THE THIN WHITE LINE: the history of a future avian influenza pandemic

Chapter 2: State of Emergency

This was Pandemic

    While government struggled to increase public confidence in its containment measures, the health system responded rapidly. By October 30, health officials in Ontario, British Columbia, Alberta and Quebec began full implementation of their pandemic response plans; the other provinces followed suit days later. The challenge to the provinces and their RHAs proved to be how and where to focus limited resources, temporarily increase resources, and institute, in stages, limitations on public mobility so as to reduce the spread of disease.
    In each province, the health system led the health sector response, such as coordinating the RHAs, delivering antiviral drugs and vaccine, and collecting and distributing information related to the epidemic. Meanwhile, each province’s emergency management department, managing the crisis from a command center, led the response related to the non-health impacts of the epidemic, such as maintaining essential services, coordinating volunteer activities, and helping families of victims.
    At a more local level were the municipalities and RHAs. Municipal government maintained public order, helped close down public buildings, set up triage and alternative healthcare sites, and maintained public infrastructure such as waste management and utilities. The RHAs met the community’s health needs, collected and disseminated information about the epidemic, and delivered antivirals and vaccine.
    These steps were all taken based on the understanding that demand for health services would dramatically exceed supply for the next one to two months, while essential services would become increasingly difficult to maintain due to a growing infection rate among skilled workers.
Confronting the Pandemic became a complicated logistics puzzle. Unfortunately, while each province’s pandemic response plans had been well-conceived and rehearsed in tabletop exercises, in reality, under pressure, problems occurred that resulted in slow, sometimes bungling staging of government action punctuated by sudden bursts of progress. Numerous issues came up and had to be resolved. People could not be located. Resources that had been thought to exist did not. The resources they had took time to set up. Communications broke down. People made bad decisions based on poor information. New developments required fast decisions that could not be made quickly.
    Meanwhile, the national government supported local health systems with its own arsenal of resources, including 165 portable hospitals containing 33,000 beds. Government deployed these hospitals, supplemented by mobile military hospitals, around the country based on need. All of the resources available to the RHAs could increase acute care capacity in any given health region by a maximum of 25-50 percent.
    It wasn’t enough. In the Calgary RHA, for example, even after increasing capacity by 25 percent, demand still represented more the 130 percent of available acute care beds, 1580 percent of ICU beds, and 240 percent of ventilator beds at the end of the epidemic’s third week, costing lives as people couldn’t access life-saving equipment.
    One of the most critical resources that needed to be distributed quickly was antiviral drugs. During the first wave of the Pandemic, this asset presented the only virus-specific intervention available.

    Antiviral drugs, which inhibit the ability of a virus to replicate itself, are proven effective against influenza. They can be used for both treatment of symptomatic cases and as a prophylaxis, or preventive measure, for people exposed to the virus. For example, if you got the flu, these drugs might help you get better. And if you didn’t have the flu but had been exposed to it, the drugs might prevent you from becoming infected. Available drugs included zanamivir, oseltamivir, amantadine and rimantadine. Of these, zanamivir, oseltamivir and amantadine had been approved for use in Canada.
    Amantadine and rimantadine susceptibility testing of Avian Flu confirmed that the virus exhibited significant resistance to these drugs, so health officials concluded that they had no potential as either a treatment or a prophylaxis.
    That left zanamivir and oseltamivir, both approved for use in Canada in 1999. The drugs, effective as a treatment if taken within 12 hours, at most two days of illness onset, attacked the ability of the H5N1 virus to replicate by interfering with the release of virions from infected cells, and other effects.

Table 2-2. Progress of epidemic in the Calgary Health Region and its estimated impact over its entire 10-week course.(33) By week 3, Calgary’s share of the national emergency stockpile increases total hospital capacity by 25 percent. By week 4, alternative care sites increase hospital bed capacity by another 25 percent. About 10 percent of the clinically ill required hospitalization; about 77.5 percent of these cases required acute care beds for an average of 7 days, 15 percent of these cases needed ICU beds for an average of 14 days, and 7.5 percent of them needed ventilators for an average of 14 days. In week 4, social distancing strategies clip the peak by 10 percent; additional business closings reduce the peak by an additional 10 percent in week 5. These strategies reduce the peak but increase the length of the epidemic from eight to 10 weeks.

