Ministry Reports

Report Card : Progress in Protecting the Public's Health

Report of the Expert Panel on the Legionnaires' Disease Outbreak

The full report was prepared by the Expert Panel on the Legionnaires' Outbreak and attempts to answer four key questions :

  • When the Legionnaires' outbreak occurred, did the system do a better job of responding than it had in the past?
  • Did the changes since SARS make a difference?
  • What worked well?
  • What can we do better in the future?


In the fall of 2005, a long-term care home in the City of Toronto experienced an outbreak of Legionnaires' disease, a type of pneumonia. A total of 135 people were infected : 70 residents, 39 staff, 21 visitors, and 5 people who lived or worked near the home. Twenty-three residents died. For the first 10 days, the cause of the outbreak was unknown.

The Legionnaires' outbreak was the first time since SARS in 2003 that Ontario faced the threat of an illness that could not be easily or quickly identified. It was also the first opportunity to test the lessons learned from SARS.

Over the past two years, Ontario's health system has been working to implement the recommendations in For the Public's Health : A Plan of Action, the final report of the Ontario Expert Panel on SARS and Infectious Disease Control (Ontario Expert Panel on SARS and Infectious Disease Control. For the Public's Health: A Plan of Action. April 2004), and to improve our ability to respond to emerging health risks and emergencies.

On October 16, the Minister of Health and Long-Term Care established an Expert Review Panel on the Legionnaires' Disease Outbreak to : assess the progress Ontario has made since SARS; identify the key lessons from the recent Legionnaires' disease outbreak; and provide advice on how to strengthen infectious disease control in Ontario. (See Appendix 1 in the full report for Terms of Reference and methodology)

Goals of Outbreak Response

The two immediate goals of outbreak response :

  • providing the best possible care for people who are ill
  • preventing or controling the spread of the infectious disease

Based on its review, the Expert Panel found that the outbreak response achieved both these goals. The right things were done in a timely way to care for people who became ill, and to prevent the spread of illness.

The other goals of outbreak response are to :

  • identify and eliminate the cause of the outbreak
  • support the people involved in the response
  • minimize social disruption.

The Expert Panel found evidence that a great deal was done right in the systems' efforts to achieve these goals. The systems' response to the Legionnaires' outbreak was more organized, efficient and effective than it had been during SARS, and it was clear that many of the learnings from SARS had been applied.

Notwithstanding the great strides that have been made, there is an enormous amount of work still to be done. There are still serious weaknesses in the public health system and in the broader health system that must be addressed.

The Legionnaires' outbreak was not large. It was a single-point event that affected just over 100 people in a contained geographic area served by the province's largest and most well resourced public health unit. If the outbreak had been larger or the disease more virulent, the system would have been far more stressed, and the outcomes could have been quite different.

As For the Public's Health stated : "basic public health and core infection control … reflect part of the social contract between the public and its government, and not simply … another fiscal pressure on a burdened health system. Even in an era of fiscal restraint, we must remind ourselves of the cost of ignoring the essentials."

Two years ago, the SARS outbreak galvanized Ontario into action. We cannot afford to lose that momentum now.

In this report, the Panel provides a mid-term report card on Ontario's efforts to revitalize the public health system and protect the public's health. The report identifies what worked well and what we must do better to manage infectious diseases now and in the future.

Summary of Recommendations

The Panel recommends that Ontario continue to implement the recommendations from For the Public's Health : A Plan of Action. We also recommend the following :

  1. Close gaps in the outbreak response system by :
    1. Ensuring all organizations have a clear understanding of their own and one another's roles and responsibilities
    2. Developing a mechanism to ensure that hospitals are part of a coordinated response during local and regional outbreaks
    3. Improving the processes and procedures used to transfer patients between facilities
    4. Establishing priorities for the use of limited hospital resources (e.g., isolation beds, negative pressure rooms) during outbreaks
    5. Encouraging all organizations to develop business continuity plans as part of outbreak planning
  2. Provide the right people and build surge capacity by :
    1. Acting quickly to implement the human resource recommendations of the public health Capacity Review Committee and build the public health workforce locally and provincially
    2. Starting immediately to recruit and develop the expertise required to make the Central Public Health Laboratory a strong provincial and national resource
    3. Encouraging all facilities to negotiate agreements with their unions that will allow staff to work at different sites during an outbreak and provide surge capacity
    4. Encouraging hospitals and other facilities to develop staffing contingency plans in the event of outbreaks where a significant portion of staff become ill and are unable to work
    5. Moving quickly to establish the Ontario Public Health Agency and making it responsible for maintaining an up-to-date list of experts locally, nationally and internationally who can assist during outbreaks
  3. Improve occupational health and safety, and infection prevention and control by :
    1. Ensuring that all decisions about the use of personal protective equipment and other infection prevention and control practices during an outbreak are based on science
    2. Clarifying the responsibilities of different ministries and ensuring consistent messages (i.e., making the Ministry of Health and Long-Term Care responsible for establishing policy regarding the appropriate infection prevention and control measures in an outbreak and the Ministry of Labour responsible for enforcing and ensuring compliance with that science-based policy)
    3. Continuing to make effective use of the Provincial Infectious Diseases Advisory Committee (PIDAC) and involving the committee as early as necessary in an outbreak to help establish the standard for infection prevention and control, explain the science behind it, and provide expert advice throughout an outbreak
    4. Ensuring all health care organizations and providers receive education on the importance of using appropriate, science-based precautions and on the reason for different levels of precautions in different practices
    5. Ensuring all health care organizations and providers have easy, immediate access to information and advice about the appropriate PPE and other precautions
    6. Engaging the health professions to educate their members about their duty to care and the safeguards in place to reduce their risk in the workplace
  4. Enhance Ontario's capacity to investigate outbreaks by :
    1. Revitalizing the Central Public Health Laboratory, and acting on recommendations to relocate the laboratory and integrate it with the university and academic health science centres
    2. Building a new autopsy suite for the Office of the Chief Coroner that meets current safety standards
  5. Improve Ontario's capacity to share accurate information during an outbreak by :
    1. Developing an information system to manage transfers between facilities
    2. Moving quickly to fully deploy and improve the functionality of iPHIS and give public health units the capacity to collect and share data, and to produce reports.
    3. Developing an information system for the Central Public Health Laboratory
    4. Developing an information system to support timely communication among all health care organizations and providers during an outbreak
    5. Requiring all health care organizations and providers to be eliterate and to have the technology to obtain information in off hours as well as work hours during an emergency
    6. Working with the media to ensure more informed coverage of disease outbreaks
  6. Ensure facility standards in Ontario are adequate to protect residents and staff in long-term care facilities by :
    1. Establishing an expert group to review the design and maintenance of cooling towers in long-term care homes, hospitals and other facilities housing people with complex health needs
    2. Reviewing the province's environmental standards against those in place in other jurisdictions to ensure they are adequate to protect residents and staff in long-term care homes

December 2005

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