“The messaging was confusing, and the natural thing to do in a state of confusion is to go for the conservative option,” said Ross Upshur, director of the University of Toronto’s Joint Centre for Bioethics and a primary-care physician.

A set of controversial studies that suggested getting a previous seasonal flu shot doubled a person's risk of catching pandemic H1N1 last spring has finally been published - though the mystery of whether the finding is real remains. Still, making public health policy during a pandemic based on data most people hadn't seen was far from ideal, said Dr. Ross Upshur.

"If you really want to hold a mirror up to our nation, you might ask the question why we're lending and not just giving," Dr. Ross Upshur, head of the University of Toronto's Joint Centre for Bioethics, said when he heard the news Canada is lending vaccine to Mexico. "What does that say about us? We're not using the vaccine that we have, we've got a surplus, but we're not big enough just to simply give?"

“I’ve been getting calls from two or three reporters a day and I like to help them try to understand a difficult story as best I can,” says Dr. Kumanan Wilson, Canada Research Chair in Public Health Policy at uOttawa. “When there’s confusion and uncertainty, it’s up to the media and media commentators to explain to the audience what is happening.”

"Given that some nations are making contributions out of their stock, one would ask the question why Canada isn't doing the same," said Dr. Ross Upshur, director of the Joint Centre for Bioethics at the University of Toronto. "I think we've got sufficient resources to make a contribution to others on the basis on generosity, solidarity, altruism."

"We may want to ask the question why Canada has A, not had any public discussion of this from our political masters, and B, why it seems that we are not good global citizens in that regard," said Dr. Ross Upshur, adding that there is a strong ethical argument for sharing Canada's H1N1 vaccine with other countries.

"Yes, mortality was less than what we expected, but look who was dying," says Dr. Ross Upshur. "It was younger people who had a probability of death that was as low as can be, on an average basis. And all of these were preventable deaths. Yes, I'm glad there weren't tens of thousands of deaths -- who would wish that? But the deaths that did occur were disproportionately in younger people, who you would not have expected to die."

"There was lots of confusion about who got what, when, who was eligible for the vaccine, and it was changing on a daily basis," says Dr. Ross Upshur, director for the Joint Centre for Bioethics at the University of Toronto. "As a clinician, when you have a family and only one of them is on a priority list, it's very hard to say, 'You get the vaccine and the rest of you don't,' because it makes no sense. Infections spread in families."

That [21.5 million doses of vaccine] is enough to vaccinate nearly 64 per cent of Canadians — considerably more than have indicated a willingness to be immunized up until now.“That would be well above anything we’ve ever achieved,” said Dr. Ross Upshur, director of the University of Toronto’s Joint Centre for Bioethics.

The government spokesperson said it will be important to hold onto some additional supply, in case increased demand is triggered by future events that cannot be foreseen. But Dr. Ross Upshur said Canada shouldn't hoard lots of vaccine while many parts of the world have little or none.

“There’s a requirement ... if we’re not going to use it that we make it available to those who can use it,” said Dr. Ross Upshur, director of the University of Toronto’s Joint Centre for Bioethics.

"Nobody has seen a flu season like this on the ground level," said Dr. Kumanan Wilson. "If you talk to any frontline worker, they've never seen anything like this. And we keep getting told this is nothing." "Emergs (emergency departments) are filled. All the children's hospitals are filled. Family docs I talk to say 'Oh my God, I've never seen so many flu cases.'"

“This kind of communication may be the new normal. I think human behaviour is starting to mirror that of influenza virus: changeable, unpredictable and subject to frequent mutation,” said Ross Upshur, director of the University of Toronto’s Joint Centre for Bioethics and a primary-care physician.

"It's not fair to make the comparison," said Kumanan Wilson, Canada research chair in public-health policy at the Ottawa Hospital Research Institute. "On the ground level, this is definitely not that much milder than the seasonal flu as those mortality stats would suggest. It's as bad, if not worse as regular seasonal flu. That's the clinical experience."

"We're sort of in the grey zone, is it worth it or not? We'll have to see how this plays out to determine that. If there is a potential third wave and the vaccine program has helped mitigate that in Canada ... then it still may be worth it," Dr. Kumanan Wilson said.

We vaccinated current soldiers en masse, along with their Taliban prisoners; per capita, the Department of National Defence has received far more vaccine than any province or territory. Why have we forgotten the veterans?

Dr. Upshur also said that, in a society where citizens generally trust each other's moral behaviour, have a collective sense of caring for one another and have confidence in their governments to deliver on their commitments, there's a low likelihood of people sneaking treatment ahead of sequencing – queue-jumping, in a word.

"I try to think how they could have done any better and it's hard to see," said Dr. Kumanan Wilson, a public health expert at the University of Ottawa. "Public health warned us about this, it did happen. They said there was going to be a second wave, there was a second wave. They do have a vaccine available."

"I think it's reasonable that the first group has to be the high risk group," Dr. Kumanan Wilson said. "But then I think before going to the general population or the next group, they should target the group that's most likely to spread the virus, that would be the school-aged children. And then they can move to the general population."

