"Safety Is Not Negotiable: The Importance of Occupational Health and Safety to Pandemic Planning" is a very appropriate title for our lead paper by Linda Silas, president, Canadian Federation of Nurses Unions; Nancy Johnson, labour relations specialist, Occupational Health and Safety/Workplace Safety and Insurance Board, Ontario Nurses' Association; and Kate Rexe, researcher, Canadian Federation of Nurses Unions. The 2003 outbreak of severe acute respiratory syndrome (SARS) generated a great deal of attention around the ability of Canada's health system to respond to a health crisis. This event underscored a serious issue - Canada's health system, on the whole, was not prepared to deal quickly and efficiently with a major emergency. This problem seemed clear in Canada's largest city, Toronto, as the hospital system could not contain the outbreak. Armed with little knowledge of the nature of the threat or the epidemiology of the disease, the health system was overwhelmed with how to deal with the crisis. Perhaps of greatest concern, however, was the inability to provide accurate and timely information to health institutions, healthcare workers and the public regarding the appropriate procedures and precautions to ensure optimal safety for all persons and to control the spread of disease. This paper makes the case that the integration of occupational health and safety into pandemic planning is essential to its success.

The authors begin,

In early March 2003, two middle-aged men were admitted to hospital within a three-hour period, one in Vancouver and one in Toronto. Both men, it turns out, had severe acute respiratory syndrome, or SARS. In the following six months, 251 probable cases of SARS were diagnosed in Canada - four in Vancouver and 247 in Toronto. Of the 247 probable cases in Toronto, 77% of the patients were exposed at a healthcare setting. Nurses, physicians, respiratory therapists, cleaners and other healthcare workers made up over half of these patients. Forty-four people died in Toronto's outbreak, including two nurses and a doctor.

According to the Commission to Investigate the Introduction and Spread of SARS in Ontario, Vancouver brought occupational health and safety and infection control to the same table very early on, and this was a major reason for its success. The authors argue that occupational health and safety in a healthcare setting does double duty by protecting both the workers and the patients and public. One of the key benefits of better integration of occupational health and safety into pandemic planning is the priority it places on the use of the precautionary principle. "If the [SARS] Commission has one single take-home message it is the precautionary principle that safety comes first, that reasonable efforts to reduce risk need not await scientific proof."

Since 2003 there has been much background work to ensure that the system can respond quickly and efficiently so that the next health emergency will be well managed, including the development of the Public Health Agency of Canada (PHAC) to help federal, provincial and territorial governments work together and develop more integrated and coordinated responses. Silas, Johnson and Rexe underscore that a great deal of work remains ahead to apply basic occupational health and safety laws and principles to pandemic planning. In their paper, the authors critically analyze the current planning around the potential threat of a pandemic - an outbreak of H5N1 influenza. They examine the scientific and policy debates currently facing decision-makers and present recommendations to ensure successful pandemic planning based on the precautionary principle. In other words, in the event of a health emergency such as a pandemic, all healthcare workers must be assured that every reasonable health and safety precaution will be taken to protect them from exposure to the threat in any form.

The key recommendations are summarized as follows:

• Infection control and respiratory protection programs should be built that integrate occupational health and safety into pandemic plans.
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• Nurses and other healthcare workers will be required to perform their duties in disasters, recognizing that their rights and protection granted under collective agreements will be ensured.
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• Collective agreements will remain in effect. Any other agreements must be subject to the Labour Relations and Occupational Health and Safety Acts in each province.
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• In the event of a pandemic, health human resource plans will need to go beyond traditional professional silos to include competency-based plans, training and options for care providers, and plans should encourage and integrate care providers.

The authors conclude that there is a need for an enhanced pandemic plan that follows the precautionary principle and meets the highest standards to ensure the health of citizens, including our health human resources. Silas, Johnson and Rexe believe that without such a plan, Canada will not be able to effectively manage a health emergency such as the predicted avian flu pandemic.

The lead paper sparked a great deal of interest from all our outstanding commentators. Mario A. Possamai who was senior advisor to the Commission to Investigate the Introduction and Spread of SARS in Ontario, which began its work in 2003, presents an excellent overview of the in-depth work of the commission. This work was concluded in January 2007, shortly before the untimely death of Justice Archie Campbell of the Ontario Superior Court of Justice, who led the investigation. Clearly, there are a number of important lessons learned from this thorough study. The details of the commission's three reports are now publicly available at www.sarscommission.com.

Possamai describes a vital lesson in worker safety - the occupational hygiene concept of a hierarchy of controls. This approach takes a holistic approach to worker safety, addressing each hazard through control at the source of the hazard, along the path between the worker and the hazard and, lastly, at the worker. The hierarchy includes controls of engineering, administration, work practices and personal protective equipment. Absent such an approach, the SARS Commission said that worker safety may focus on a particular piece of personal protective equipment or on specific policies and procedures such as fit testing the N95 respirator to the wearer. In worker safety, said the commission, the integrated whole is greater than the uncoordinated parts.

