Legislative Assembly of Ontario

EMERGENCY SERVICES WORKERS NOTIFICATION PROGRAM GUIDELINES

CONTENTS

Monday 28 November 1994

Emergency services workers notification program guidelines

STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE

*Chair / Président: Marchese, Rosario (Fort York ND)

*Vice-Chair / Vice-Président: Harrington, Margaret H. (Niagara Falls ND)

Bisson, Gilles (Cochrane South/-Sud ND)

Chiarelli, Robert (Ottawa West/-Ouest L)

Curling, Alvin (Scarborough North/-Nord L)

*Haeck, Christel (St Catharines-Brock ND)

Harnick, Charles (Willowdale PC)

Malkowski, Gary (York East/-Est ND)

Murphy, Tim (St George-St David L)

*Tilson, David (Dufferin-Peel PC)

*Wilson, Gary (Kingston and The Islands/Kingston et Les Iles ND)

*Winninger, David (London South/-Sud ND)

*In attendance / présents

Substitutions present/ Membres remplaçants présents:

O'Connor, Larry (Durham-York ND) for Mr Bisson

Also taking part / Autres participants et participantes:

Ministry of Health:

Schabas, Dr Richard, chief medical officer of health

Wallace, Dr Evelyn, senior medical consultant, STDs/AIDS unit

Clerk / Greffière: Bryce, Donna

The committee met at 1542 in room 228.

EMERGENCY SERVICES WORKERS NOTIFICATION PROGRAM GUIDELINES

The Chair (Mr Rosario Marchese): We welcome Dr Richard Schabas, chief medical officer of health of Ontario, and Dr Evelyn Wallace, senior medical consultant on the mandatory program guidelines for emergency health workers' notification. I understand that your briefing would take 20 minutes or so, more or less.

Dr Richard Schabas: It can take as long or as short as you'd like.

The Chair: Twenty minutes would probably suffice, and there was an agreement with some of the members that 10 minutes per caucus would suffice for questions, so we'll leave it like that. Dr Schabas, please begin as soon as you're ready.

Dr Schabas: I'm just going to give a very general introduction and then Dr Wallace will walk you through the draft manual. But to pick up, it's been almost exactly a year since we last discussed this matter at this committee and I was given the undertaking that Bill 89 would be stood down pending our ability to implement a mandatory guideline under the Health Protection and Promotion Act to accomplish essentially the same ends.

Following the meeting, I think on November 2, we proceeded to complete the process of consultation that we were already well into with emergency service workers and public health departments and other interested parties -- and of course many of them presented at this committee around Bill 89 -- and arrived at an acceptable mandatory guideline and some general protocols in support of that. They were signed off by the Minister of Health, Ruth Grier, in I believe March or April --

Dr Evelyn Wallace: End of June.

Dr Schabas: End of June; pardon me -- allowing for the usual bureaucratic delays, which seem to be unavoidable. But in conjunction with that, we also prepared the manual for designated officers which Dr Wallace is going to walk you through as a way of describing the protocol.

As of I think August, we have distributed our copies through the public health system. I gather there's been some delay with the emergency health system, but I'm assured that they'll be distributed through that system within the next two months, and in addition the emergency health services branch of the ministry is preparing a video to support this.

I'm now going to turn the floor over to Dr Wallace, who's going to just walk us through the protocol as it's laid out in this manual.

Dr Wallace: This is the binder we sent to our 42 health units in August of this year, and at that time I believe the members of this committee received a copy of both the mandatory guideline and the protocol for notification, so there are three components to the contents of this binder.

Probably of most interest is the protocol. I don't know if you've all had a chance to read it or if you're familiar with it or if you're ready to ask questions. My understanding was that I was going to take you through the actual manual for the designated officer, which was why I was asked to be here today, but if you'd like me to talk about the protocol for notification, I'd be happy to do that.

Another content of the binder is this red booklet, which we actually bought from the American Red Cross, Public Safety Workers and the HIV Epidemic. It's just an additional tool to help educate the workers out in the field.

Shall I move straight to the manual for the designated worker? Okay? I believe you now all have a copy of that as well.