If the shortfall continues, officials may need to rethink their distribution plan and shift priority, once high-risk groups are vaccinated, to the single largest reservoir of infection — schoolchildren. "That's probably the most effective way to reduce the spread of the virus," says Dr. Kumanan Wilson, Canada research chair in public health policy and a specialist in general internal medicine at the Ottawa Hospital.

Kumanan Wilson, an expert on pandemic preparedness at University of Ottawa, said there is not enough public information to decipher what, if anything, has created a bottleneck in trying to mass immunize the Canadian public.

"It looked initially like we were perhaps going to be too late," Kumanan Wilson, Canada Research Chair in public-health policy at the Ottawa Hospital Research Institute. "But in retrospect it looks like we may have actually made the right call."

Christopher McDougall, of the University of Toronto's Joint Centre for Bioethics, which deals with ethical issues of a pandemic response, says protective measures along those lines would not be of much help and believes the time has passed to be largely effective in airports.

For now, "I think there's a lot of public uncertainty about this vaccine," said Kumanan Wilson, a former Frederictonian now at the University of Ottawa. But Wilson himself, a medical doctor as well as public health policy expert, says "I trust our public health officials that the vaccine is safe."

"While we hope there will not be a major second wave of the H1N1 flu, there is limited cause for optimism and we could well see the pandemic's full onset late this year or early next when the traditional flu season begins," says JCB Director Ross Upshur

The anticipated onset of a second wave of the H1N1 influenza pandemic could present a host of thorny medical ethics issues best considered well in advance, according to the University of Toronto Joint Centre for Bioethics, which today released nine papers for public discussion.

The CanPREP White Paper Series provides a preliminary analysis of The Canadian Program on Research of Ethics in a Pandemic (CanPREP) research findings. Each paper discusses ethical issues related to a particular research theme (e.g., priority setting, duty to care) and addresses several questions.

"We'll know who's smarter at the end of the flu season," said Ross Upshur, director of the University of Toronto's Joint Centre for Bioethics and a primary care physician. "What we assuredly have is an outbreak of unpublished research which is causing an epidemic of confusion."

Kumanan Wilson, Canada Research Chair in public health policy at the University of Ottawa, said Canada must not repeat the mistakes that were made during past public health emergencies, such as the SARS outbreak and the tainted blood scandal, and that the fundamental ethos of public health — the precautionary principle — must be applied.

Ontario announces a three-phase plan for fighting the flu this fall. Includes interview with Dr. Ross Upshur

"There's going to be a lot of uncertainty to decision-making, even in a mild pandemic," says Dr. Ross Upshur, director of the University of Toronto's bioethics centre, which released a series of research papers on pandemic ethics on Wednesday.

'People will refuse to take the vaccine if they don’t have confidence in how the vaccine is being rolled out,' warned Dr. Kumanan Wilson.

The anxiety comes despite assurances from the Public Health Agency of Canada, Health Canada and the World Health Organization that the vaccine will adhere to high safety standards. "New vaccines always provoke anxieties," said Dr. Ross Upshur of the University of Toronto's bioethics department. Questions about the vaccine's effectiveness and its risks is only compounding anxiety, he said.

Dr. Ross Upshur discusses the 'pandemic of indecency' on CBC Radio's The Current.

"They're going to get enough vaccine for everybody to have it; nobody's going to want it, and any sequence that they can come up with of who gets it first isn't going to satisfy anybody because somebody has to go second for a vaccine that they don't want to get," said Dr. Ross Upshur

Dr. Jennifer Gibson discusses the ethics surrounding pandemic planning

"There is an obligation for the better-off nations of the world to help support the low- and middle-income countries address and respond to novel pandemics, and that wouldn't be just for H1N1, but I think for every form of serious infectious disease that threatens global health security," Dr. Ross Upshur said.

Powerpoint presentation by CanPREP's Shawn Tracy, given at the 2009 National Healthcare Leadership Conference in St. John's, Newfoundland, Canada.

"Now is the time to have those conversations," said Jennifer Gibson, director of partnerships with the Joint Centre for Bioethics. "They appreciate the difficulty of the choices that have to be made," Gibson said of the people they have spoken to.

Increasing Internet usage has accelerated the spread of such mis-information about vaccines in the United States and in Canada, says Dr. Kumanan Wilson, who holds a Canada research chair in public health policy at the Ottawa Hospital. Vaccine skeptics are using social networking sites to meet other skeptics and they can share their views through blogs and Web sites, he said.

Mr. Upshur, of the University of the Toronto, says some argue anti-virals and other resources shouldn't go to people who do not have a "high probability of survival." In other words, younger and healthier adults should be first in line.

Dr. Ross Upshur said CanPREP researchers see public engagement as providing valuable input to help shape policy, build consensus and resolve moral conflict in dealing with health crises. CanPREP has already taken the issues to the public through a national public opinion telephone survey.

CanPREP was highlighted in the January edition of this Newsletter. Click the above link to view the full newsletter in pdf.

CanPREP was highlighted in the Canadian Pandemic Preparedness Meeting held in Winnipeg, Manitoba, Canada. Click to read the meeting's entire executive summary.