Infectious outbreaks are an increasing public health concern in today’s modern world. Inevitably, due to growing population sizes, globalization, anti-microbial resistance, and climate change, there is increasing concern surrounding the possibilities of infectious outbreaks. In 2004, the SARS epidemic shone a glaring light on the overall lack of public health preparedness across the globe, and showed how fast an emerging and infectious pathogen can spread globally. In a few months, SARS caused thousands of infections glob-ally, resulting in 44 deaths in Canada and nearly a billion dollars in economic damage between 2003 and 2006. The dramatic effect of SARS prompted reinvention of Canada’s Public Health system. Ultimately, the public health agency of Canada (PHAC) as well as several sub-committees, provincial, territorial, and municipal public health networks were formed to improve communication regarding communicable diseases, outbreak monitoring, reporting, research, and out-break response.

Between 2009 and 2010, the world saw the first pandemic of the 21st century with the massive spread of H1N1, providing the first major test to Canada’s outbreak preparedness strategies and global outbreak communication. While the virus certainly had devastating effects, there was a definite improvement in the ability to respond to an unknown, rapidly spreading pathogen to which individuals had little to no immunity. Several concerns also needed to be addressed after the H1N1 outbreak, including vulnerability of Canada’s First Nations population, rural communities, and interprovincial communication. Today there are a variety of pathogens and illnesses that have seized the world’s attention including Ebola virus, Zika virus, and most recently acute flaccid myelitis (AFM), a rare polio-like illness causing outbreaks in North America. We are constantly becoming aware of more outbreaks and unknown diseases. Our history and current events beg the question of just how prepared are we for another major outbreak, what are current concerns regarding emergency response plans, and what is being done to address them?

There are some key features of Canada’s emergency outbreak strategy that have been developed over the last 15 years. As previously mentioned, there are now public health entities at the municipal, provincial, and federal levels to allow for rapid detection and communication to necessary individuals depending on the severity of the outbreak. In addition, there are networks of deployable teams to aid in assessment, containment, and distribution of necessary treatments. A critical feature of preparing for an outbreak is immunization strategies.

The first challenge regarding vaccination in the event of an outbreak is that there may or may not be a vaccine or avail-able treatment for the disease. In the case of no available vaccine, such as during the H1N1 pandemic or the Ebola epidemic, there is rapid global communication regarding pathogen type and strain. This allows for increased research coordination and rapid treatment development. Once viable options have been elucidated, all treatments needs to pass safety standards and undergo a regulatory process. Canada has developed protocols to facilitate this process in the event of a pandemic when normal regulatory processes are too lengthy and cannot be used, such as in the event of an emergency, treatments are most likely needed as soon as they are manufactured.

There are three ways that an emergency vaccine can be ap-proved through a regulatory process. If there is a current vaccine regulated under the Food and Drug Administration (FDA) for another strain of the disease, surrogate immunogenicity can be used with the understanding that there be subsequent validation of the new strain following vaccine re-lease. If this process is unavailable there is the Extraordinary Use New Drugs Act (EUND) started in 2011 that allows the Canadian government the ability to fast track the regulatory process using animal data supplemented with some human data, provided there are strict quality measures followed by the manufacturer and the ability for post distribution surveillance. Finally, if the EUND cannot be employed, orders from the Minister of Health can be issued to suspend features of the Food and Drug Administration Act in the event of a public health emergency. However, missing information and data must be submitted as soon as possible, and manufacturers again must follow strict surveillance protocols. Canada was also one of the first countries to sign contracts with manufacturers that allocate a certain number of treatment doses to Canadians prior to the manufacturer being able to sell doses to other populations. Vaccine stockpiles are also available around the globe that facilitate rapid distribution in the event of an emergency. However, in an extreme emergency there will most likely not be enough doses for an entire population, so vaccine allocations are in place to facilitate distribution to those individuals most in need and who carry the most risk, such as health care workers. Finally, Canada’s outbreak preparedness includes several research laboratories both at the national and provincial level which, play key roles in investigating emerging pathogens, monitoring epidemiological data, and tracking community and hospital outbreaks. In addition, this research helps provide data to mathematically model pandemic scenarios to better predict flaws in the system. All the communication and re-search strategies are framed within global communication often facilitated by the World Health Organization (WHO). The WHO tracks current emerging infectious pathogens and epidemics occurring around the globe and provides information regarding priority pathogens that require some type of treatment development to better direct efforts in protecting the global community from large scale outbreaks.