If you read through the table of contents, you will see the various aspects of this problem that we've tried to address. One of the problems with the designated officer status was that we discovered that the level of information and knowledge varied quite greatly across the three emergency services, from ambulance attendants, who could indeed have honorary medical degrees, to voluntary firemen, who really had very rudimentary knowledge about the transmission of infectious diseases. So it was quite a challenge to produce this manual. To do it, we once again formed a subcommittee of the Public Safety Services Liaison Committee with representation from the three services, and with a bit of effort we put this together.

The introduction and the background I don't think need have much said about them. Guiding principles for universal precautions I think are now accepted by all three organizations, and I think what makes this protocol unique to Ontario is the designation of a designated officer in each of the emergency services. If you look at perhaps page 5, you'll see in that section we've listed everyone's roles and responsibilities, including the responsibility of designated officer. It will be up to each emergency service organization, hopefully in conjunction with joint health and safety committees, to nominate this individual, who will use this manual when they are dealing with difficult scenarios.

It's the expectation that the worker who thinks they've had an exposure to the specified communicable diseases that are listed will contact the designated officer, who will then do an assessment of the circumstances of the exposure and may or may not be able to reassure the worker at that stage, but if they need further information, they will contact the local medical officer of health, who will then also investigate the circumstances and give information back to the designated officer, who will contact the worker.

To help the designated officer and to aid with the education, we've put in a fair bit of information about the various diseases. We've also put in various scenarios and walked the designated officer through these, and these are at the back of the binder. We've also put in forms relating to workers' compensation claims for the worker and the employer.

That's it sort of in a nutshell. I'd be willing to talk more about any specific details of the contents.

1550

Mr David Tilson (Dufferin-Peel): Thank you very much, Dr Schabas and Dr Wallace, for coming. It was I who introduced this bill in the House, and it was as a result of conversations and discussions particularly with firefighters, although that then spread to ambulance workers and police officers across the province, and I received substantial correspondence and had substantial meetings with the different groups with respect to the problems in this bill, and you have indeed responded.

Just for your own information, and it is not a critical comment, I too, having only been here a short period of time, understand the slow workings of the system. But I will say that many of the leaders of firefighters and others have received this book, Protocols for Notification of Emergency Services Workers. I spoke to a convention of the firefighters last Tuesday at the Royal York, and many of the groups across the province have not received it. I know it was promised for Thanksgiving. So my comments are made on the assumption that the communication has improved, because there was some criticism, rightly or wrongly, of communication with the emergency care workers.

Perhaps that leads to my first question, which is not with respect to the guidelines but with respect to communication with respect to the various groups. Have there been any changes, specific changes that perhaps improved the system of discussing this or any other types of problems with these types of people?

Dr Schabas: To answer the two questions, I mentioned in my preamble that we knew there had been delays with the distribution to emergency service workers, and that's unfortunate. The first part, which was distribution through the public health system, we accomplished last August. The production for the emergency service workers, as I understand it, involves a much larger production and there have just been some delays in that branch of the ministry in terms of getting the tendering and the costs and I apologize for that. That's not an excuse, it's just an explanation of what happened.

On the second question, have we learned something, I think the answer from a public health standpoint is yes, we've learned a lot. These are not groups that we have a long tradition of consulting with. Firefighters, ambulance attendants and police officers are not a group that public health, at a provincial level in any case, is used to interacting with. I think there's more experience at a local level. I think we've not only learned how to work with them, I think from our standpoint it's been a very successful experience because we've produced a product that everybody is reasonably satisfied with -- maybe not everybody is absolutely delighted with, but everybody is reasonably satisfied with.

If I've learned any one lesson, it's that perhaps we should have been a little more proactive in dealing with the concerns of these groups and having had these guidelines maybe a year or two earlier instead of waiting till we had a fire lit under us by your bill.

Mr Tilson: Notwithstanding the fact that many of the groups have not received copies of it, when I spoke to the firefighters, I guess it was at a convention last week, I was told that the one important thing that came as a result of this bill is that with many emergency care workers, as a result of this booklet that you prepared, these guidelines that you prepared, if anything, there has been an improvement in the education, an awareness of problems. People are talking about it so they're taking more precautions. I'm sure you'd be pleased with that.

