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Pandemic or Panic?. Influenza A (H1N1) Jennifer Hughes May 21, 2009. Outline. Influenza outbreaks, epidemics and pandemics Epidemiology of novel H1N1 SOIV Our local picture Vaccine Things you should know about treatment. Epidemic:

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Pandemic or panic

Pandemic or Panic?

Influenza A (H1N1)

Jennifer Hughes

May 21, 2009


Outline

Outline

  • Influenza outbreaks, epidemics and pandemics

  • Epidemiology of novel H1N1 SOIV

  • Our local picture

  • Vaccine

  • Things you should know about treatment


Pandemic or panic

Epidemic:

From the Greek epi (upon) + demos (people): affecting a disproportionately large number of individuals within a population at the same time.

Pandemic:

pan (all) + demos (people):

occurring over a wide geographic area.


Influenza

Influenza

  • High attack rates

  • Low mortality (on average) – 0.1% - 20%

  • More people have died from influenza in a short period time than from any other disease.

  • Affects birds and mammals


Influenza a

Influenza A

  • Surface glycoproteins:

    • HA (hemoagglutinins)

    • NA (neuraminidases)

  • H1, H2, H3

  • N1, N2


A typical flu year

A typical flu year

  • Two flu seasons (one per hemisphere)

  • 2-5 million cases of severe illness

  • 500,000 deaths worldwide

  • Annual pandemic?


Putting it in perspective

Putting it in perspective


Remember h5n1

Remember H5N1 ?

  • Avian-adapted, highly pathogenic

  • Endemic and panzootic in birds

  • Not efficiently or sustainably transmitted to humans or between humans

  • 2008 : 44 cases, 33 deaths (75% mortality)

  • 2009: 29 cases, 11 deaths (38% mortality)


Sars for comparison

SARS for comparison

  • SARS coronavirus

  • Near pandemic between Nov 2002 – July 2003

  • 8096 cases, 774 deaths

  • Case fatality rate 9.6%

  • Last human case 2003

  • “fully contained”


Pandemic or panic

y


Tracing the beginning

Tracing the beginning

  • March 18 – Mexico reports increase in late-season ILI

  • April 21 samples are sent to CDC to confirm

  • First death April 13

    • Diabetic woman from Oaxaca

  • 2 Children San Diego country diagnosed April 24


Mexico

Mexico

  • 3648 cases

  • 72 deaths

  • Hospitalization rates high in young people

  • Surveillance challenging


H1n1 outbreak what is known

H1N1 outbreak: what is known

  • Novel virus (to animals and humans)

  • No pre-existing immunity

  • More contagious than seasonal influenza

  • Primary attack rate 35%

  • Unclear origin


Pandemic or panic

  • Mild illness (except Mexico)

  • Severe and lethal cases seen in younger patients

  • Case fatality rate estimate of 0.3-1.4%

  • Could result in 6-12 million deaths

    WHO Rapid Pandemic Assessment Collaboration


The current h1n1 soiv situation

The current H1N1 SOIV situation…

  • 21 May 2009 06:00

    • 41 countries

    • 11 034 cases

    • 85 deaths

    • 791 cases since May 20

    • 5 new deaths


Surveillance in canada

Surveillance in Canada


Alberta s cases

Alberta’s cases

  • 30 had traveled to affected areas;

  • 9 in contact with travelers

  • 16 no travel history

  • 31 cases have travel/exposure histories to be determined.

  • Median 33 years of age


Gift lake alberta

Gift Lake, Alberta

  • Woman in 30s with chronic underlying medical conditions

  • No travel to Mexico

  • Household contact + H1N1 SOIV

  • Died in Edmonton April 28, 2009

  • Autopsy report May 14 : inconclusive about role of H1N1


Reverse zoonosis in alberta

Reverse Zoonosis in Alberta

  • Rocky Mountain House

  • 2200 pigs under quarantine

  • “some” animals had Influenza A H1N1

  • From carpenter who traveled to Mexico

  • 500 culled for overcrowding


Testing

Testing

  • NP swab or aspirate

  • M5 Universal Transport Medium

  • “Influenza testing” on ProvLab req (mark as “EI 236”)

  • Prov Lab requisition


Across the region

Across the Region

  • PLC

  • ACH

  • FMC

  • RGH


Laboratory diagnosis

Laboratory Diagnosis

  • Confirmed case definition:

    • RT-PCR

    • Viral culture

    • 4 x increase in H1N1 specific neutralizing AB

  • Probable case:

    • Positive testing for influenza A

    • Untypable, with/without clinical sx


Reporting

Reporting

  • Mild ILI – report if you swabbed them

  • Severe - call MOH on call

  • Positive results followed by public health


Infection prevention control

Infection Prevention & Control

  • Patients

  • Health care workers

    • Site to site


Respiratory precautions

Respiratory Precautions

  • Within 2 m of patient

  • Surgical mask

    • Patient is compliant with resp hygiene

    • Weak or no cough

  • N95 mask

    • Aerosol-generating medical procedures

    • Non-compliant patient


Swine flu kit for 39 95 8 95 shipping

Swine Flu Kit for $39.95 (+ $8.95 shipping)


Vaccine

Vaccine

  • Current seasonal flu vaccine: no immunity

  • H1N1 vax available in 5-6 months

  • Global capacity of 1-2 billion doses/year

  • Will not be incorporated into seasonal vaccine

  • 1 vs 2 doses?

