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Phase 1

Medical Officers of Health, or their designees, from 29 of the 36 Ontario Public Health Units and 22 primary care physicians from across Ontario agreed to participate in key informant interview that were designed to address experiences and perceptions relating to five key characteristics of their local Public Health Unit's Plans for an Influenza Pandemic.

The Public Health Survey instrument sought answers to questions in 6 categories:
Plan for an Influenza Pandemic (PIP);
Vulnerable/Priority Populations;
Mass Immunization Model;
Financial and Human Resources; and,
Collaboration with Primary Care.
Other Issues or Topics that should be Addressed (which opened the field for broader input)

The Primary Care Survey instrument was a shorter instrument that was addressed to physicians, with questions that focused on:

Involvement of Primary Care Providers in the Pandemic Influenza Plan;
Local Level Collaboration between Public Health and Primary Care;
Local Pandemic Influenza Plan;
Lessons Learned; and,
Additional Comments and Suggestions.

There were several similarities in both these instruments. Respondents were asked to:

Describe the role of primary care in both the development and implementation phases of the Plan for Influenza Pandemic (PIP).
Quantify on a 5 point scale, the level of collaboration between Public Health and Primary Care, during both the development and implementation phases of their PIP, and to indicate if they would like the level of collaboration to change in the future.
Identify elements of their Plan for an Influenza Pandemic and Mass Immunization Model that did or did not work well and to explain their answers. (Respondents were provided with prompt lists of possible PIP and MIM elements to help focus responses.)
Describe any lessons learned, things missing from the PIP and Mass Immunization Model, and what should be done differently next time.
Make specific policy suggestions for: PHUs, primary care providers, and/or the MOHLTC.

The main difference between the two instruments was the extent of the information sought from the Public Health Units. The MOHs were asked:

To describe how well prepared they felt with respect to their planned response activates prior to the pandemic.
To describe the perceived comprehensiveness of their PIP - i.e., was it more a strategic, guiding document or closer to a fully operational policy and procedure manual?.
What guided the development of their PIP?
Whether significant changes were made to the PIP between the first and second waves of the pandemic,
Whether the Incident Management System (IMS) was used as an emergency response model, and
To describe their PHUs' Mass Immunization Model (i.e., the how/what/when/where and who of how vaccines were delivered to people, including how the priority groups were addressed).
Questions about their financial and human resources capacity, as a means to better understand a local PHU's ability to implement its plan as documented, and to understand the need or dependency upon additional financial or human resources.

An Overview of Themes that Emerged from the Interviews:

The first overall impression drawn from the responses to both the Public Health and Primary Care surveys was that people had a lot to say and wanted their thoughts known. Both instruments had been designed to be delivered over the telephone and were tested and revised so that they would require about 45 minutes of the MOH's time for the Public Health instrument, and 15 minutes for the doctor responding to the Primary Care survey. The Public Health key informant interviews averaged well over an hour (range: 60 to 130 minutes), and the Primary Care interviews averaged over 30 minutes in duration (range: 25 to 70 minutes). All the respondents displayed significant passion when relating their experiences, and undoubtedly wanted to be better organized and prepared, next time around.

Generally, people were critically aware of problems implementing their first pandemic influenza plan and were clear in identifying issues they had encountered, including the implementation of new mass immunization models, and certain elements of plans designed to reduce demand on local emergency rooms via Influenza Assessment Centres (FACs).

Specific themes emerged where people were very interested in discussing and where they clearly wanted things to be done differently - that is, better or with less confusion - the next time around. Below, an overview of the issues that emerged from the interviews is presented, grouped in their four main themes. These issues were used to develop the symposium agenda.

1. Mass Immunization Models

The mass immunization models that were implemented varied across Public Health Units. Personal experience often illuminated weaknesses in planned approaches or areas that were not well thought through, or not fully operationalized. Questions were raised about the overall approach to use a province-wide PIP implementation policy when different PHUs had to deal with local situational variations, different operational facilities and capacities, and varying population characteristics. Urban and rural PHUs experienced different types of problems emanating from varying local conditions; such as basic issues associated with whether or not to engage and utilize primary care providers in the process, and, if they were to be engaged as a functional part of the local PIP immunization strategy, then when and how to best do so. There also were clear issues with how and when different PHUs decided to provide vaccines to their vulnerable populations and those specified as high priority groups, versus the general public in their area.