The final lesson in worker safety learned from the SARS outbreak is the importance of having a robust safety culture in the workplace, in which workers play an integral role in promoting a safe workplace. As stated by the Health and Safety Commission in the United Kingdom, the safety culture of an organization is the product of individual and group values and patterns of behaviour that support an environment of mutual trust and a shared perception of the importance of safety.Roslyn Devlin, Samer Abou-Sweid and John King of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, reflect on the experience of SARS at St. Michael's Hospital. They comment,

Our staff are our most valued resource. During SARS, our staff demonstrated their dedication and courage every day. This should never be lost in the discussions that occur as we plan to mitigate damage in the event of a pandemic. In turn, we are obliged to provide our healthcare workers with the best level of protection available to enable them to do what they do best … Our goal is to ensure that our workers remain healthy and are able to come to work so that the health sector continues to operate effectively and care for patients during a pandemic. The question then becomes, What is the best way to protect our staff?

The authors then go on to discuss the importance of infection prevention and control strategies, N95 respirators, vaccination and chemoprophylaxis against influenza A.

Michael S. Kerr, assistant professor, School of Nursing, Faculty of Health Sciences, University of Western Ontario, aptly describes the scariness of a potential global pandemic. It is indeed chilling, not only because of the possible extent of the epidemic itself but also because of the burden it would likely place on an already thinly stretched healthcare workforce. It therefore raises a rather alarming contradiction:

Given our recent experience of living through the consequences of the much less extensive outbreak of severe acute respiratory syndrome, one would think that we would be more than willing this time around to err on the side of caution and be as prepared as possible to deal with the next emerging infectious agent that comes our way. But, surprisingly, as is carefully outlined in Silas et al.'s paper, this does not seem to be the case. In a healthcare environment that is increasingly focused on the need for evidence upon which to base change in practice, are we possibly dragging our heels in raising our preparedness for a future pandemic? It is an interesting debate, and one that certainly merits further examination.

The unique challenges facing the home and community care sector in preparing for a pandemic are presented by an excellent team from the Victoria Order of Nurses Canada: Judith Shamian, president and chief executive officer, Teresa Petch, Freya Lilius, Esther Shainblum and Rita Talosi. They acknowledge that the healthcare setting is one of the most important areas to prepare for such an event but that it is crucial that discussions include all settings in which care is delivered: "As the home and community care sector is increasingly utilized and likely to be relied upon even more during a pandemic, addressing the challenges to occupational health and safety uniquely faced by this sector will be vitally important to the entire health system." Quite appropriately, they stress that "a pandemic plan that does not consider healthcare outside of the institutional setting is incomplete and will be likely to fail."

Bennet Waters of the Department of Health Policy and Administration, School of Public Health, the University of North Carolina at Chapel Hill, is currently on assignment as counsellor to the Deputy Secretary in the US Department of Homeland Security. He indicated that in November 2005, President George W. Bush unveiled the United States' National Strategy for Pandemic Influenza: "The president outlined three pillars of the strategy: (1) preparedness and communication, (2) surveillance and detection and (3) response and containment. Preparedness is the bedrock upon which surveillance, detection, response and containment rest." Accordingly, the paper by Waters focuses on the strategic aspects of effective pandemic preparedness and the cyclical architecture that links them.

Waters appropriately stresses, "A pandemic is much more than simply a public health or medical event. A pandemic will certainly have significant health and medical consequences that could overwhelm local resources and capacity. It will just as certainly have profound economic consequences and raise border security issues and will potentially affect the sustained operation of critical infrastructures. For these reasons, it is insufficient to plan for a pandemic on the basis of medical or public health consequences alone; pandemic planning must incorporate the full spectrum of preparedness activities." He also indicates, "It is not enough merely to have a local plan or to rely on the government to respond to a pandemic. Rather, effective pandemic plans must leverage the totality of community, state (or provincial) and national resources in a carefully integrated manner, and they must be tested, evaluated and continually refined." Waters clearly indicates that "developing and maintaining such plans require significant investments of time and a deliberate commitment to the process of capability-driven preparedness."

Waters describes very effectively how successful contingency planning for a pandemic needs a disciplined approach to the iterative cycle of preparedness, which includes planning, equipping, training and educating, exercising and evaluating, and identifying and incorporating lessons learned.

The idea of a possible pandemic is one that has frightening implications for individuals, communities, countries and the world. I ask you: Are you prepared at home for your family's safety? Has your organization put steps in place to outline which persons will be responsible for taking charge and how responsibilities will be delegated? How will essential services be maintained and under what circumstances? Are there contingencies in place for different scenarios, and have there been practice sessions? As Waters stresses, "The adage 'practice makes perfect' is never as apropos as when used in the context of preparedness planning."

I hope this issue of Healthcare Papers will stimulate your thinking about appropriate strategies for you personally and professionally.

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