I only have one other question, and it has to do with the topic of the good Samaritan, the off-duty emergency care worker or the passerby. It's referred to on page 1, and it's more importantly referred to at page -- well, I'm not too sure of the numbering here.

Dr Schabas: It's not numbered. It's the fourth page of the protocol.

Dr Wallace: It's item 7 of the protocol.

Mr Tilson: Item 7, exactly. Thank you. The sentence that jumps out, referring to the good Samaritan or the off-duty emergency service workers, is, "These people will not necessarily be covered under the general provisions of these guidelines." I think I understand that, but perhaps you could clarify or elaborate on item 7.

Dr Schabas: Sure. The basic protocol for notification really is aimed at the emergency service worker who has exposure in the course of his or her work and works through the designated officer.

I think what is meant here is that certainly good Samaritans operating on their own, and to some extent possibly off-duty emergency service workers, don't fall into those protocols. A good Samaritan wouldn't call a designated officer with a question, so they're not covered under the -- maybe the wording should have referred to the general provisions of the protocols. What this is really meant to do is to alert medical officers of health to treat good Samaritans when they come to their attention, either because, in the course of investigation, they come across a good Samaritan or because a good Samaritan comes to them with concerns. They treat them at their end, at the medical officer of health end, in exactly the same way they would a request from a designated officer.

Mr Larry O'Connor (Durham-York): Thank you for coming today and sharing this with us. I'd like to congratulate you on your annual report that you put out and commend you for the way you've delivered that and have delivered it on an annual basis. I think it certainly is one that helps keep public health and the health of Ontarians in the forefront.

As Mr Tilson has raised in regard to, for example, the good Samaritan, it's quite often the work that's done by public health that is overlooked in a lot of communities. A lot of communities don't realize the value they add to our community, so I think your annual report certainly does allow that to take place.

Within your protocol, just to comment, I would like to point out that by using the actual case scenarios, I think you actually -- I was, for example, looking at the one on page 20 about the car accident. It actually points out a real-life situation and a process that people should go through. I think the way you've designed this manual will certainly encourage discussion and interaction, hopefully by all the emergency workers, so that they can make sure they know how to respond when they feel they've been placed at risk.

Dr Schabas: Thank you for those comments. I think that some of the strength of the manual really reflects on the consultation that went into it. The fact that it seems to be a down-to-earth, real-life kind of manual I think reflects the fact that we had a very good working relationship with the emergency service workers and they had a lot of input, not only into the design of the protocol but into the actual content of the manual.

1600

Ms Christel Haeck (St Catharines-Brock): It is most informative to flip through these different pages and see how much work has gone into developing this information manual.

I noticed, though -- and this is something I must admit I hadn't really thought of and I guess this is what makes these sessions so interesting; it is definitely an illuminating experience -- you refer to the sexual assault victim. This is towards the back of the manual. While I understand that the initial treatment will in all likelihood happen at the hospital, have you been doing any work at all, and this is relating more to hepatitis, with the transition houses, the women's shelters, on some of these issues relating to possibly hepatitis, since this is what's being referred to, and how they might be able to deal with people in this situation?

Dr Schabas: I don't know for a fact that they have been part of these discussions. Evelyn, do you know?

Dr Wallace: Not in this context, but is your question related to whether they have access to hepatitis B vaccines?

Ms Haeck: Not strictly. I'm a layperson. I'm a librarian in my other life; I'm not a medical practitioner. I've looked at the list of the different kinds of blood-borne diseases and you're talking about some that I know are more than just contagious. They are in fact, in the case of Ebola, not something that you monkey around with.

Dr Schabas: No pun intended since some of these are monkey borne.

Ms Haeck: No, no. You're right, no pun intended. So you're talking about some of these situations and realizing that there is a range of factors, some real serious health outcomes for the individual who has hepatitis, but as well what the situation is in those shelters for people who may in fact come in contact with someone.

