Looking at similar communication frameworks from outside Canada can reveal some of the common challenges associated with health product risk communication, provide lessons learned, and help identify areas in which Canada could improve and be a leader. The Panel examined four jurisdictions: the United States, the United Kingdom, Australia, and the European Union. United States: Food and Drug Administration
In the United States, the FDA shares many of the same responsibilities as Health Canada. It is responsible for “protecting the public health by assuring the safety, effectiveness, quality, and security of human and veterinary drugs, vaccines and other biological products, and medical devices” (FDA, 2014a). Similar to Health Canada’s past authority, while the FDA can cancel the market authorization of a product, it cannot require MAHs to issue a recall, but can request one. The FDA’s largely passive post-marketing evaluation of health products is also similar to that of Health Canada. In 2007, however, the FDA was granted greater powers in post-marketing risk identification (FDA, 2007b; Wiktorowicz et al., 2010). It now has the authority to order MAHs to carry out post-marketing studies (under certain conditions) or make safety label changes (FDA, 2007b). Unlike Health Canada, however, the FDA does not impose regulations on natural health products, and manufacturers of these products are only required to register with the agency (FDA, 2014c).
The FDA’s equivalent to Health Canada’s communication framework is the
Strategic Plan for Risk Communication (FDA, 2009), which incorporates a multi-
dimensional understanding of risk. Effective risk communication is defined as the ability to influence individuals by informing them of both the positive and negative consequences of health-related decisions. Unlike Health Canada, the FDA explicitly outlines “intermediate outcomes” for assessing the effectiveness of risk communications:
• better understanding of both the risks and benefits of regulated products; • increased public awareness of crisis events;
• increased public view of the FDA as an expert; and
• increased confidence that affected populations are getting information that is useful and timely.
(FDA, 2009) The FDA has also set several goals related to risk communication:
• increasing the use of plain language so that target audiences can understand the message;
• increasing the quality and timeliness of messages;
• increasing feedback on communications from the public and healthcare professionals; and
• increasing the number of highly credible websites linking to FDA communications. (FDA, 2009) It is difficult, however, to assess whether the principles of the FDA’s strategic plan are used in practice. It is also unclear whether its tools have been evaluated against these outcomes and goals because evidence of evaluation is difficult to track down or lacking in publicly available strategic and guidance documents. United Kingdom: Medicines and Healthcare Products Regulatory Agency Each EU member state has an agency that issues market authorizations and regulates health products. In the United Kingdom, this responsibility lies with the Medicines and Healthcare Products Regulatory Agency (MHRA), an executive agency of the Department of Health. The MHRA has many of the same responsibilities as Health Canada, regulating medicines (including advanced therapies such as somatic cells), medical devices, and blood products. Market authorization for most innovative drug products is done through the European Union, with the MHRA (along with national authorities for EU member states) contributing to the process under the coordination of the EMA (EMA, 2015b). Only medicines require market authorization. Industry- led organizations approve medical devices, and natural health products are simply registered with the MHRA. Unlike its counterparts in the United States (and until recently Canada), the MHRA has the authority to require a
product recall. This power is rarely used, however, and the MAH generally issues recalls in the United Kingdom (Wiktorowicz et al., 2010). As is the case for Health Canada, the MHRA has a largely passive system for post-marketing health product monitoring.
The MHRA’s (2010) Communication Strategy 2010–2015 outlines its current approach to communicating health risks, setting out a series of overarching priorities and success measures rather than a strict set of policy-oriented goals. The Strategy advocates focusing less on reach (e.g., the number of people who receive or view communications) and more on use (e.g., the number of people who change their behaviour in response to communications), impact (e.g., how communications affect public health), and stakeholder engagement. Most important is the need for two-way communication with affected groups and the ability to adapt communication practices as online media become more accessible and effective in reaching a variety of populations. In its strategy, the MHRA recognizes the need to rely on its priority groups — health professionals, industry, and MHRA staff — to communicate with the public (MHRA, 2010). The MHRA also recognizes the importance of evaluating risk communication. In its communication strategy, the MHRA states that “to measure the effectiveness and success [of our risk communication] strategy, evaluation needs to be an integral part of the planning process, [and] take place at regular intervals throughout implementation.” Furthermore, it recognizes that evaluation has not been done consistently in the past, yet is necessary “to ensure maximum return on our investment in communication” (MHRA, 2010). To measure the effectiveness of its approach to risk communication, the MHRA alludes to measureable objectives. It does not, however, provide a clear definition of effective communication, and it appears that either little evaluation of its risk communication tools has been done or that any such evaluation is not publicly available in the guidance documents provided.
