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The Globe and Mail

Ottawa prepares for pandemic with new rules for treatment

People walk by a sign inside St. Michael's Hospital in Toronto


For the first time in decades, doctors across the country will be given rules to help determine which patients get access to life-saving treatments in the event an influenza pandemic hits the country hard this fall.

Drafting these rules signals how seriously Canadian health authorities take the H1N1 virus, which they fear could become deadlier and more widespread during flu season.

Experts say there is a strong likelihood that a vaccine will be in place by November to stop an H1N1 pandemic from taking down large segments of the population.

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But the effectiveness of preventive medicine is by no means a certainty. Production of a vaccine has already hit a snag, with manufacturers reporting a disappointingly low yield when the virus is grown in eggs, according to the World Health Organization.

To be prepared in the event a pandemic does take hold, the federal and provincial governments are developing a plan which stipulates, among many other things, that guidelines be developed to assist doctors in making tough choices about the allocation of scarce treatments.

"There may come a point where there is definitely an overcrowding situation where triaging has to occur if you have limited resources," Theresa Tam, director general of infection disease and emergency preparedness for the Public Health Agency of Canada, told The Globe and Mail in an interview.

Some of the work to develop the rules around triage has already been done, said Dr. Tam. It is primarily the job of the provinces, but the federal government is assisting by providing information.

"We knew that we had to pull together a multidisciplinary group" to analyze the potential situations, she said, "because you have legal issues, clinical issues, ethical issues that have to come together."

With most diseases, it is the elderly and the infirm who are worst affected. But the H1N1 virus has a predilection for people in their prime. On Friday, public health officials issued a warning telling pregnant women that it is hitting them with peculiar ferocity.

"We may be faced with two young persons who may be competing for the same health-care resources, and those are some of the questions that we will be facilitating discussions on," Dr. Tam said.

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The primary fear of health officials is that a flu pandemic will follow the same course as the Spanish flu, which arrived in a mild form in the spring of 1918 and then mutated into something far more vicious when traditional flu season returned in the fall of that year.

In the end, an estimated 50 million people were killed worldwide, including 50,000 in Canada - or 0.6 per cent of the population. If the 1918 experience were replicated this year and 0.6 per cent of the Canadian population fell seriously ill, that would be close to 200,000 people.

Respiratory technicians say there are not enough members of their profession currently practising in this country to care for patients during an influenza pandemic. Nor, they say, are there enough critical-care nurses.

The public-health agency is looking at ways to bring health professionals out of retirement, getting students fast-tracked into the work force, and allowing credentials to be accepted across jurisdictions.

Some doctors have also suggested that the problem of finding enough ventilators will pale in comparison to finding enough isolation rooms.

In fact, said Dr. Tam, isolation rooms are unlikely to be needed because hospitals could simply close off entire wards or wings and devote them to influenza patients. Under that scenario, it is the number of ventilators that has many health experts worried.

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There is no official tally of the machines in Canada, and Dr. Tam said there is no point in counting those that are not attached to critical-care beds because a ventilator needs trained personnel to operate it. By using a number of different mathematical models, she and her staff have concluded that there are about 3,500 to 4,500 ventilators in Canada that could be used in a pandemic.

Some doctors say their H1N1 patients require oscillating ventilators that push air into patients' lungs in short, rapid bursts rather than the long, slow breaths afforded by the regular machines.

The public-health agency is purchasing 370 of the regular ventilators to add to the federal stockpile of 130 that can be distributed to the provinces as needed. Dr. Tam said the regulators will be selected with ease of transportation and operation in mind. The agency expects to spend about $10,000 per machine.

The Respiratory Therapy Society of Ontario questions that choice.

"Any true critical-care ventilator capable of managing the pulmonary insult that the H1N1 virus has produced comes at a minimal cost of approximately $40,000," the society said in an e-mail.

"The devices that are around the $10,000 range are typically used for transport or management of patients who require ventilatory support, but do not suffer from any pulmonary compromise. As a result, these devices are not capable of properly oxygenating (provision of oxygen to the blood) or ventilating (removing carbon dioxide from the blood) critically ill patients."

That debate is likely to continue into the fall as health officials assess the severity of the flu.

In the meantime, governments will continue to write the rules around triage. But Dr. Tam does not assume any guidelines developed in the coming months will eliminate the burden faced by doctors who may have to make life-and-death decisions.

"While we can have maybe some high-level guidance, it doesn't make the job of the people on the ground that much easier," she said.

With a report from The Canadian Press

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