Overall, Canada has facilitated the growth of a sophisticated public health system that is designed to protect Canadians in the event of a variety of foreseeable public health emergencies, as well as provide aid to other regions of the world. However, there are still a variety of challenges that need to be acknowledged. Firstly, there are several considerations regarding the current system that may need to be addressed. At present, in a public health emergency, Canada’s vulnerable populations such as the homeless, rural northern communities, and First Nations peoples are still at the greatest risk despite the acknowledgement that this is a major flaw in the public health system. Providing services to these communities is challenging, not only does our system fail to protect many of these people, but also increases the risk of an infection spreading without detection.

Another flaw in our system is that while there are exceptional national and provincial networks, there is no great consistency in how these networks should communicate with each other. Local and provincial public health systems are facilitated differently, some areas still use paper records, and there are many different digital systems; therefore, there is often a lack of ability to rapidly communicate within this hierarchy. While sufficient for our day to day needs, this is-sue could be very detrimental in the face of a major outbreak and must be addressed. Another major critique is that many researchers question the ability of municipal laboratories to have proper infection control training in place for first line personnel such as paramedics, nurses, and ICU staff. There are also concerns about whether there are appropriate protocols in place at the laboratory level in order to allocate machinery and lab space dedicated to specific infectious pathogens. Often this is not a concern in large city centres with many resources but a greater issue in smaller community research centres. Overall, this again points at a glaring hole in the system regarding Canada’s rural populations, which happen to represent a large proportion of the population.

Coordination of community networks is further complicated by the fact that during an outbreak there are often cultural and community barriers that affect the success of even the best facilitated pandemic emergency protocols. Although we have legislation to provide Canadians access to vaccines and treatments during an outbreak, this is only successful if communities are receptive. Continued community outreach and consideration of cultural barriers prior to an emergency are necessary but not always immediately considered. An extreme case of cultural barriers and need for understanding became strikingly clear during the Ebola epidemic. Communities refused treatment or contributed to improper infection control often due to fear of those trying to help. Success in controlling the outbreak requires an understanding of these barriers and finding ways to appropriately address them with the community.

Finally, one of the largest challenges Canada faces is the fact that public health systems are not well funded, less than 1% of the federal health spending budget is allocated to public health each year. In 2016-2017, less then 1 billion out of an estimated 250-billion-dollar health budget was set aside for public health. Similarly, provincial budgeting only allocates 1-2% of health spending to public health. While many argue that with an already strained health system we cannot afford to spend more on public health, it is also worth noting that public health spending has declined each year since 2015. While there are alternative funding sources such as public and private grants, infectious disease research constitutes a small portion of granted funds each year with most of the funding being dedicated to chronic diseases. Although these are also incredibly worthy causes we cannot ignore the reality that emerging infectious disease are a very real and growing threat to modern society.

As with any prevention strategy, there is no ability to accurately predict the future. With so many potential threats and emerging pathogens such as influenza, Zika, AFM and many more, Canada is doing its best to keep up with the rising threat of infectious disease; however, there are challenges that need to be addressed prior to the next major epidemic or pandemic. All too often funding and time is only allocated during or after an event occurs that exposes the most vulnerable defects in our system. Continued understanding of the value of public health infrastructure is critical in the rapidly evolving microbial world.

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Megan Gusdal

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