2. Local Health System Integration (Public Health & Primary Care)

Both Public Health and Primary Care respondents reported issues associated with their interdependent relationship under pandemic conditions. In general, Public Health found difficulty in engaging primary care practitioners during the planning and development phase of local PIPs (e.g.: "Primary care is not organized, locally."). From the other camp, issues relating to the lack of pre-existing Public Health / Primary Care partnerships were also cited, as was the lack of specific provincial policy guidelines identifying primary care practitioners as front-line pandemics influenza vaccine delivery agents.

This lack of pre-engagement and pre-planning, in combination with cumbersome record keeping requirements and a time-consuming billing bureaucracy, caused primary care provider groups in some areas to decide not to take part in the delivery of pH1N1 vaccine, either to their patients, or as part of a FAC. This was found to have occurred in some areas where, heretofore, primary care had typically been very active as vaccine delivery agents during the annual influenza season. Primary care respondents often indicated that more consultation with primary care was needed, a priori, and that there was a need for Public Health to take stock of local primary care capacity and resources - and to "let them do what they do well". Again, there was a clear indication of a desire for better integration (i.e., to improve coordination and collaboration) between Primary Care and Public Health. However, respondents to both surveys recognized that a formal conduit to facilitate such integration does not currently exist. All agreed that they did not know how to best achieve this result.

3. Influenza Assessment Centres (FACs)

Issues with the setting-up and running of FACs emerged as an unexpected theme during the interviews. While there was no specific section or line of questioning that addressed FACs in either the public health or primary care instruments, FACs were listed in the prompt box for discussion of components of a Plan for an Influenza Pandemic, and they often came up under the 'Additional Comments and Suggestions' and 'Other Issues or Topics that should be Addressed' sections. There was often confusion and disagreement regarding which entity or organization should be responsible for developing FAC policy and procedures. During the pandemic, certain operational issues arose regarding who should staff the FACs, staff salaries, timeliness of surveillance information and the nature of 'triggers' to signal when to open or close a FAC. The issue of the mismatch between the responsibility to establish a FAC [there is a perception that PHUs have it] and the legislative authority to diagnose and prescribe treatment (which is to perform a "controlled act" as defined by the Regulated Health Professions Act, 1991) is not clearly resolved [PHUs generally don't have it, except as delegated by the MOH, and therefore must 'hire' someone who does have it - and there is a recognized shortage of such individuals, in Ontario]. As well, at the time, PHUs' resources were stretched thin managing other components of the local PIP, such as the mass immunization of the populace.

4. Information and Communication

Critical information (including needed practical research), day-to-day updates, and the means of their communication also emerged as a theme. Primary care respondents often expressed frustration with information streams that came from multiple origins (national, the OMA, the Colleges, several sources at the MOHLTC, local PHUs, and the local, regional and national media) sometimes providing contradictory information, often arriving too frequently and thereby creating significant confusion. Concerns were also raised about the availability of evidence-based information regarding the safety and appropriate use of adjuvanted versus unadjuvanted vaccines. Retrospectively, there was a call for more quantitative and qualitative research studies, such as to firmly establish best practices in the event of a future pandemic, and to investigate the impact of delivering a vaccine at different time periods relative to local infection peaks.

In general, communication at the local level (i.e., Public Health notices to community stakeholders, and to the public) was considered good, although the frequency and timeliness of some centrally generated communiqués, in combination with the fact that local media could not always deliver time-sensitive information quickly, did cause some difficulty. In some of the more rural regions of the province, residents' primary source of local printed information is bi-weekly newspapers, and most local radio stations use 'canned' programming or simply re-broadcast feeds from larger centres, so local content is minimal and infrequent. Difficulty in the logistics of delivering important information to front-line workers was also cited. When working full days in the field, these workers had no access to computers and could not receive update communiqués in a timely fashion. Critical information was often received and implemented a day or more after it was transmitted. At the peak of the pandemic, this meant that, sometimes, recommended changes to the management of the pandemic being implemented at mass immunization clinics had already been superseded by updates, as yet, un-received by those workers.