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TARRANT Annual Meeting 2010. J Dickinson April 2010. Welcome. Interesting mix Sentinels and their staff. ProvLab staff Alberta Health: AHW, AHS Public Health Community Medicine residents Our staff: Karen Rivera Sandy Berzins , Craig Pierce, Leah Ricketson. Goals.

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tarrant annual meeting 2010

TARRANT Annual Meeting 2010

J Dickinson

April 2010

welcome
Welcome

Interesting mix

  • Sentinels and their staff.
  • ProvLab staff
  • Alberta Health: AHW, AHS
  • Public Health
  • Community Medicine residents
  • Our staff: Karen Rivera
    • Sandy Berzins, Craig Pierce, Leah Ricketson
goals
Goals
  • Review the year
  • Inform what we are doing
  • Obtain feedback from sentinels and staff
development
Development
  • Start from Sentinel program: Mike Tarrant 1983
    • Baseline for what we do: with Kevin Fonseca ProvLab
    • Informs Public Health what is happening in the community. Judy Mac Donald

Add on Vaccine Effectiveness research program

    • Danuta Skowronski CIHR
  • Survey of Family Physicians
    • Responses to threat of pandemic
  • Analysis of our own data
surveillance system
Surveillance System
  • Practitioners across Alberta
    • 40-50 each week
surveillance system1
Surveillance System
  • Practitioners across Alberta
  • Systematically Take Swabs from ILI pts
    • Influenza Like Illness: fever and cough
  • Send to Provlab
  • Weekly reports to Alberta Health
      • Combine with hospital, school, nursing homes data
    • Thence to PHAC
    • Onwards to WHO
influenza surveillance canada
Influenza Surveillance: Canada
  • FluWatch animated maps:
slide14

2009

2010

surveillance system2
Surveillance System
  • Practitioners across Alberta
  • Systematically Take Swabs from ILI
    • Influenza Like Illness
  • Send to Provlab
    • Uses PRC methods: very sensitive
  • Consistent measure of community viruses
    • We look at 6 other respiratory viruses too…
provlab tests for
ProvLab tests for:
  • Influenza A
    • Types (including pH1N1)
  • Influenza B
  • Respiratory syncytial virus
  • Adenovirus
  • Enterovirus/rhinovirus
  • Coronavirus
  • Parainfluenza virus
  • Human metapneumovirus
accuracy of fp diagnosis
Accuracy of FP diagnosis
  • Positive predictive value
    • Related to severity of epidemic
    • Always less than 50%
    • Always majority of unidentifiable viruses
accuracy of fp diagnosis1
Accuracy of FP diagnosis
  • Positive predictive value
    • Related to severity of epidemic
    • Always less than 50%
    • Always majority of unidentifiable viruses
  • Implications for oseltamivir prescribing?
    • Especially withoseltamivirresistance
accuracy of fp diagnosis2
Accuracy of FP diagnosis
  • Positive predictive value
    • Related to severity of epidemic
    • Always less than 50%
    • Always majority of unidentifiable viruses
  • Implications for oseltamivir prescribing?
  • Age relationship
    • Highest viral retrieval in children
    • Very low in old: who get more severe illness
research questions
Research Questions
  • How did family physicians in Alberta respond to the epidemic?
    • Clinic pandemic plan
    • Measures taken in their clinic to reduce influenza transmission
  • What were physicians’ reactions regarding pandemic H1N1 preparedness in Alberta?
survey methods
Survey Methods
  • 3558 general practitioners from College of Physicians and Surgeons of Alberta
  • 1,000 physicians from list
    • 250 from Calgary
    • 250 Edmonton
    • 250 Other Urban Areas
    • 250 Rural Areas
survey methods1
Survey Methods
  • Paper survey
    • Limited to 4 pages
    • Mixture of closed questions and spaces for comment
    • Piloted during July/ August.
  • Survey conducted
    • early September through October 2009
    • Reminders sent up to 3 times
    • Response rate 21.9%
    • Last survey was received November 5, 2009
precautions to prevent transmission
Precautions to Prevent Transmission
  • 92% of physicians put in place some form of precaution
    • Providing hand sanitizer for patients (85%)
    • Posting signs on doors (69%)
    • Providing masks for patients (69%)
    • Isolating ILI patients in separate room (54%)
    • 2 meter space between patients and receptionists (27%)
    • 2 meter space between patients (19%)
    • Direct patients with cough/cold elsewhere (17%)
slide35

Alcohol Sanitizer Use

Calgary

Edmonton

Other Urban

Rural

use of personal protective equipment
Use of Personal Protective Equipment
  • Use of PPE – recommended during nasopharyngeal swab
    • 76% ‘always’ or ‘mostly’ wear gloves
    • 63% ‘always’ or ‘mostly’ wear a procedural mask
    • 42% ‘never’ wear an N95 mask
    • 42% ‘never’ wear eye or face shield
obtaining ppe
Obtaining PPE
  • 53% of physicians did not encounter trouble in obtaining PPE
  • 35% had trouble obtaining N95 masks
    • Calgary (57%)
    • Edmonton (26%)
    • Other Urban (26%)
    • Rural (25%)
replacement staff
Replacement Staff
  • 73% of physicians did not think there would be enough replacement staff for their clinic if some fell ill.
  • How would clinic staff react?
    • 21% continue working regular hours
    • 58% fearful to deal with ILI patients
    • 32% stay at home to care for family
    • 22% don’t know
willingness to work in epidemic
Willingness to work in epidemic
  • 64% of respondents expressed concern about being infected
  • 78% of males and 60% of females would work longer in severe pandemic
limitations
Limitations
  • Low response rate of 21.9% (192 surveys completed)
  • Timing of survey
  • Limited amount of open ended feedback
    • Interpretation
    • Bias of opinions
conclusions
Conclusions

Most doctors accept their responsibility to work in an epidemic.

They are concerned, and are less willing to work in identified high risk situations.

Unhappy about:

  • potential for negative triage decisions for certain cases
  • being required to work in situations not trained for
physicians legal rights and duties
Key Points:

Primary duty of care to patients where relationship exists

In Emergency or rural settings, duty of care to community who use the facility

Particular susceptibility justifies refusal. e.g. pregnancy, reduced immunity

CMAJ 2009.DOL:10.1503/cmaj.091628 (Jan 2009)

Physicians legal rights and duties
conclusions recommendations
Conclusions/Recommendations
  • Develop a pandemic plan
    • Involve all staff members
  • Build own stocks of PPE
    • Sanitizer, masks, swab kits, gowns, gloves, eye/face shield
  • Be cautious and use protection
    • when seeing coughing patients
    • while taking NP swabs
  • Public Health planning:
    • Focus on supporting front line when epidemic threatens.