Scientific Illiteracy Impairs Canada's Pandemic Plans
BY DR UGIS BICKIS
© 2006 FrontLine Security (Vol 1, No 2)

Beware of an alarming illiteracy in Canada! This problem is evident among health officials tasked with protecting the public. It appears that they have not read, or possibly not understood, the science – we know they have disregarded it. Their lack of understanding is egregious. They also have not called upon the cadre of professionals who are well versed in the science and art of protecting people from disease, particularly airborne disease.

As indicated in the November 2005 submission of the International Occupa­tional Hygiene Association (IOHA) to the World Health Organization (WHO):

To most effectively protect the public at large from a virulent and transmissible strain of avian influenza that (by general consensus) is likely to develop in the near future, it is necessary to minimize the exposure of two “front line” worker groups (FLWs) who are at greatest risk – poultry workers, who are in direct contact with the immediate source, and health care workers (HCWs), who will be the first to encounter the ill (and contagious) members of the public. Once these FLWs become infected, they (in addition to personally experiencing the direct consequences, and society thereby losing their valuable services at the outset) will transmit the disease further.

As the world moves inexorably closer to an influenza pandemic, with the potential for it to be the most societally-devastating event in this century, our Pandemic Preparation Plans continue to be based on myth and baseless hopes.

Pandemic Plans should and can be effective, they must make use of available science and technology, and can be maintained at lower cost than is currently envisaged. To do this, our public health officials must update their education rapidly and, especially in view of the time constraints, seek immediate help from the occupational hygiene community.

The response from Ontario’s Chief Medical Officer of Health, to this author’s suggestion that its Plan constitutes criminal negligence on the part of its Health Minister, was to indicate that PIDAC (the Provincial Infectious Diseases Advisory Committee) had “endorsed the recommendation... [including] the use of a surgical mask... as appropriate.”

Unfortunately, no one in PIDAC is qualified in occupational hygiene, nor more specifically, in the critical aspects of aerosol science and respiratory protection.

There was no response received from the Chief MOH to a follow-up communiqué emphasizing that “a fundamental requirement in a scientific review is the ability to rely only on primary references,” providing some specific examples, and including an offer of assistance.

When it comes to diseases such as Influenza, the basic tenets one would expect to see accepted, based on decades of scientific and professional work, are:

  • an expelled or exhaled aerosol is largely of respirable size, or rapidly becomes so as a result of the evaporation of water in any droplets;
  • this aerosol can remain suspended in air for a long time, and can travel considerable distances;
  • surgical and procedure masks are inappropriate for use as respiratory protective devices (RPDs); and,
  • air purifying respirators must have an air-tight seal between the device and the skin of the face if they are to provide the anticipated degree of protection.

However, and to the contrary, the accepted dogma in Infection Control is:

  • exhaled droplets are large, and travel in air no more than 3 feet (1m); and
  • a surgical mask provides protection.

PIDAC drew upon the Canadian Pandemic Influenza Plan (CPIP), which introduced this erroneous dogma into national Pandemic Plans.

Personnel involved in the production of the CPIP have similar backgrounds to those that participated in PIDAC’s work; as the saying goes – if you keep doing what you’ve been doing, you’ll keep getting what you’ve been getting.

Infection Control was, for many years, a concept not given its due support - why bother to prevent a disease, when there’s a cure? Consequently, the Infection Control community has indeed “circled the wagons,” they (seemingly) do not want science confusing matters further.

In anticipation of a disease of major proportions, and in preparation of our corresponding defence, it is more than appropriate to consider modes of transmission. We must understand “exposure” in order to prevent it most effectively.

There has long been argument of whether influenza is transmitted through the air. In the internationally respected medical journal, The Lancet, one finds this statement: “It seems to be without doubt to be carried through the air.” That was in 1897. Over the years, some have disagreed; however, the weight of evidence clearly indicates that influenza is transmissible (and contagious) through the air.

Many authorities have “got it” – for example, the U.S. Centers for Disease Control and Prevention wrote of influenza in October 2005: “Airborne spread is the predominant form of transmission.”

On the other hand, Canada’s national preparation plan continues to act on the belief that airborne transmission is “contro­versial,” and has based its plan on that premise. The matter is not controversial among those with expertise in airborne disease.

The Plans’ sections on “prevention” consider agents such as vaccines and anti-virals as the first line of defence – never mind that these are going to be unavailable or unreliable – they don’t start to take effect until the virus is within the body.

In security terms, that’s like considering a “perimeter defence” consisting of checking ID at the food line of the dining hall – it may actually catch some of the “bad guys,” but it’s hardly primary prevention.

Can we rely on primary prevention to prevent a pandemic? No. But, we have a choice as to how many millions become ill, may well die and, the concomitant degree of societal disruption. Such measures protect not just from pandemic ‘flu, but also from other novel pathogens, the newly-resistant strains of “old” bacteria that could formerly be treated with antibiotics, and from diseases re-emerging due to a relaxation of preventive measures such as vaccination.

