunogenicity of a novel pandemic influenza vaccine, provide population-based estimates of vaccine safety and effectiveness, measure vaccine coverage, and facilitate the rapid implementation of pandemic influenza vaccine programs.”
While declaring that the criteria for a flu pandemic had been met and raising the pandemic alert level to phase 6, the WHO cast the overall severity of the pandemic as “moderate,” which means that most people recover from infection without hospitalization or medical care, that the cases of severe illness are similar to those of seasonal influenza periods and that most hospitals and health care systems can cope with the additional load.
In Canada, one of the heaviest burdens fell on health facilities in Manitoba as a consequence of swine flu’s run through the community of St. Theresa Point, where 27 native people had to be transported south to Winnipeg for treatment.
As the situation worsened, Native chiefs complained that the federal government failed to expeditiously supply flu masks, respirators and hand sanitizer, as it was required to under the Canadian Pandemic Influenza Plan.
In subsequent testimony before the Senate committee on Aboriginal peoples, Health Canada indicated that it was reluctant to send hand sanitizer for fear the alcohol-based gel would be orally consumed.
Overall in Canada, 9 provinces and 3 territories have reported a total of 6457 laboratory-confirmed cases of A(H1N1) flu virus, including 404 hospitalizations and 15 deaths, as of Jun. 22, according to the Public Health Agency of Canada (www.phac-aspc.gc.ca/alert-alerte/swine-porcine/surveillance-eng.php).
The WHO, meanwhile, reported that as of Jun. 24, some 76 countries had reported 55 867 cases of swine flu, including 238 deaths.
The United States had the highest incidence of cases (21 449), followed by Mexico (7847), Canada (6457), Chile (4315), the United Kingdom (2905), Australia (2857) and Argentina (1213).
The WHO updates suggest that the highest growth rates of new cases are in Canada and some countries in the southern hemisphere.
The highest numbers of deaths have occurred in Mexico (115), followed by the United States (87) and Canada (15).
Mixed reception
United States President Barack Obama drew several standing ovations but also a round of boos from delegates to the American Medical Association’s annual meeting for expressing opposition to limits on jury awards in medical malpractice lawsuits. Caps on such awards “can be unfair to people who’ve been wrongfully harmed,” Obama said in a keynote address at the annual meeting in Chicago, Illinois. “But I do think we need to explore a range of ideas about how to put patient safety first, how to let doctors focus on practising medicine, how to encourage broader use of evidence-based guidelines. I want to work with the AMA so we can scale back the excessive defensive medicine that reinforces our current system and shift to a system where we are providing better care simply —rather than simply more treatment.” Rising insurance premiums have compelled doctors to lobby for malpractice caps, but the US Congress is split on the issue, with Democrats generally opposing limits and Republicans supporting them (CMAJ 2009;180[7]:E4–E5). Obama also indicated that his planned health care reforms, which included providing health insurance to roughly 50 million Americans who now have no coverage, will cost at least US$1 trillion over the coming decade.
Other highlights of the annual meeting included an endorsement of police use of tasers rather than “deadly force” to constrain criminals, on the grounds that fewer lives would be lost. An association committee had urged the policy, on the proviso that law enforcement departments and agencies “have in place specific guidelines, rigorous training, and an accountability system” for the use of tasers.
The association also adopted guidelines for handling security breaches of electronic medical records. In such instances, doctors should “ensure patients are properly informed of the breach; follow ethically appropriate procedures for disclosure; support responses to security breaches that place the interests of patients above those of the physician, medical practice or institution; (and) to the extent possible, provide information to patients to enable them to diminish potential adverse consequences of the breach of personal health information.”
Revamp PHAC
A parliamentary committee was sharply divided along partisan lines over whether a full public inquiry is needed into the 2008 listeria outbreak and whether the Public Health Agency of Canada should have legislated independence from Health Canada to ensure that it can function as a watchdog of pubic interests.
In a report to Parliament, Beyond the Listeriosis Crisis: Strengthening the Food Safety System, representatives of the 3 opposition parties (Liberals, New Democrats and Bloc Québécois) on the House of Commons Standing Committee on Agriculture and Agri-Food contended that only a full-scale public inquiry could ascertain whether government actions during the outbreak were appropriate.
The Conservatives, however, issued a dissenting report affirming their belief that the government’s own investigation into the performance of agencies makes a full inquiry unnecessary. Prime Minister Stephen Harper earlier this year appointed former Edmonton Health Authority president Sheila Weatherill to conduct a limited investigation (CMAJ 2009;180[5]:503) that is projected to cost $2.7 million.
The opposition parties recommended that the government “review the legislative basis for the Public Health Agency of Canada and the Chief Public Health Officer with a view to ensuring independence from government departments and ministerial influence, so as to protect and restore faith and confidence in Canada’s public health system.”
The committee also urged the government to undertake a “comprehensive review of the resources, including training, that Canadian Food Inspection Agency needs to properly implement, execute and enforce all food inspection activities; and that the government make that review public.” As well, it urged the government to improve its surveillance by developing programs to gather epidemiological data on foodborne illnesses and add those to the list of nationally notifiable diseases.
Breech births
The Society of Obstetricians and Gynaecologists of Canada has unveiled new guidelines for breech births.
Cesarean sections have become a matter of course for babies that have not aligned themselves in the womb in a head-down position, but vaginal deliveries should be offered “when possible,” the society’s maternal fetal medicine committee says.
Cesarean sections, though, should continue to be the norm in “any situation in which a cesarean section would normally be recommended, even if the baby were not in a breech position; if the baby weighs less than 2500g (5.5 lbs) or more than 4000g (8.8 lbs); if the baby presents as a footing breach; if the mother has a narrow or small pelvis, which could make vaginal delivery difficult; if the baby’s umbilical cord is positioned in such a way that it is likely to become entangled or compressed during delivery; (or) if the head of the baby is in hyperextension.”
According to Statistics Canada, roughly 3%–4% of all pregnant women, or between 11 000 to 14 500 pregnancies, present with a baby in breech position at time of delivery. — Wayne Kondro, CMAJ