Australia: Therapeutics Goods Administration
In Australia, regulation of therapeutic goods (medicines, medical devices, biologics, and complementary medicines, the latter of which are called natural health products in Canada) is the responsibility of the Therapeutics Goods Administration (TGA), part of the Australian Government Department of Health. As in Canada and the United States, regulation includes pre-market assessment of products, post-marketing monitoring, licensing of domestic manufacturers, and verification that overseas manufacturers comply with local regulations. As in the United Kingdom, although recalls are generally MAH-led, the TGA has the authority to issue mandatory recalls (TGA, 2014c). Similar to the other jurisdictions discussed, Australia has a largely passive post-marketing monitoring system to detect health product risks.
In 2011, the TGA carried out a review of how it communicates its regulatory methods and decisions related to drug approvals, with the aim of improving their transparency (TGA, 2011). The government stated that the review was called because “a perception has arisen in the community that the TGA does not provide the public with sufficient information about its activities and about the therapeutic goods that it regulates” (TGA, 2011). The review led to several recommendations, grouped into three areas:
• Raise stakeholder involvement in the TGA: for example, by establishing a Australian Therapeutic Goods Advisory Council.
• Improve market authorization process: for example, working with stakeholders to improve the requirements for labels and packaging.
• Improve post-marketing activities (monitoring and compliance): for example, conducting a feasibility study into an early post-marketing risk communication scheme (i.e., similar to the black triangle system in the European Union, described in Section 3.2.1).
(TGA, 2011) The review also recommended that “the TGA develop and implement a comprehensive communication strategy to inform and educate,” as the agency does not currently have such a strategy (TGA, 2011). As of publication, no such strategy could be found on the TGA website, although the government had agreed with the recommendation to develop one (TGA, 2014b). The TGA’s review did not include an evaluation of its current health product risk communication tools, beyond stating that more effective communication was needed. In addition, the review did not mention evaluation of the effectiveness of future communication efforts. The agency has carried out, however, some qualitative and quantitative market research with consumers, health professionals, and industry, to help identify communication gaps and inform the development of effective communication strategies (TGA, 2014e, 2014a).
Europe: European Medicines Agency
For health products in the European Union, the EMA has some of the same regulatory roles as Health Canada. It is responsible for evaluating centralized procedure applications for medicines, the safety monitoring of these medicines, and referrals (scientific assessments of a drug on behalf of the European Union). The EMA does not, however, issue market authorizations (providing only advice to either the European Commission or the relevant authorities in member states), develop laws or policies related to medicines, or evaluate all medicines in the European Union (only those that have centralized procedure applications). The EMA, the European Commission, and regulatory authorities in member states are all involved in pharmacovigilance in the European Union. Some pharmacovigilance activities are complicated by jurisdictional issues,
as EU and national legislation are not always the same. Patient registries, for example, are under national legislation, which can make post-marketing studies at the EU level more challenging (Wiktorowicz et al., 2010).
The EMA adopted the European Risk Management Strategy to help mitigate health-related risks from medicines (EMA, 2008) and included information on risk communication in the guidelines for pharmacovigilance in the Rules
Governing Medicinal Products in the European Union (European Commission, 2008).
The EMA updated its risk management initiative in 2010 to increase openness and transparency in communicating safety-related issues associated with medicines (EMA, 2010).
The EMA has since released more specific guidance related to health product risk communication through its guideline on good pharmacovigilance practices. Module XV of the guideline, released in 2013, provides guidance to MAHs, the EMA, and authorities in member states on safety communications for medicines (EMA, 2013). This includes broad principles on communication and general information on several different classes of communication tools (e.g., websites, press communications), with detailed material on direct healthcare professional communications. The module defines a communication as effective “when the message transmitted is received and understood by the target audience in the way it was intended, and appropriate action is taken by the target audience” and states that effectiveness should be evaluated (EMA, 2013).
Furthermore, Module XVI on risk minimization efforts (released in 2014) provides general guidance on educational tools for risk minimization and highlights the importance of both process and outcome evaluation (EMA, 2014a). Evaluation and communication will also be a specific focus of Module XII, which will provide guidance on continuous pharmacovigilance (including communication planning and ongoing evaluation) and is expected to be released for public consultation in 2015 (EMA, 2015a).