	Week 1	Week 2	Week 3	Week 4	Week 5
Clinically ill	18,020	30,034	45,051	51,358	45,652
Hospital admissions	1,802	3,003	4,505	5,136	4,565
Hospital acute care bed capacity	2,105	2,105	2,631	3,158	3,158
Requiring acute care beds	1,397	2,328	3,491	3,980	3,538
Bed demand as % capacity	66%	111%	133%	126%	112%
Requiring ICU beds	270	721	1126	1446	1455
ICU bed capacity	57	57	71	71	71
ICU demand as % capacity	474%	1265%	1581%	2030%	2042%
Requiring ventilators	135	360	563	723	728
Ventilator bed capacity	186	186	233	233	233
Ventilator demand as % capacity	73%	194%	242%	311%	313%
Mortality (1.25% of clinically ill)	225	375	563	642	571
Mort. in hospital (70% of deaths)	158	263	394	449	399

	Week 6	Week 7	Week 8	Week 9	Week 10+
Clinically ill	45,051	30,034	18,020	11,413	5,707
Hospital admissions	4,505	3,003	1,802	1,141	571
Hospital acute care bed capacity	3,158	3,158	3,158	3,158	3,158
Requiring acute care beds	3,491	2,328	1,397	885	442
Bed demand as % capacity	111%	74%	44%	28%	14%
Requiring ICU beds	1361	1126	721	442	257
ICU bed capacity	71	71	71	71	71
ICU demand as % capacity	1910%	1581%	1012%	620%	360%
Requiring ventilators	680	563	360	221	128
Ventilator bed capacity	233	233	233	233	233
Ventilator demand as % capacity	293%	242%	155%	95%	55%
Mortality (1.25% of clinically ill)	563	375	225	143	71
Mort. in hospital (70% of deaths)	394	263	158	100	50

    Studies of oseltamivir prior to the Pandemic suggested that the drug, properly administered, could reduce hospitalizations by nearly 60 percent while reducing the duration of symptoms by 25-30 percent. As a prophylaxis, both oseltamivir and zanamivir demonstrated 70-90 percent effectiveness in preventing influenza under lab conditions.
    It is still too early to know if these drugs had a similar effect during the Pandemic, as studies are pending, but some public health officials have estimated that their use cut the mortality rate overall by about 50 percent when available, saving an estimated 100,000 lives in Canada.(34)
    Drug patent laws protected both of these drugs, however, limiting access. Both were relatively expensive and in limited supply due to limited production capacity. And both had a shelf life of about five years.
By 2011, Health Canada had increased the National Antiviral Stockpile to 55 million doses, about 90 percent oseltamivir and 10 percent zanamivir, and distributed it to the provinces and territories based on population.(35)
    At 10 doses per individual, this was estimated as sufficient to cover 5.5 million people, or nearly 20 percent of the population. However, Avian Flu proved remarkably resilient. It required 15 doses, sufficient for 3.7 million people, or about 12 percent of the population. About 25 percent of Canadians became clinically ill during the first wave of the Pandemic, and about half of these required treatment with antivirals, so the National Antiviral Stockpile barely covered the population that became clinically ill during the Pandemic.(36)
    In the epidemic’s first weeks, health officials faced the challenge of timely distribution of drug stocks as the drugs, to be effective, needed to be taken within 12, at most 48 hours of onset of illness. Later, the black market would present an additional challenge: As stocks became depleted at pharmacies and rumors told of shortages in some health regions, people increasingly turned to the black market and paid outrageous prices not only for real antiviral drugs that had been stolen from pharmacies and clinics, but for antivirals that proved ineffective against Avian Flu, such as amantadine, and fake remedies that turned out to be just dressed-up children’s aspirin.

    By early November, nearly 1.3 million Canadians had become infected and more than 15,000 people had died.
    Across Canada, the epidemic stopped being something that happened on the news, in other countries, to other people. Everywhere, people gradually awakened to the reality that the nation found itself in the midst of a developing catastrophe.
    And it had only gotten started.
    This was Pandemic.