I know there are a lot of volunteers who are working in those shelters who again may not be aware of the range of conditions they may find themselves coming in contact with. I'm just wondering to what degree, that you're aware of, either the public health officers throughout the province or the shelters themselves are carrying on an awareness campaign that they may be coming in contact with these serious situations.

Dr Schabas: The simple answer is that I'm not aware of to what extent they are, but I think the point's very well taken. We like to learn from our experiences and we've certainly learned through this experience of the need to be more sensitive to the levels of knowledge of, in this case, emergency care workers. But I think you've raised another group who might well profit either from a copy of this manual or from some sort of interaction with their local health departments.

It may well be that in a lot of health departments there are those kinds of contacts because they'd have contacts around other things, around sexuality, education and around sexually transmitted diseases. But it certainly bears our looking into it and making sure that's done systematically.

Mr David Winninger (London South): This isn't directly related but since I have the experts before me, perhaps I'll ask you the question.

From time to time, I have inquiries about reporting of positive AIDS findings and how the local health units deal with them. I think I know now how our local health unit in London deals with this, and it's rather complicated. But what I'm wondering is whether guidelines have been issued through your office to all of the health units so that they can report in a fairly uniform way and balance the right to anonymity against the public's right to know and to monitor.

Dr Schabas: There was a policy statement actually issued by the Minister of Health in May 1991 which very nicely laid out what the principles of reporting were. Ontario basically allows three kinds of reporting of HIV infection.

There's the nominal reporting, which is similar to other reportable diseases where information about the individual, including their name and address, is submitted. Almost 50% of HIV-positive individuals in Ontario are reported in that way.

The second is non-nominal reporting whereby the medical officer of health will accept initials and dates of birth rather than full name and address, on the condition that the family doctor will ensure that there is adequate counselling of the infected individual, that there are reasonable efforts made at partner notification and partner counselling and that there's some assessment as to the risk that individual might pose to others. Assuming all those criteria are met, the medical officer of health then can accept only the initials and dates of birth. I believe about 40% of positive tests in the province are made non-nominally.

Furthermore, there's the provision of anonymous testing, and that's only through designated anonymous testing clinics. In those situations the person doesn't give their name at all. In fact, they are the only one who knows who they are and that they have a positive HIV test. They do of course receive counselling as part of that when they receive their positive result and there are efforts made to encourage them for partner notification.

Clearly there aren't the same public health safeguards with anonymous testing. The tradeoff is that it is thought that it encourages a small group of individuals who otherwise wouldn't get tested at all to come forward for testing. I believe about 10% of our positive HIV tests in Ontario come through the anonymous testing system.

Mr Winninger: Okay. Now let's say that a patient is examined by a physician and the physician does the requisite tests and determines the patient is HIV positive. Who decides? Is it the physician who decides how the testing will be reported, or is it the patient, or is it a combination of both?

Dr Schabas: The way the protocol is supposed to work, the patient is supposed to be informed by the physician before the test is done as to what their options are -- that's a position taken by the College of Physicians and Surgeons of Ontario -- so that they can go for anony mous testing if they wish or they can ask for non-nominal or they can agree to nominal testing. If the patient chooses non-nominal, the physician is supposed to make it clear to them that that's only allowed, that will only be accepted by the medical officer of health, provided these criteria are met.

Ultimately it's up to the medical officer of health to decide, as things stand right now, what they will or will not accept, although generally speaking there's not conflict with the physician. If the physician assures the medical officer of health that these things have been done, with very rare exceptions that's accepted by the medical officer of health.

The Chair: Thank you, Dr Schabas and Dr Wallace, for all the work you have done in creating the guidelines around emergency health workers' notification.

Dr Schabas: Thank you for your patience.

The Chair: Mr Tilson, you have a motion?

Mr Tilson: I move that the Chair be authorized to report to the House that the following bill be not reported: Bill 89, An Act to amend the Health Protection and Promotion Act.

The Chair: Any discussion? Seeing none, all in favour? Opposed? The motion carries.

This committee is adjourned.

The committee adjourned at 1606.