What is in these various Plans? They include the basic premise that around every infective person, at a distance of 3 feet (1m), there is some kind of shield through which infectious organisms cannot pass. Call it the ‘Magineit Line’ – even more nebulous than the Maginot Line on France’s eastern border – considered by some as exemplary of a situation where authorities came to believe their own propaganda: that the mere existence of the Line rendered them impervious to invasion.

To highlight how broadly accepted this faulty presumption is, Ottawa’s Interagency Influenza Pandemic Plan considers front-line workers to be only those who “would be within one metre of influenza patients.”

Does exposure decrease with increasing distance from the source? Typically, yes. Is there a “barrier,” or any other quantum leap in exposure, at 3 feet? No.

A 1996 editorial in the New England Journal of Medicine attributed the so-called “Three-Foot Barrier” notion to J.A. Glover. Anyone who reads the original (1920) reference will recognize not only that the concept of such a “barrier” is ludicrous but, from Glover’s government report, that there is no basis for devising one. However, he did devote considerable attention to “dangerously deficient ventilation,” which, notably, has been disregarded in today’s health care environment.

The basic principles of occupational hygiene stipulate control at source. If you find yourself in a hospital (whether as staff, patient or visitor), note the visible ventilation system components. In the Emergency Department for instance, consider the relative placement of:

  1. air supply and exhaust; and
  2. triage staff and incoming patients.

Air should be supplied to the area usually occupied by staff, drawn through the area usually occupied by the patient(s), then exhausted. This minimizes the likelihood and extent of patient bio-effluents impinging on staff. Ventilation is often “backwards” with the system directing bio-effluents from the patient towards the staff.

And, we wonder why existing occupational and nosocomial infection rates are high? Pandemic Flu will prove much less forgiving in this situation.

What else is in the Plans? The Health Care Worker’s proverbial “new clothes.” Many plans call for the use of “masks,” such as surgical masks. There are many scientific and technical reasons why this is negligent advice. For those under federal jurisdiction, though, it’s simple: the Occupational Safety and Health (OSH) regulations stipulate that an RPD must be listed in the “NIOSH Certified Equipment List.” “Masks” are not.

When it comes to respiratory protection, some jurisdictions have “got it right,” British Columbia, for example – the “other” province to experience the SARS problem.

During SARS, British Columbia stipulated that surgical masks do not provide adequate protection, and that a filtration capacity at the NIOSH N95 level is the minimum acceptable. On the international front, France also stipulates and regulates to the same standard (including, of course, the EU equivalent).

“The next outbreak, however, may be even more insidious than SARS. Canada may have to deal with a deadly airborne virus, or a virus transmitted via droplets but with such a long incubation period that quarantine would be worthless. Will we be ready?” asked Dr. Naylor, Chair of the National Advisory Committee on SARS and Public Health (October 2003, Learning from SARS – Renewal of Public Health in Canada.)

Not unless our Pandemic Plans are soon changed.

The good news might be that the Public Health Agency of Canada has called for a “consensus” meeting on Influenza Prevention (in Toronto on June 15 and 16). Of course, consensus depends on whom you ask. In this case, a provincial nursing organization has been rejected because this is a “technical scientific meeting where all participants are bringing in-depth experience and knowledge on the use of masks to protect health care workers. We are inviting specific national organizations… [this meeting] will bring together key authorities in infection control and prevention and occupational health and hygiene from across the country and abroad.”

Is this an acceptable approach? It would be – if it were true.

Health Canada offers this definition of Occupational Hygiene: the art and science dedicated to the anticipation, recognition, evaluation, communication, and control of environmental hazards or stressors in, or arising from the workplace that may result in injury, illness, or impaired well-being of workers and/or members of the community.    

The Canadian Registration Board of Occupational Hygienists (CRBOH) is the national organization of accredited professional hygienists and represents Canadian practitioners of the discipline at international forums. Like the nurses, its interest in participating was rebuffed because it had not been invited.

Ironically, a member of the CRBOH (and, as the designate of the International Association representing its 20,000-plus professional hygienists in 20-plus member nations) was one of some 15 invited non-WHO technical experts participating in the WHO Pandemic RR&C Geneva meeting in March.

The President of the Treasury Board (responsible for the administration of ­federal OSH laws) writes, on behalf of our Prime Minister: “Accountability is the foundation on which Canada’s system of responsible government rests. It is key to assuring Parliament and Canadians that the Government of Canada is using public resources efficiently and effectively, and that it answers for its actions.”

What can you do to encourage and ensure the immediate and ongoing accountability of our public health officials in view of these serious challenges to our preparedness and to your health?

It’s not too late... is it?

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Ugis Bickis, MEng, PhD, CIH, ROH is a Principal of Phoenix OHC, Inc., on (adjunct) faculty of Queen’s University at Kingston and the Royal Military College of Canada, and is CRBOH’s representative to IOHA.
© FrontLine Security 2006

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