  • Federal gov + GlaxoSmithKline have signed a deal for Canadian Production


Treatment

Treatment

  • Oseltamivir (Tamiflu): Roche

  • Zanamivir (Relenza) : GlaxoSmithKline

  • Neuraminidase inhibitor : prevents virion release from infected cells

  • Age-based, weight-based dosing in children

  • Pregnancy Category C

  • Most effective when started within 48 hours


Oseltamivir

Oseltamivir

  • 25-30% reduction in symptom duration

  • 59% reduction in hospitalization

  • 63% reduction in antimicrobial use

  • 1 day reduction in work days lost

  • Reduction in mortality (OR 0.21, p<0.03)

  • Statement on influenza vaccination for the 2008-2009 season. An Advisory Committee Statement (ACS). Can Commun Dis Rep 2008 Jul 15;34(ACS-3):1-46.  Available at:  http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/08pdf/acs-3.pdf

  • Centers for Disease Control and Prevention. Antiviral agents for seasonal influenza:  dosage. 2009 [updated 2009 Feb 11, cited 2009 Mar 20]. Available at: http://www.cdc.gov/flu/professionals/antivirals/dosage.htm


Oseltamivir in canada

Oseltamivir in Canada

  • NOT RECOMMENDED for treatment or prophylaxis of mild cases

  • Tamiflu use should be consistent with use for seasonal influenza


Indications for tamiflu

Indications for Tamiflu

  • All hospitalized patients with confirmed, probable or suspected influenza (novel or seasonal)

  • Patients who are at higher risk for seasonal influenza complications


Indications for tamiflu1

Indications for Tamiflu

  • Influenza-like illness

  • < 48 hours onset

  • High risk of influenza-related complications

    • cardiac or pulmonary disorders

    • diabetes mellitus

    • cancer

    • immunodeficiency

    • renal disease

    • anemia or hemoglobinopathy

    • conditions that compromise the management of respiratory secretions

    • children with conditions treated for long periods with acetylsalicylic acid

    • children < 2 years

    • pregnant women

    • > 65 years


Who should get pep

Who should get PEP?

  • Close contact of case (suspected, probable and confirmed)

  • High risk for complications of influenza

  • Health care workers with recognized, unprotected close contact exposure

  • During infectious period (Day 0 – Day 7)


Influenza antiviral dosing

Influenza Antiviral Dosing


Canada s pandemic plan

Canada’s pandemic plan

  • Stockpile to treat 17.5% of population

  • 55.7 million doses stockpiled in Canada

  • 5 million doses of zanamivir

  • Alberta would get ~10%

    Canadian Pandemic Influenza Plan for the Health Sector :The Use of Antiviral Drugs During a Pandemic. Public Health Agency of Canada. May 12, 2009.


Oseltamivir in the region

Oseltamivir in the Region

  • Available for purchase by prescription

  • NOT a restricted medication

  • Hospitals and outpatient pharmacies have stockpile for MOH cases


Neuraminidase resistance

Neuraminidase Resistance

  • HIN1 SOIV

    • 101 isolates : 0 % resistance to neuraminidase inhibitors

    • 96 isolates : 100% resistance to adamantanes

      http://www.cdc.gov/h1n1flu/recommendations.htm#table2


Speculating on the future

Speculating on the future

  • Clinical spectrum not yet fully apparent

  • Spread to southern hemisphere/interaction with seasonal flu

  • Antigenic drift of influenza viruses


Pandemic or panic

  • H5N1 avian influenza + H1N1 = “Armageddon Virus”


Assessing the severity of an influenza pandemic

Assessing the severity of an influenza pandemic

  • Inherent virulence

  • Population vulnerability

  • Waves of spread

    • 8 gene segments commonly and unpredictably mutate

  • Capacity to respond


Pandemic or panic

  • WHO Phase 5: sustained community-level outbreaks in at least two countries in one WHO region.

  • Pandemic is “imminent”

  • Currently “sustained community-level outbreak”


Staving off a pandemic

Staving off a pandemic?

  • May 18, 2009:

    Britain, Japan, China, US and others urge WHO to change its definition of a pandemic to reflect the virulence of a disease, not just how far it spreads around the world.


Summary

Summary

  • First wave of the outbreak appears mild

  • Future is unpredictable

  • Still on upswing of epidemiological curve

  • Vaccine is still months away

  • Oseltamivir and zanamivir work… for now

  • Major political and economic impacts of pandemic


References

References

Public Health Agency of Canada. FightFlu. Http://www. Fightflu.ca. Access May 20, 2009.

The Lancet: H1N1 Resource Centre: http://www.thelancet.com/H1N1-flu

McGeer A, Green KA, Plevneshi A, et al. Antiviral therapy and outcomes of influenza requiring hospitalization in Ontario, Canada. Clin Infect Dis 2007;45:1568-75.

Kaiser I, Wat C, Mills T, et al. Impact of oseltamivir treatment on influenza-related lower respiratory tract complications and hospitalizations. Arch Intern Med 2003;163:1667-72.

Cooper NJ, Sutton AJ, Abrams KR , et al. Effectiveness of neuraminidase inhibitors in treatment

and prevention of influenza A or B: systematic review and meta-analysis of controlled trials.

BMJ 2003;326:1-7.

Canadian Pandemic Influenza Plan for the Health Sector: The Use of Antiviral Drugs During a Pandemic. Annex E. Public Health Agency of Canada. May 12, 2009. http://www.phac-aspc.gc.ca/cpip-pclcpi/pdf-e/annex_e0513-eng.pdf

Aoki FY , Macleod MD, Paggiaro P, et al. Early administration of oral oseltamivir increases the benefits of influenza treatment. J Antimicrob Chemother 2003;51:123-9.

Balicer RD , Huerta M, Davidovitch N, et al. Cost benefit of stockpiling drugs for influenza pandemic. Emerg Infect Dis 2005;11:1280-2.


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