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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
slide3
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?
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”
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
slide14
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
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
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)
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
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
slide46
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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